Use of Vital Pulp Therapies in Primary Teeth 2024

Purpose: The purpose of this study was to present an evidence-based guideline for primary teeth with deep caries or trauma requiring vital pulp therapies (VPT). Methods: A systematic review/meta-analysis on vital primary teeth resulting from trauma or caries was conducted using GRADE to assess the certainty of evidence for clinical recommendations. A decision tree was provided for choosing VPTs. Results: No articles on trauma VPT were found. For VPT in primary teeth with deep caries, indirect pulp treatment (IPT) or pulpotomy using the calcium silicate cement (mineral trioxide aggregate [MTA] or Biodentine®) show increased success over using direct pulp capping (DPC) and other pulpotomies. Different liners do not affect IPT success (high certainty) or DPC capping agents' success (very low certainty) after 24 months. It is strongly recommended, with high certainty from 24-month data, that calcium silicate cement pulpotomy is preferred over formocresol, ferric sulfate, zinc oxide eugenol pulpotomy, and other pulpotomies. Using selective caries removal and IPT for deep caries is strongly recommended with moderate certainty over complete and stepwise removal. Statistically, this results in significantly fewer pulp exposures. No caries removal and Hall technique crown may be used when indicated (moderate certainty at 24 months). For vital primary incisors with deep caries, pulpotomy was significantly better statistically than pulpectomy. Teeth diagnosed with/without reversible pulpitis pain showed comparable success after 12 months of treatment by IPT or calcium silicate cement pulpotomy. The following had little or no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; anterior or posterior teeth. Conclusions: Indirect pulp treatment or calcium silicate cement pulpotomy is likely to increase vital pulp therapy success over other VPTs such as direct pulp capping and other pulpotomies after 24 months (moderate certainty).

Primary Tooth Vital Pulp Treatment Interventions: Systematic Review and Meta-Analyses

Purpose: to update the 2016 systematic review evidence for vital pulp therapy (VPT) for primary teeth affected by caries or trauma. Methods: The population, intervention, comparison, outcomes, and study (PICOS) design inclusion/exclusion was used for multiple databases. Risk of bias, meta-analyses using RevMan, and certainty of evidence was created. Results: A total of 299 studies were included; no trauma was found. Indirect pulp treatment (IPT) resulted in 97 percent success. Two calcium silicate cement (CSC) pulpotomies' success using mineral trioxide aggregate (MTA) and Biodentine® were 94 percent and 90 percent, respectively, greater than for direct pulp capping (DPC; 86 percent) and other pulpotomies (moderate certainty). The success of IPT versus pulpotomy at 24 months showed no significant difference (P=0.31). Different liners or capping agents did not affect the success of IPT (P=0.79) or DPC at 24 months (P=0.24). The two CSC pulpotomies were not significantly different based on 24-month success (P=0.34). The formocresol pulpotomy success at 24 months was significantly lower than for MTA (P=0.02). Ferric sulfate had a significant lower success at 24 months than MTA pulpotomy (69 percent versus 92 percent; P=0.03). Zinc oxide eugenol, as a singular pulpotomy, had low success (65 percent). Selective/stepwise caries removal did significantly better at avoiding pulp exposures than complete excavation (P<0.001). Complete, selective, and no caries removal (Hall technique [HT], steel crown placement with no caries removal) had no significant difference in pulp vitality success for deep caries at 24 months (P=0.29). For deep caries affecting vital incisors, pulpotomy had significantly greater success than pulpectomy (P=0.002). The following had no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; and anterior or posterior teeth. Conclusions: Vital pulp therapy success of indirect pulp treatment or two calcium silicate cement pulpotomies demonstrated improved success over direct pulp capping and other pulpotomies based on 24-month evidence with moderate certainty. The Hall technique did not significantly reduce pulp vitality success versus caries removal.

Effects of LED curing light on silver diamine fluoride penetration into dentin

This ex-vivo study investigated the effect of a light-emitting diode (LED) curing light on the depth of penetration of Silver Diamine Fluoride (SDF) into carious lesions. Twenty-four primary teeth with untreated caries lesions were allocated into groups and treated within 5 min after extraction: (1) n = 6 treated for 1 min with one drop of SDF followed by 10 sec rinse with tap water, (2) n = 6 treated for 10 sec with one drop of SDF and exposed to LED light for 20 sec (30 sec total SDF exposure) followed by 10 sec rinse with tap water, (3) n = 6 treated for 10 sec with one drop of SDF followed by a 10 sec rinse with tap water, (4) n = 3 untreated, and (5) n = 3 untreated but exposed to LED light for 20 sec. Samples were prepared, embedded, sectioned and silver penetration was measured using backscattered electron imaging in the scanning electron microscope and energy-dispersive X-ray spectroscopy analysis. Results were expressed as the average relative depth of penetration (%) = Ag depth/lesion depth × 100 from 5 sites in each lesion. Group means were compared using mixed model analysis. Mean ± standard deviation (SD) penetration was: 86.4 ± 20.7% in Group 1, 94.3 ± 13.7% in Group 2, and 26.7 ± 13.9% in Group 3. Groups 1 and 2 were statistically similar and different from Group 3 (p < 0.001). Groups 4 and 5 had no silver present. Use of LED light for 20 sec after 10 sec SDF application appears to facilitate silver penetration, similar to a 1 min SDF application. Clinical studies are needed to define the role of silver penetration in sustained caries arrest.

A scoping review on the association of early childhood caries and maternal gender inequality

AIM

The objective of this scoping review is to present current evidence regarding the association between early childhood caries (ECC) and maternal-related gender inequality.

METHODS

Two independent reviewers performed a comprehensive literature search using three databases: EMBASE, PubMed, and Web of Science. Literature published in English from 2012 to 2022 was included in the search and was restricted to only primary research by using the following key terms: "dental caries", "tooth decay", "gender", "sex", "preschool", "toddler," and "infant". The included studies were limited to those reporting an association between ECC and maternal aspects related to gender inequality. Titles and abstracts were screened, and irrelevant publications were excluded. The full text of the remaining papers was retrieved and used to perform the review. The critical appraisal of selected studies was guided by the Joanna Briggs Institute (JBI) Critical Appraisal Tools.

RESULTS

Among 1,103 studies from the three databases, 425 articles were identified based on publication years between 2012 and 2022. After full-text screening, five articles were included in the qualitative analysis for this review. No published study was found regarding a direct association between ECC and maternal gender inequality at the level of individuals. Five included studies reported on the association between ECC and potential maternal-gender-related inequality factors, including the mother's education level (n = 4), employment status (n = 1), and age (n = 1). Regarding the quality of the included studies, out of five, two studies met all JBI criteria, while three partially met the criteria.

CONCLUSIONS

Based on the findings of this scoping review, evidence demonstrating an association between gender inequality and ECC is currently limited.

Evidence-Based Caries Management for All Ages-Practical Guidelines

Introduction: The purpose of the present paper is to provide step-by-step guidelines for dental healthcare providers to manage dental caries based upon caries risk assessment (CRA) for ages 0–6 years and 6 years through adult. The manuscript reviews and updates the CAMBRA (caries management by risk assessment) system which includes CRA and caries management recommendations that are guided by the assessed risk level.

Caries Risk Assessment: CAMBRA CRA tools (CRAs) have been evaluated in several clinical outcomes studies and clinical trials. Updated CAMBRA CRAs for ages 0–6 years and 6 years through adult are provided. These CRAs have been refined by the addition of a quantitative method that will aid the health care provider in determining the caries risk of individuals.

Caries Management Based Upon Risk Assessment: Guidelines for individualized patient care are provided based upon the caries risk status, results of clinical exams and responses of the patient to questions in the CRA. These guidelines are based upon successful outcomes documented in several clinical outcomes studies and clinical trials. The paper includes a review of successful caries management procedures for children and adults as previously published, with additional emphasis on correct use of silver diamine fluoride (SDF) for children. The caries management plan for each individual is based upon reducing the caries risk factors and enhancing the protective factors with the additional aid of behavior modification. Beneficially altering the caries balance is coupled with minimal intervention restorative dentistry, if appropriate. These methods are appropriate for the management of dental caries in all patients.

In vitro rehardening and staining effects of silver diamine fluoride with and without mucin on early enamel caries lesions

PURPOSE

To evaluate the rehardening ability of SDF and its individual components, silver, and fluoride ions, on early enamel caries lesions using artificial saliva with and without mucin.

METHODS

Early caries lesions were created in human permanent enamel specimens. The specimens (n=36 per group) were then treated with a single application of: SDF (38%), SDF followed by application of potassium iodide (SDF+KI), potassium fluoride (KF); fluoride control, 44,800 ppm (F), silver nitrate (AgNO3); silver control, 253,900 ppm (Ag), or deionized water (DIW). Immediately, the specimens were subjected to 4 days of continuous remineralization with or without mucin (n=18 per subgroup). Changes in Vickers surface microhardness from lesion baseline (ΔVHN) were calculated. Data were analyzed using two-way (intervention vs. rehardening models) ANOVA.

RESULTS

In both rehardening models (with or without mucin), SDF (ΔVHN data; mean ± standard deviation; with/without mucin: 26± 19/3± 11) was significantly less effective in rehardening promotion than SDF+KI (37± 12/39± 16) and KF (40± 17/41± 29; P≤ 0.0332). Compared to AgNO3 (9± 9/18± 15) and DIW (3± 7/12± 9), SDF was more effective in the presence of mucin (P≤ 0.001) but not in its absence, similar to DIW (P= 0.1117); less effective vs. AgNO3 (P= 0.0061). The presence of mucin significantly increased the rehardening ability of SDF (P< 0.0001). However, mucin did not affect the extent of rehardening in the other groups (P≥ 0.082). SDF+KI and KF were superior in their ability in rehardening promotion than AgNO3 and DIW in both rehardening models (P< 0.0001). In both rehardening models, ΔL* values from baseline to post-rehardening show that applying KI after SDF significantly lessened the dark staining caused by SDF (P< 0.0001). Under the present in vitro conditions, SDF does not appear to enhance surface rehardening of early enamel caries lesions. The co-presence of mucin during rehardening enhanced the efficacy of SDF which warrants further investigation.

CLINICAL SIGNIFICANCE

Silver diamine fluoride + potassium iodide may be a viable option in rehardening of early enamel caries lesions.

Global Oral Health Policies and Guidelines: Using Silver Diamine Fluoride for Caries Control

Silver diamine fluoride (SDF) was developed in Japan in the 1960s. It is a clear solution containing silver and fluoride ions. Because of its anti-bacterial and remineralizing effect, silver diamine fluoride has been used in managing dental caries for decades worldwide. This paper aims to summarize and discuss the global policies, guidelines, and relevant information on utilizing SDF for caries management. SDF can be used for treating dental caries in most countries. However, it is not permitted to be used in mainland China. Several manufacturers, mainly in Australia, Brazil, India, Japan, and the United States, produce SDF at different concentrations that are commercially available around the world. The prices differ between contents and brands. Different government organizations and dental associations have developed guidelines for clinical use of SDF. Dental professionals can refer to the specific guidelines in their own countries or territories. Training for using SDF is part of undergraduate and/or postgraduate curriculums in almost all countries. However, real utilization of SDF of dentists, especially in the private sector, remains unclear in most places because little research has been conducted. There are at least two ongoing regional-wide large-scale oral health programs, using SDF as one of the components to manage dental caries in young children (one in Hong Kong and one in Mongolia). Because SDF treatment does not require caries removal, and it is simple, non-invasive, and inexpensive, SDF is a valuable strategy for caries management in young children, elderly people, and patients with special needs. In addition, to reduce the risk of bacteria or virus transmission in dental settings, using SDF as a non-aerosol producing procedure should be emphasized under the COVID-19 outbreak.

Predicting Treatment Nonresponse in Hispanic/Latino Children Receiving Silver Diamine Fluoride for Caries Arrest: A Pilot Study Using Machine Learning

Objectives: Silver diamine fluoride (SDF) is a nonsurgical therapy for the arrest and prevention of dental caries with demonstrated clinical efficacy. Approximately 20% of children receiving SDF fail to respond to treatment. The objective of this study was to develop a predictive model of treatment non-response using machine learning. Methods: An observational pilot study (N = 20) consisting of children with and without active decay and who did and did not respond to silver diamine fluoride provided salivary samples and plaque from infected and contralateral sites. 16S rRNA genes from samples were amplified and sequenced on an Illumina Miseq and analyzed using QIIME. The association between operational taxonomic units and treatment non-response was assessed using lasso regression and artificial neural networks. Results: Bivariate group comparisons of bacterial abundance indicate a number of genera were significantly different between non-responders and those who responded to SDF therapy. No differences were found between non-responders and caries-active subjects. Prevotella pallens and Veillonella denticariosi were retained in full lasso models and combined with clinical variables in a six-input multilayer perceptron. Discussion: The acidogenic and acid-tolerant nature of retained bacterial species may overcome the antimicrobial effects of SDF. Further research to validate the model in larger external samples is needed.

Oral Health Policies to Tackle the Burden of Early Childhood Caries: A Review of 14 Countries/Regions

Aim: Early childhood caries (ECC) has significant public health implications but has received inadequate global attention. There is limited information regarding the success of oral health policies implemented to address the challenges of ECC. This review aimed to summarize such policies to tackle ECC from different countries/regions. Method: Independent collaborators from 14 countries/regions (Australia, Brazil, Cambodia, China, Hong Kong, Egypt, India, Indonesia, Japan, Nigeria, Thailand, UK, USA, and Venezuela) collected the data. The ECC status, dental workforce, oral health policies on ECC prevention in different countries/regions were summarized by each country. Results: The findings indicated that ECC prevalence varied in different countries/regions. The lowest prevalence of ECC among 5-year-old children was found in Nigeria (7%), and the highest was found in Indonesia (90%). The existing dental workforce and resources are limited in most countries. The smallest dentist to population ratio was reported by Nigeria at 1:48,400, whereas the highest ratio was in Brazil (1:600). Out of 14, three (21%) countries namely India, Venezuela and Cambodia had no national oral health policies addressing ECC and four (29%) countries (Cambodia, China, India, Venezuela) had no publicly funded dental care program for 0-5-year-old children. Water fluoridation is available in four countries/regions (Australia, Brazil, Hong Kong, USA). Conclusion: ECC remains a global health challenge and dental workforce is limited. National/regional programs to tackle ECC are not yet prioritized in many countries/regions. Evidence to support demonstration projects is limited. Further research on the cost-effectiveness of interventions strategies is required for policymakers.

A Comparison of Four Caries Risk Assessment Methods

Introduction: Caries risk assessment (CRA) is essential as the basis for successful management of dental caries. Of the many published CRA tools, four well-known ones are CAMBRA, Cariogram, American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD) CRAs. The predictive accuracy of CAMBRA and Cariogram CRA tools have been examined in clinical outcomes studies in thousands of patients and the tools are widely used all over the world. The purpose of the present paper is three-fold, namely (1) to briefly review, compare and contrast these four CRA methods, (2) to provide a concise method for CRA introducing a quantitative component to the CAMBRA forms (CAMBRA 123), and (3) to guide the choice of CRA methods that will support caries management decisions. Comparison of Caries Risk Assessment Methods: In the present evaluation, the above-mentioned four CRA methods for ages 0-6 years and 6 years-adult were compared using 26 hypothetical patients (13 per age group). Comparison results show that Cariogram and CAMBRA categorized patients into identical risk categories. Each of the ADA and AAPD tools gave different results than CAMBRA and Cariogram in several comparison examples. CAMBRA 123 gave the same caries risk level results as the Cariogram and the CAMBRA methods for all hypothetical patients for both age groups. Conclusions: Both the Cariogram and the CAMBRA CRA methods are equally useful for identifying the future risk of dental caries. CAMBRA 123 shows promise as an easy-to-use quantitative method for CRA in clinical practice. The health care providers will be the ones to decide which CRA method will allow them to establish individualized, successful caries management therapies and how to combine these for the best care of their patients.

Microbial population shift and metabolic characterization of silver diamine fluoride treatment failure on dental caries

The objective of this pilot study was to describe the microbial profiles present in the plaque and saliva of children who continued to develop new carious lesions following treatment with silver diamine fluoride ("nonresponders") compared to caries active, caries-free, and children immediately receiving SDF treatment for untreated caries in order to identify potential microbial differences that may relate to a re-incidence of caries. Saliva and plaque samples from infected and contralateral sites were obtained from twenty children who were either caries free, had active carious lesions, were caries active and received SDF treatment immediately before sampling, or had previously received SDF treatment and developed new caries. In total, 8,057,899 Illumina-generated sequence reads from 60 samples were obtained. Reads were processed using the Quantitative Insights Into Microbial Ecology pipeline. Group differences were assessed using Analysis of Variance Models and Tukey Honest Significant Differences. To identify significant taxa between treatment groups, Linear discriminant analysis Effect Size (LefSe) and Analysis of Differential Abundance Taking Sample Variation Into Account were used. Differential abundant analysis indicated that members of the Lachnospiraceae family were significantly enriched in non-responders and the genus Tannerella and species Granulicatella adiances were also highly abundant in this group. LefSe analysis between non-responders and SDF-treated groups revealed that genera Leptotrichia and Granulicatella were enriched in non-responders. We observed the highest abundance of phosphotransferase system and lowest abundance of lipopolysaccharide synthesis in non-responders. The microbiome in dental biofilms is responsible for initiation and progression of dental caries. SDF has been shown to be effective in arresting the progression carious lesions, in part due to its antimicrobial properties. Findings suggest that the differential abundance of select microbiota and specific pathway functioning in individuals that present with recurrent decay after SDF treatment may contribute to a potential failure of silver diamine fluoride to arrest dental caries. However, the short duration of sample collection following SDF application and the small sample size emphasize the need for further data and additional analysis.

The effect of silver diamine fluoride in preventing in vitro primary coronal caries under pH-cycling conditions

OBJECTIVES

This study investigated the ability of SDF, and its individual components, silver (Ag⁺) and fluoride (F^-) ions, in preventing enamel demineralization under pH-cycling conditions in the presence or absence of twice-daily fluoride application.

DESIGN

Polished human enamel specimens were assigned to five treatment groups (n = 36 per group): SDF (38 %); SDF followed by application of a saturated solution of potassium iodide (SDF + KI); silver nitrate (AgNO₃; silver control, 253,900 ppm Ag); potassium fluoride (KF; fluoride control, 44,800 ppm F); deionized water. Treatments were applied once. Specimens in each treatment group were divided into two subgroups (n = 18). During the subsequent 7-day pH-cycling phase, specimens were treated twice daily with either 275 ppm fluoride as sodium fluoride or deionized water, immediately before and after a 3-h cariogenic challenge with exposure to artificial saliva at all other times. Changes in color, Vickers surface microhardness (SMH), transverse microradiography (TMR) was calculated. Data were analyzed using two-way ANOVA.

RESULTS

In both models, SDF, SDF + KI and KF were superior in inhibiting demineralization compared to AgNO₃ and deionized water (p < 0.0001). There was no statistically significant difference between SDF, SDF + KI and KF with twice daily fluoride treatments (p > 0.8). However, KF was more effective in preventing demineralization than SDF and SDF + KI in the absence of fluoride treatments (p = 0.0002). KI did not affect the ability of SDF to prevent demineralization (p > 0.4).

CONCLUSION

SDF and SDF + KI appears to be an effective option in preventing primary coronal caries.

Teaching and utilization of silver diamine fluoride and Hall-style crowns in US pediatric dentistry residency programs

BACKGROUND

Nonsurgical caries management, particularly silver diamine fluoride (SDF) and Hall-style crowns, present alternative options for populations that have barriers to traditional treatment. The authors aimed to assess changes in the teaching and utilization of these modalities in pediatric dental residency programs.

METHODS

The authors e-mailed a 29-question electronic survey regarding the utilization and teaching of nonsurgical caries management agents to US pediatric dentistry residency program directors. Data were compared with results from a similar survey conducted in 2015 to analyze trends, report protocols, barriers for utilization, and possible reasons for changes.

RESULTS

Respondents from 82 programs completed the surveys (89% response rate). Although only 26% of respondents reported using SDF in 2015, 100% reported its utilization in 2020 (P < .001). The Hall-style crown technique is taught didactically in 90% of programs, and 69.5% of respondents use it at least sporadically in their clinics. Long wait times for the operating room (4 weeks-14 months) and sedation (1 week-12 months) motivate increased utilization of SDF, interim therapeutic restorations, and Hall-style crowns. Guidelines supporting off-label utilization of SDF have also resulted in its increased utilization.

CONCLUSIONS

US pediatric residency programs have universally adopted SDF for caries arrest in the primary dentition, and this trend seems to extend to other nonsurgical caries management agents. These changes are likely driven by diverse barriers to delivery of traditional restorative care.

PRACTICAL IMPLICATIONS

The rapid increases in teaching and utilization of minimal intervention techniques provide clinicians with more options for caries management in patients with barriers to traditional treatment.

Use of Non-Vital Pulp Therapies in Primary Teeth

Purpose: To present an evidence-based guideline for non-vital pulp therapies due to deep caries or trauma in primary teeth. Methods: The authors, working with the American Academy of Pediatric Dentistry, conducted a systematic review/meta-analysis for studies on non-vital primary teeth resulting from trauma or caries and used the GRADE approach to assess level of certainty of evidence for clinical recommendations. Results: GRADE was assessed from high to very low. Comparing teeth with/without root resorption, pulpectomy success was better (P<0.001) in those without preoperative root resorption. Zinc oxide plus iodoform plus calcium hydroxide ([ZO/iodoform/CH]; Endoflas TM ) and zinc oxide and eugenol (ZOE) pulpectomy success did not differ from iodoform (iodoform plus calcium hydroxide; Vitapex^TM, Metapex^TM) (P=0.55) after 18-months; however, ZO/iodoform/CH and ZOE success rates remained near 90 percent while iodoform was 71 percent or less. Network analysis ratings showed ZO/iodoform/CH and ZOE better than iodoform. Lesion sterilization tissue repair (LSTR) was better (P<0.001) than pulpectomy in teeth with preoperative root resorption, but pulpectomy results were better (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual, but the quality of fill did not differ (P=0.09) and both had comparable success. Network analysis ranked ZO/iodoform/CH the best, ZOE second, and iodoform lowest at 18 months. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Conclusions: Pulpectomy 18-month success rates supported ZO/iodoform/CH and ZOE pulpectomy over iodoform. LSTR had limited indication for teeth with resorbed roots and requires close monitoring.

A Systematic Review and Meta-Analysis of Nonvital Pulp Therapy for Primary Teeth

Purpose: The purpose of this systematic review and meta-analysis was to assess success rates for nonvital treatment in primary teeth for caries/trauma. Methods: Databases were searched between 1960 and 2020 for randomized controlled trials, cohorts, case series, and in vitro studies. The primary outcome was overall success (clinical and radiographic) for pulpectomy and lesion sterilization tissue repair (LSTR). Included articles were independently determined, agreed upon, data extraction assessed, risk of bias, meta-analyses, and assignment of quality of evidence (GRADE). Results: Comparing teeth with and without root resorption, pulpectomy success was better (P<0.001) in teeth without preoperative root resorption. Success with pulpectomies performed with zinc oxide eugenol [ZOE] and with Endoflas (ZOE plus iodoform plus calcium hydroxide) did not differ from that observed using Vitapex or Metapex (iodoform plus calcium hydroxide; P≥0.50) after 18 months; however, Endoflas and ZOE success rates remained near 90 percent versus 71 percent or less for iodoform. Network analysis ratings showed Endoflas and ZOE performed better than iodoform alone. Also, LSTR performed better (P<0.001) than pulpectomies in teeth with preoperative root resorption, but pulpectomy results were superior (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual instrumentation. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Conclusions: Eighteen-month success rates support Endloflas and zinc oxide eugenol pulpectomies over iodoform pulpectomies. Lesion sterilization tissue repair had limited indication for teeth with resorbed roots.

Effectiveness of in vitro primary coronal caries prevention with silver diamine fluoride - Chemical vs biofilm models

OBJECTIVES

The main goal of this study was to investigate the effectiveness of SDF and its individual components, silver (Ag⁺) and fluoride (F^-) ions, in preventing enamel demineralization using biofilm and chemical models.

METHODES

Polished human enamel specimens were assigned to five treatment groups (n = 18 per group): SDF (38 %); SDF followed by application of a saturated solution of potassium iodide (SDF + KI); silver nitrate (AgNO₃; silver control, 253,900 ppm Ag⁺); potassium fluoride (KF; fluoride control, 44,800 ppm F); deionized water (DIW). Treatments were applied once to sound enamel. In the biofilm model, specimens were demineralized by aerobic overnight incubation using cariogenic bacteria isolated from human saliva in brain heart infusion supplemented with 0.2 % sucrose for three days. In the chemical model, enamel specimens were immersed in a demineralizing solution containing 0.1 M lactic acid, 4.1 mM CaCl₂, 8.0 mM KH₂PO₄, 0.2 % Carbopol 907, pH adjusted to 5.0 for five days. Vickers surface microhardness was used to determine the extent of enamel demineralization. Data were analyzed using one-way ANOVA.

RESULTS

In the chemical model, there was no statistically significant difference between SDF and SDF + KI in preventing coronal caries (p < 0.0001). In the biofilm model, SDF + KI was significantly less effective in preventing demineralization than SDF (p < 0.0001). In both models, SDF and SDF + KI were superior in their ability to prevent caries lesion formation than AgNO₃ and DIW.

CONCLUSION

KI application after SDF treatment appears to impair SDF's ability to prevent biofilm-mediated but not chemically induced demineralization.

CLINICAL SIGNIFICANCE

SDF may be a viable option in preventing primary coronal caries.

Quality Appraisal of Child Oral Health-Related Quality of Life Measures: A Scoping Review

BACKGROUND

Children's oral health-related quality of life (COHQoL) measures are well known and widely used. However, rigorous systematic reviews of these measures and analyses of their quality are in absence.

OBJECTIVES

To systematically review and quantitatively assess the quality of COHQoL measures through a scoping review.

DATA SOURCES

Systematic literature search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (Excerpta Medica database), HaPI (Health and Psychosocial Instruments), and DOSS (Dentistry and Oral Sciences Source).

STUDY ELIGIBILITY

The measure's focus was COHQoL; the child age ranged from 5 to 14 years; the publication was either a research article or a systematic review and related to caries; and it was written in English or had an English abstract. Two authors independently selected the studies. Disagreements were reconciled by group discussions with a third author.

APPRAISAL

The International Society for Quality of Life Research minimum standards for patient-reported outcome measures were used for quality appraisal.

SYNTHESIS

Descriptive analysis.

RESULTS

We identified 18 measures. Their quality scores ranged from 9.5 to 15.0 on a scale of 16. The quality appeared to bear no relationship to the citation and use of these measures. However, elements of these measures might be more useful than others, depending on the age-specific use and primary quality concerns.

LIMITATIONS

Some of the information on the minimum standards of the 18 measures cannot be found in the existing literature. Measures published without English abstract were not searched.

CONCLUSIONS

The quality of these measures is suboptimal. Researchers and practitioners in this field should exercise caution when choosing and using these measures. Efforts at improving the quality of the COHQoL measures, such as refining existing ones or developing new measures, are warranted.

KNOWLEDGE TRANSFER STATEMENT

Researchers, clinician scientists, and clinicians can use the results of this study when deciding which oral health-related quality of life measure they wish to use in children.

Silver and fluoride content and short-term stability of 38% silver diamine fluoride

BACKGROUND

As silver diamine fluoride (SDF) gains popularity for caries arrest, the authors aimed to investigate the content of fluoride and silver in 38% SDF produced for the US market and its short-term stability.

METHODS

Five samples of 38% SDF were evaluated when the bottle was first opened, and at 7 and 28 days. Fluoride concentrations were determined with a fluoride ion-selective electrode, and silver concentrations were determined with a simultaneous inductively coupled plasma mass spectrometer. pH was measured with a pH probe. Weight and volume of individual drops were measured.

RESULTS

At day 0, 40% of individual measured values were above the expected fluoride concentration, and at day 28, 93% were above the expected fluoride concentration (P = .005). At day 0, 19% of individual measured values were below the lowest expected silver concentration, and at day 28, 93% were below (P < .001). Acidity (pH 10) was consistent over the 3 periods. Mean (standard deviation) weight of a drop was 40 (4.0) milligrams, and mean (standard deviation) volume was 32.55 (1.89) microliters, 30% more than the reported value of 25 μL.

CONCLUSION

Over 28 days, the product pH is stable, whereas the fluoride content tends to increase and the silver content tends to decrease. Drops were larger than expected when dispensed from the bottle.

PRACTICAL IMPLICATIONS

Drops are larger than expected, so each delivers higher than expected quantities of silver and fluoride. Clinicians should exercise caution when using this product on young children, replace the cap immediately, and use as soon as dispensed.

Evidence-Based Dentistry Update on Silver Diamine Fluoride

This article reviews current evidence on the effectiveness of silver diamine fluoride (SDF) as a caries arresting and preventive agent. It provides clinical recommendations around SDF's appropriate use as part of a comprehensive caries management program. Systematic reviews confirm that SDF is effective for caries arrest on cavitated lesions in primary teeth and root caries in the elderly. It may also prevent new lesions. Application is easy, noninvasive, affordable, and safe. Although it stains the lesions dark as it arrests them, it provides clinicians with an additional tool for caries management when esthetics are not a primary concern.

Silver Diamine Fluoride is Effective in Arresting Caries Lesions in Primary Teeth

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Silver diamine fluoride has efficacy in controlling caries progression in primary teeth: A systematic review and meta-analysis. Chibinski AC, Wambier LM, Feltrin J, Dourado Loguercio A, Stadler Wambier D, Reis A. Caries Res 2017;51:527-41.

SOURCE OF FUNDING

This study was partially supported by the National Council for Scientific and Technological Development of Brazil under grants 304105/2013-9 and 305588/2014-1 TYPE OF STUDY/DESIGN: Systematic review with meta-analysis.

Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs

BACKGROUND

This manuscript presents evidence-based guidance on the use of 38 percent silver diamine fluoride (SDF) for dental caries management in children and adolescents, including those with special health care needs. A guideline workgroup formed by the American Academy of Pediatric Dentistry developed guidance and an evidence-based recommendation regarding the application of 38 percent SDF to arrest cavitated caries lesions in primary teeth.

TYPES OF STUDIES REVIEWED

The basis of the guideline's recommendation is evidence from an existing systematic review "Clinical trials of silver diamine fluoride in arresting caries among children: A systematic review." (JDR Clin Transl Res 2016;1[3]:201-10). A systematic search was conducted in PubMed®/MEDLINE, Embase®, Cochrane Central Register of Controlled Trials, and gray literature databases to identify randomized controlled trials and systematic reviews reporting on the effect of silver diamine fluoride and address peripheral issues such as adverse effects and cost. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of the evidence and the evidence-to-decision framework was employed to formulate a recommendation.

RESULTS

The panel made a conditional recommendation regarding the use of 38 percent SDF for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program. After taking into consideration the low cost of the treatment and the disease burden of caries, panel members were confident that the benefits of SDF application in the target populations outweigh its possible undesirable effects. Per GRADE, this is a conditional recommendation based on low-quality evidence. Conclusions and practical implications: The guideline intends to inform the clinical practices involving the application of 38 percent SDF to enhance dental caries management outcomes in children and adolescents, including those with special health care needs. These recommended practices are based upon the best available evidence to-date. A 38 percent SDF protocol is included in Appendix II.

Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions

PURPOSE

This manuscript presents evidence-based guidance on the use of vital pulp therapies for treatment of deep caries lesions in children. A guideline panel convened by the American Academy of Pediatric Dentistry formulated evidence-based recommendations on three vital pulp therapies: indirect pulp treatment (IPT; also known as indirect pulp cap), direct pulp cap (DPC), and pulpotomy.

METHODS

The basis of the guideline's recommendations was evidence from "Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-Analysis." (Pediatr Dent 2017;15;39[1]:16-23.) A systematic search was conducted in PubMed®/MEDLINE, Embase®, Cochrane Central Register of Controlled Trials, and trial databases to identify randomized controlled trials and systematic reviews addressing peripheral issues of vital pulp therapies such as patient preferences of treatment and impact of cost. Quality of the evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation approach; the evidence-to-decision framework was used to formulate a recommendation.

RESULTS

The panel was unable to make a recommendation on superiority of any particular type of vital pulp therapy owing to lack of studies directly comparing these interventions. The panel recommends use of mineral trioxide aggregate (MTA) and formocresol in pulpotomy treatments; these are recommendations based on moderate-quality evidence at 24 months. The panel made weak recommendations regarding choice of medicament in both IPT (moderate-quality evidence [24 months], low quality evidence [48 months]) and DPC (very-low quality evidence [24 months]). Success of both treatments was independent of type of medicament used. The panel also recommends use of ferric sulfate (low-quality evidence), lasers (low-quality evidence), sodium hypochlorite (very low-quality evidence), and tricalcium silicate (very low-quality evidence) in pulpotomies; these are weak recommendations based on low-quality evidence. The panel recommended against the use of calcium hydroxide as pulpotomy medicament in primary teeth with deep caries lesions. Conclusions and practical implications: The guideline intends to inform the clinical practices with evidence-based recommendations on vital pulp therapies in primary teeth with deep caries lesions. These recommendations are based upon the best available evidence to-date.

Parental perceptions and acceptance of silver diamine fluoride staining

BACKGROUND

The caries arrest that can be achieved by using silver diamine fluoride (SDF) offers a minimally invasive and inexpensive alternative to traditional restorative caries treatment. The authors evaluated how the dentinal staining that is associated with SDF influences the acceptance of this treatment among parents of young children in the New York City metropolitan area.

METHODS

The authors invited the parents of children who had experienced dental caries and who had appointments at the New York University Pediatric Dentistry Clinic and at several private clinics in New Jersey to participate in a Web-based survey designed to assess parents' demographics, perceptions of photographs of SDF-treated carious teeth, and acceptability of treatment in different behavior management scenarios.

RESULTS

Ninety-eight mothers and 22 fathers from diverse backgrounds participated. Most parents (67.5%) judged SDF staining on the posterior teeth to be esthetically tolerable, but only 29.7% of parents made this same judgment about anterior teeth (P < .001). In the absence of their child having behavioral barriers to conventional restorations, 53.6% of parents reported that they were likely to choose SDF to treat their child's posterior teeth, but only 26.9% of parents were likely to choose SDF to treat their child's anterior teeth. As the number of children's behavioral barriers increased, so did the parents' level of acceptance. In extreme cases, in which parents had to decide whether their children should undergo general anesthesia during treatment, parents' acceptance rate of SDF as a treatment method increased to 68.5% on posterior teeth and to 60.3% on anterior teeth. Parents' acceptance of the treatment also varied according to their socioeconomic status.

CONCLUSIONS

Staining on posterior teeth was more acceptable than staining on anterior teeth. Although staining on anterior teeth was undesirable, most parents preferred this option to advanced behavioral techniques such as sedation or general anesthesia.

PRACTICAL IMPLICATIONS

Clinicians need to understand parental sensitivities regarding the staining effect of SDF to plan adequately for the use of SDF as a method of caries management in pediatric patients.

Silver Diamine Fluoride Treatment Considerations in Children's Caries Management

By arresting and preventing caries, silver diamine fluoride (SDF) offers an alternate care path for patients for whom traditional restorative treatment is not immediately available. Current data from controlled clinical trials encompassing more than 3,900 children indicate that biannual application of SDF reduces progression of current caries and risk of subsequent caries. The purpose of this paper was to highlight the best evidence from systematic reviews and clinical trials for clinicians to consider the benefits, risks, and limitations as they implement silver diamine fluoride therapy on young children.

Silver Diamine Fluoride in Pediatric Dentistry Training Programs: Survey of Graduate Program Directors

PURPOSE

The purpose of this study was to investigate practice, teaching, and perceived barriers to the use of silver diamine fluoride and other caries control agents in U.S. pediatric dentistry residency programs.

METHODS

A 14-question survey regarding use and teaching of caries control agents was sent via email to residency program directors in 2015. Survey participants responded, using a web-based survey tool, by completing a paper and pencil survey instrument, or by interview.

RESULTS

Surveys were completed by 74 directors or associate directors (87 percent adjusted response rate). More than a quarter (25.7 percent) reported use of silver diamine fluoride, with 68.9 percent expecting to increase use. The use of silver diamine fluoride was not associated with region or program type. Programs reported commonly used caries control agents of fluoride varnish (100 percent), acidulated phosphate fluoride foam (48.6 percent), silver nitrate (9.5 percent), and povidone iodine (1.3 percent). Most felt silver diamine fluoride should be used only with high-risk patients (89.2 percent), and the majority agreed it could be used in primary and permanent teeth. The most frequently reported barrier to use of silver diamine fluoride was parental acceptance (91.8 percent).

CONCLUSIONS

Silver diamine fluoride is being rapidly adopted in graduate pediatric dentistry training programs, with the majority expecting to incorporate it into their teaching clinics and curricula.

Caries risk assessment, prevention, and management in pediatric dental care

The recent increase in the prevalence of dental caries among young children has highlighted the need for a new approach to prevent caries in children at a younger age. New disease prevention management models call for children to have their first visit to the dentist at age 1 or when their first tooth erupts. This article addresses early childhood caries risk assessment, prevention, and management strategies in young children using the concept of the "dental home" and a simple six-step protocol to conduct an effective and comprehensive infant oral care visit.

Pediatric dental care: prevention and management protocols based on caries risk assessment

Recent increases in caries prevalence in young children, especially among minorities and the economically disadvantaged, highlight the need for early establishment of dental homes and simple, effective infant oral care preventive programs for all children as part of a medical disease prevention management model. This article presents an updated approach and practical tools for pediatric dental caries management by risk assessment in an effort to stimulate greater adoption of infant oral care programs among clinicians and early establishment of dental homes for young children. [corrected]