An in vitro assessment of the residual dentin after using three minimally invasive caries removal techniques

To evaluate the efficiency and effectiveness of three minimally invasive (MI) techniques in removing deep dentin carious lesions. Forty extracted carious molars were treated by conventional rotary excavation (control), chemomechanical caries removal agent (Brix 3000), ultrasonic abrasion (WOODPECKER, GUILIN, China); and Er, Cr: YSGG laser ablation (BIOLASE San Clemente, CA, USA). The assessments include; the excavation time, DIAGNOdent pen, Raman spectroscopy, Vickers microhardness, and scanning electron microscope combined with energy dispersive X-ray spectroscopy (SEM-EDX). The rotary method recorded the shortest excavation time (p < 0.001), Brix 3000 gel was the slowest. DIAGNOdent pen values ranged between 14 and 18 in the remaining dentin and laser-ablated surfaces recorded the lowest reading (p < 0.001). The Ca:P ratios of the remaining dentin were close to sound dentin after all excavation methods; however, it was higher in the ultrasonic technique (p < 0.05). The bur-excavated dentin showed higher phosphate and lower matrix contents with higher tissue hardness that was comparable to sound dentin indicating the non-selectiveness of this technique in removing the potentially repairable dentin tissue. In contrast, the MI techniques exhibited lower phosphate and higher organic contents associated with lower microhardness in the deeper dentin layers. This was associated with smooth residual dentin without smearing and patent dentinal tubules. This study supports the efficiency of using MI methods in caries removal as conservative alternatives to rotary excavation, providing a promising strategy for the clinical dental practice.

Comparing the effectiveness of caries arrest by micro-operative treatment to operative treatment: A 2-year randomized controlled clinical trial

OBJECTIVES

To compare the effectiveness of caries arrest by micro-operative treatment (sealing) to operative treatment (flowable resin composite restoration) through a 2-year randomized controlled clinical trial.

MATERIALS AND METHODS

A prospective randomized controlled trial was conducted among 7-9-year-old children. At baseline, 630 subjects were screened and 92 children who had at least one carious lesion classified as ICDAS 3 on the pit and fissure of first permanent molar were included. Then they were randomly assigned to the sealant group (73 lesions) and the flowable resin composite group (76 lesions) to receive the corresponding intervention. Lesions status in each group was evaluated every 6 months up to 24 months. Clinical progression of dental caries and materials retention were the outcomes used for group comparisons at p-value < 0.05.

RESULTS

After 24 months, three lesions (4.1%) in the sealant group clinically progressed to dentin caries. No lesion in the flowable composite group was observed a progression. The results of Life-table survival analysis show that the cumulative caries arrest rate had no statistically significant difference between the two groups (p = 0.075). However, the cumulative retention rate was 57.5% in the sealant group and 92.1% in the flowable composite group, with significant differences (p < 0.001). The multilevel mixed model showed the sealant had higher risk of retention failure than the flowable composite (OR = 8.66, p < 0.001), while tooth position did not influence material retention (p = 0.083). In addition, the results of Fisher Exact test show that dentin lesions had more retention failure than enamel lesions in the sealant group (p = 0.026).

CONCLUSION

Although sealing microcavitated carious lesions of the first permanent molar achieved lower retention rate than resin composite restoration, both sealing and restoration effectively arrested caries progression for two years.

CLINICAL RELEVANCE

To preserving dental structure and delaying or eliminating the need for operative procedures, microcavitated carious lesion can be arrested by sealing.

TRIAL REGISTRATION

Registered at http://www.chictr.org.cn ; Feb 15th, 2020; No. ChiCTR2000029862.

3-year randomized clinical trial to evaluate the performance of posterior composite restorations lined with ion-releasing materials

To evaluate the impact of using ion-releasing liners on the 3-year clinical performance of posterior resin composite restorations after selective caries excavation with polymer burs. 20 patients were enrolled in this trial. Each patient had two deep carious lesions, one on each side of the mouth. After selective caries removal using polymer bur (PolyBur P1, Komet, Brasseler GmbH Co. KG, Lemgo, Germany), cavities were lined with bioactive ionic resin composite (Activa Bioactive Base/Liner, Pulpdent, Watertown, MA, USA) or resin-modified glass ionomer liner (Riva Light Cure, SDI, Bayswater, Victoria, Australia). All cavities were then restored with nanofilled resin composite (Filtek Z350XT, 3M Oral Care, St. Paul, MN, USA). All the tested materials were placed according to the manufacturers' instructions. Clinical evaluation was accomplished using World Dental Federation (FDI) criteria at baseline and after 6 months, 1, 2, and 3 years. Data were analyzed using Mann-whitney U and Friedman tests (p < 0.05). The success rates were 100% for all resin composite restorations either lined with ion-releasing resin composite or resin-modified glass ionomer liner. Mann-whitney U test revealed that there were no statistically significant differences between both ion-releasing lining material groups for all criteria during the follow-up periods (p > 0.05). Resin composite restorations showed acceptable clinical performance over 3 years either lined with bioactive ionic or resin-modified glass ionomer liners after selective caries excavation preserving pulp vitality. After the 3-year follow-up period, Activa Bioactive and Riva Light Cure liners were clinically effective and they exhibited with the overlying composite restorations successful clinical performance.Trial registration number: NCT05470959. Date of registration: 22/7/2022. Retrospectively registered.

Carious typodont teeth's effectiveness in pre-doctoral SIM lab to reinforce operative learning

INTRODUCTION

The concept of ideal preparations in dental schools are highly emphasized during the first two years of students' learning. However, students do not have as much opportunity to practice skills that would prepare them for real-life stituations such as non-ideal preparations and caries removal.

OBJECTIVE

This study aimed to determine the benefits of utilizing carious typodont teeth in the Operative curriculum for first- and second-year UCSF dental students METHODS: This study was completed by hosting a workshop in which the students performed a Class II preparation on #19 carious typodont tooth. The students filled out pre- and post-surveys with questions about their confidence with performing a preparation and their opinions on the current curriculum.

RESULTS

The pre-survey responses showed that the majority of the first- and second-year students did not believe that the traditional non-carious typodont teeth were a good representation of prepping on real, carious teeth. The pre-survey responses also showed that most of the first- and second-year students thought that the addition of carious typodont teeth would improve their learning experience. The post-survey results displayed that the majority of the students thought that prepping carious typodont teeth helped to better reinforce concepts such as preparation design, taught them the difference between ideal and non-ideal preparations, and allowed them to better understand tooth anatomy with the addition of the dentin layer.

CONCLUSION

The use of the carious typodont teeth in pre-clinical operative lab was found to be beneficial to first- and second-year UCSF student's learning based on the pre- and post-survey results.

Effects of silane coupling treatment on the clinical performance of direct repaired resin-based composite (RBC) restorations with or without prior surface sandblasting: A randomized controlled trial

OBJECTIVE

To evaluate the effects, of using silane coupling agent within the procedures of repairing old composite restorations with or without sandblasting their surfaces, on the clinical performance of repaired composite restorations.

METHODS

The study involved repairing 130 Class I and II defective composite restorations. After recurrent caries removal, the repair process included etching with 37 % phosphoric acid, Adper Single Bond 2 application for bonding and Filtek Z250 composite for restoring all defects. The restoration surfaces were subjected to one of the following additional surface treatments within the repair process: Control: No additional treatment; the Silane-Adhesive treatment: A separate step involved the application of a silane coupling agent after acid etching; and the Sandblast-Silane-Adhesive treatment: included intra-oral sandblasting of old composite surfaces followed by silane application. Two calibrated examiners evaluated all repaired restorations according to a modified USPHS criteria after 6 months. Comparisons of the clinical performance between the treatment groups were made using Chi-square test, while responses to cold tests before and after repair treatment were made using Wilcoxon's Signed Rank's (α = 0.05).

RESULTS

Of 130 cases, only 116 cases turned up for evaluation. The primary reasons for composite repair were recurrent caries and anatomical deficiencies. No statistically significant differences were found between the groups for all clinical criteria (p > 0.05). The control group experienced one total and two partial retention losses.

CONCLUSIONS

The application of a silane coupling agent, with or without intra-oral sandblasting, demonstrated no improvement on the clinical performance of repaired posterior composites after 6-months.

CLINICAL SIGNIFICANCE

Surface treatment of defective composite restorations using silane with intra-oral sandblasting within their repair process offered marginal improvement in their clinical performance over conventional etching technique, but insignificantly so. Repair reduced exaggerated cold test responses and eliminated POS within 6-months. Repair reduces cold sensitivity and promotes restoration longevity. This clinical trial was registered at ClinicalTrials.gov with the registration number NCT06005571.

One-year outcome of selective caries removal versus pulpotomy treatment of deep caries: A pilot randomized controlled trial

AIM

This study aimed to compare the outcome of SCR and Pulpotomy in teeth with deep caries extending at least 75% into dentine.

METHODOLOGY

This two-armed, parallel-group, randomized, superiority trial included vital mature permanent teeth with deep primary or secondary caries diagnosed radiographically as being at least 75% into the thickness of dentine, without clinical signs of symptomatic irreversible pulpitis or radiographic evidence of a periapical lesion. Carious teeth were blindly allocated to receive either SCR or Pulpotomy using computer-generated randomized patient codes concealed in opaque envelopes. All teeth were reviewed clinically and radiographically at 6 months and 1 year post-treatment. Using a significance level of p < .05, the log rank test and Cox proportional hazards regression were used to compare the outcome of SCR and Pulpotomy and to identify potential prognostic factors, respectively.

RESULTS

In all, 58 teeth in the SCR group and 55 teeth in the pulpotomy group completed treatment, after excluding 6 teeth because they did not complete the allocated treatment and another due to severe periodontal disease. At one year, 57/58 (98.3%) teeth from the SCR group and 48/55 (87.3%) teeth from the Pulpotomy group were available for analysis. One tooth in the Pulpotomy group (2.1%) and eight teeth in the SCR group (14.0%) required the further intervention of root canal treatment (p < .05). There were no other significant prognostic factors for survival. Overall, 91.4% of teeth treated with either SCR or Pulpotomy survived without requiring further intervention over a period of one year. No other adverse events occurred over the review period.

CONCLUSION

Within the limitations of this study, Pulpotomy fares better than SCR in preserving the remaining pulp and periapical health. As a treatment modality, Pulpotomy carries greater cost outlay to patient and takes a longer time to complete treatment than SCR. Long-term follow-up is needed to study the pulpal and restorative outcomes of Pulpotomy and SCR.

Subjective versus objective, polymer bur-based selective carious tissue removal: 2-year randomized clinical trial

OBJECTIVES

We aimed to compare subjective (S) selective carious tissue removal using hand instruments versus objective (O) removal using a self-limiting polymer bur in a single-blind cluster-randomized controlled superiority trial.

METHODS

115 children (aged 7-8 years) with ≥1 vital primary molar with a deep dentin lesion (>1/2 dentin depth) were included and randomized (60 S/55 O); all eligible molars in a child were treated identically (91 S/86 O). Cavities were prepared and carious tissue on pulpal walls selectively removed using hand instruments (S) or a self-limiting polymer bur (Polybur P1, Komet), followed by restoration using a glass hybrid material (Equia Forte, GC). Treatment time and satisfaction data have been reported in a 1-year-interim report. We here report on 2 year survival (tooth retained with or without further retreatments being needed, or tooth exfoliated), analyzed using multi-level Cox-regression analysis, as well as success (ART criteria 0/1, no pulpal complications, no re-intervention needed, or tooth extraction).

RESULTS

71 restorations in S and 65 in O were examined after a mean (SD, range) of 22 (11; 3-31) months, of which 50 S and 48 O restorations were successful and 70 S and 65 O survived. The majority of failures were restorative, not pulpal, and distribution of ART codes was not significant different between groups. Risk of failure was not significantly associated with the removal protocol (HR; 95 % CI: 0.95; 0.51-1.78), and also not age, sex or dental arch, while single surfaced restorations showed significantly lower hazard (0.14; 0.06-0.37).

CONCLUSION

There was no significant difference in success or survival between objective and subjective carious tissue removal.

CLINICAL SIGNIFICANCE

In primary teeth, subjective selective excavation had no disadvantage compared with objective excavation, which required a separate instrument (polymer-based bur) for carious tissue removal. Polymer-based burs may be particularly useful when standardized excavation is needed.

Should compromised first permanent molar teeth in children be routinely removed? A health economics analysis

OBJECTIVE

To evaluate the cost-effectiveness of retaining one or more compromised first permanent molars (cFPMs) affected by dental caries or enamel hypomineralization, compared to timely extraction, in children aged 8 years.

METHODS

A Markov model was developed to simulate the lifetime of a cFPM. Two management strategies were compared: extraction facilitating spontaneous space closure or maintenance of teeth with restorations. Ten health states were utilized to capture long-term outcomes including various tooth restorations, prostheses or a retained gap at the cFPM site. Outcomes were expressed as Quality Adjusted Tooth-Years (QATYs). The model was informed by survey data on patient preferences for treatment outcomes and UK data on costs. Discounted costs and QATYs were calculated over 62 years.

RESULTS

Regardless of the number of cFPMs, retaining cFPMs was more effective than early removal, generating an additional 2.3 QATYs per cFPM. Early removal of one or two cFPM under general anaesthetic (GA) was more expensive than retention and hence never cost-effective. Retaining a cFPM was more expensive than early removal under local anaesthesia or where four cFPMs were extracted under GA. In these cases, retaining cFPMs was cost-effective if a QATY was valued at £100 or £35, respectively. Results were robust to sensitivity analysis.

CONCLUSION

Preserving a cFPM was more cost-effective than the early loss of one, or two cFPMs under GA. Preservation of four cFPMs was cost-effective if sufficient value was placed on a QATY. These findings can guide clinical practice on management of cFPMs alongside patient/payer values on maintaining teeth.

Assessing the Acceptability of Less Invasive Caries Removal Techniques for treating Deep Carious Lesions: A Conjoint Survey among Dentists Practicing in a Midwestern American State

This study identified factors that influence dentists' decisions regarding less invasive caries removal techniques such as stepwise removal (SW) and selective removal (SE) using a marketing research technique, conjoint analysis. A survey was sent to 1,434 dentists practicing in Iowa. Dentists were randomly assigned to receive a questionnaire to rate the likelihood they would use either SW/SE in hypothetical clinical scenarios. The scenarios were carefully created by conjoint design and included three relevant attributes: depth of lesion, hardness of carious dentin, and patient age. Descriptive and conjoint analyses were performed to assess trade-offs between these attributes, using SPSS. The study revealed that depth of lesion was the most important factor in the dentists' decisions (49 importance value) when choosing a SW to treat a deep carious lesion, followed by hardness of carious dentin and patient age (21 importance value). For the SE group, depth of the lesion was also the predominant factor when selecting a treatment. The study also identified that a high proportion of dentists (24.9%) indicated they would never consider using SW or SE under any circumstances. Our survey showed that depth of lesion was the most important reason to select a less invasive caries removal method. The high proportion of dentists indicating they would never consider selective caries removal (SE) techniques suggests that these less invasive options are underutilized.

Outcome of Partial Pulpotomy in Immature Permanent Teeth with Symptomatic Irreversible Pulpitis: A Prospective Case Series Assessment

INTRODUCTION

The aim of this prospective case series was to assess the clinical and radiographic outcome of partial pulpotomy in caries-exposed symptomatic, vital, immature, permanent molars.

METHODS

Thirty-four immature molars with deep caries and symptoms of irreversible pulpitis were treated by partial pulpotomy and ProRoot MTA as a capping material. After complete caries removal, the inflamed part of the pulp was removed. Complete hemostasis was achieved using a sterile cotton pellet moist initially with sodium hypochlorite 1.5% and then with sterile saline. ProRoot MTA (Dentsply Sirona, Charlotte, NC) was placed as a capping material onto the remaining pulp tissue. The cavity was sealed using a light-curing resin-modified Ca(OH)2 cavity liner, and patients were referred to a pediatric dentist for permanent restoration. Descriptive statistics and cross tabulations were performed including variables examined before, during, and after the procedure.

RESULTS

All examined teeth presented a favorable clinical and radiographic outcome with normal periapical tissues, complete apical closure, and formation of a dentinal bridge beneath the capping material. Signs of partial pulp chamber calcification were only detected in 2 cases. Postoperatively, most patients did not report any pain (23/34, 67.7%), whereas the rest reported minor intensity pain (11/34, 32.3) and the use of analgesic or anti-inflammatory drugs only for 1 day (10/34, 29.4%).

CONCLUSIONS

Partial pulpotomy seems to provide a universally successful outcome when managing symptomatic vital immature teeth with no signs of complications and completion of apical closure. It could be a viable treatment of choice in cases of caries-exposed vital immature teeth with symptoms of irreversible pulpitis.

Impact of Medical and Surgical Obesity Treatment on Dental Caries: A 2-Year Prospective Cohort Study

The objective was to study the long-term effects on oral health of bariatric surgery compared with medical treatment of obesity. Swedish females with morbid obesity (n = 66; 18-35 years at baseline) were followed prospectively from before obesity treatment until 2 years after treatment. The main response variable was dental caries registered according to the ICDAS-II system. Possible confounding factors, such as sociodemographic characteristics, general health, oral health habits, and oral hygiene, were controlled for. The statistical methods included χ2 tests, Student's t tests, one-way ANOVA, Wilcoxon's nonparametric tests, and linear regression models. In the surgically treated patients (n = 40), a significant increase over time in enamel caries (mean increase 4.13 tooth surfaces ICDAS1-2), dentine caries (mean increase 2.18 tooth surfaces ICDAS3-6), and total caries (mean increase 6.30 tooth surfaces ICDAS1-6) was registered (all p < 0.001), which was not seen in the medically treated patients (n = 26). However, the difference between the treatment groups (surgical or medical) was only statistically significant for enamel caries (crude β 4.89, p = 0.003) and total caries (crude β 6.53, p < 0.001). The relationships were stable and independent of differences in confounders as socioeconomy, general health, and oral health behaviors. In conclusion, 2 years after obesity treatment, a significant increase in dental caries was registered in the surgically treated but not in the medically treated women. The dental service should intensify its preventive efforts in individuals undergoing obesity treatment.

Level of difficulty of tooth extractions among roughly 100,000 procedures in primary care

OBJECTIVES

The study examined treatment codes of extracted teeth and aimed to assess degree of difficulty concerning all tooth extractions.

MATERIALS AND METHODS

Retrospective data on treatment codes of all tooth extractions during a two-year period were obtained from the patient register in primary oral healthcare of the City of Helsinki, Finland. Prevalence, indication, and method of extraction appeared in the treatment codes (EBA-codes). Degree of difficulty was determined from the method and classified as non-operative or operative and as routine or demanding. Statistics included frequencies, percentages, and χ2 test.

RESULTS

Total number of extraction procedures was 97,276, including 121,342 extracted teeth. The most frequent procedure was a routine extraction of a tooth with forceps (55%, n = 53,642). The main reason for extraction was caries (27%, n = 20,889). Of the extractions, 79% (n = 76,435) were non-operative, 13% (n = 12,819) operative, and 8% (n = 8,022) multiple extractions in one visit. Level of difficulty was distributed as routine non-operative (63%), demanding non-operative (15%), routine operative (12%), demanding operative (2%), and multiple extractions (8%).

CONCLUSIONS

Two-thirds of all tooth extractions in primary care were relatively simple. However, 29% of procedures were classified as demanding.

CLINICAL RELEVANCE

As earlier methods for assessing level of difficulty were aimed at third molars alone, an analysis was presented for all tooth extractions. This approach may be useful for research purposes, and the profile of tooth extractions and their difficulty level may be practical also for decision-makers in primary care.

Complications following dental treatment in a child with haemophilia A: lessons to be learnt

A boy in his middle childhood with severe haemophilia reported with facial swelling following dental treatment for a carious upper primary molar done at a private dental clinic elsewhere. On presentation, he had a large, tense and tender swelling of the left cheek and a haematoma on the buccal mucosa adjacent to the treated tooth. The child was found to have a low haemoglobin level. He was taken for an emergency procedure under general anaesthesia for dental extraction with incision and drainage, and simultaneously underwent packed cells and factor replacement. He recovered in the ward postoperatively with no complications and with a gradual reduction of the swelling. This report highlights the importance of caries prevention in children, especially those with haemophilia. They need to be educated about restricting cariogenic foods in their diet and maintaining good oral hygiene. Management of such patients should be carefully coordinated to minimise undesirable outcomes.

Survival Analysis and Risk Factors of Pulpectomy among Children with Severe Early Childhood Caries Treated under General Anesthesia: A Retrospective Study

OBJECTIVES

This study aims to retrospectively evaluate the survival rate of pulpectomy performed under dental general anesthesia (DGA) through long-term follow-up and to explore the risk factors associated with treatment failure.

METHODS

The medical records of the children who were diagnosed with S-ECC and received pulpectomy treatment under general anesthesia (GA) from 1 August 2014 to 1 December 2019, in the Stomatological Hospital of Xi'an Jiaotong University, were collected. Two dentistry postgraduates extracted the necessary information and filled in a predesigned excel form. Survival analysis was performed using the Kaplan-Meier method. The shared frailty model was used to explore possible factors affecting the success rate of pulpectomy in primary teeth.

RESULTS

A total of 381 children (mean age 3.49 ± 0.90) with S-ECC and 1220 teeth were included in the study, including 590 primary anterior teeth and 630 primary molars. The overall 35-month survival rate was 38.5%, which was 52.9% for anterior teeth and 31.1% for molars. The overall median survival time was 31 months, in which anterior teeth were 35 months and molars were 26 months. The older the children were, the greater the risk of treatment failure (HR 1.56, 95% CI 1.09, 2.24). The risk of pulpectomy failure of primary molars was 1.9 times that of primary anterior teeth (95% CI 1.36, 2.65) and the teeth with abnormal radiological findings before treatment was 1.41 times higher than that of teeth without imaging abnormalities (95% CI 1.74, 3.36).

CONCLUSION

The survival rate of primary tooth pulpectomy is acceptable but decreased gradually with time. The failure rate of pulpectomy in primary molars is higher than that of primary anterior teeth. When the primary caries has extended to the pulp and resulted in a nonvital lesion, pulpectomy could be an option for maximum retention of the primary tooth.

Deep caries removal strategies: Findings from The National Dental Practice-Based Research Network

BACKGROUND

The International Caries Consensus Collaboration (ICCC) has published recommendations on carious tissue removal to treat cavitated carious lesions in a manner that preserves hard tissue and retains teeth long term. This study quantifies The National Dental Practice-Based Research Network dentists' use of selective caries removal.

METHODS

This cross-sectional questionnaire study assessed reported use of selective caries removal when treating deep caries in asymptomatic and symptomatic teeth in response to clinical case scenarios. Statistical methods included the proportion of respondents concordant with ICCC guidelines at various thresholds and logistic regression to model factors associated with concordance.

RESULTS

A total of 500 dentists responded. The study sample was 57% male, mean (SD) age was 50.9 (12.6) years, and 60% worked in private practice settings. Higher levels of concordance for choosing selective caries removal 50% or greater of the time were found for asymptomatic (62.4%; 95% CI, 57.6 to 67.2) than for symptomatic caries (49.3%; 95% CI, 44.4 to 54.2). These differences were significantly associated with type of practice setting.

CONCLUSIONS

The National Dental Practice-Based Research Network dentists reported using selective caries removal strategies when managing deep carious lesions more often than in previous US and Japanese practice-based research network studies and from results of a systematic review and meta-analysis. Nonetheless, substantive discordance with the ICCC guidelines was seen by the authors of this study.

PRACTICAL IMPLICATIONS

More dissemination and continuing education activities, as well as implementation studies, may further encourage use of selective caries removal to soft or firm dentin when indicated.

Improvement in Iron and Iron-Related Nutritional Status Following Pediatric Dental Surgery To Treat Severe Early Childhood Caries

Purpose: To investigate improvement in iron and iron-related nutritional status of children with severe-early childhood caries (S-ECC) following dental rehabilitation under general anesthesia (GA). Methods: Children with S-ECC were recruited into a prospective study investigating changes in nutritional status before and after surgery. Parents completed a questionnaire, as their child had a venipuncture while under GA. Children returned for follow-up at a minimum of three months postsurgery, and parents completed a follow-up questionnaire and their child had an additional venipuncture and dental examination. Statistical analyses included descriptive, bivariate, and multivariable regression analyses. Results: A total of 150 children participated (mean age 47.7±14.1 months). The mean baseline ferritin concentration was 27.9±19.1 μg/L, while mean iron and hemoglobin levels were 12.3±4.3 μmol/L and 107.5±9.2 g/L, respectively. Overall, 53 percent were anemic, 30 percent had iron deficiency (ID), and 20 percent had iron deficiency anemia (IDA) at baseline. In total, 106 participants returned for follow-up. Paired t-tests revealed significant improvements in ferritin (27.0±18.4 μg/L versus 34.3±18.2 μg/L, P<0.001) and hemoglobin (108.2±8.3 g/L versus 123.7±9.4 g/L, P<0.001) levels. There was a 16 percent reduction in children with ID (P<0.001) and a 20 percent reduction in children experiencing IDA (P=0.011) from baseline to follow-up. Multivariable regression revealed that follow-up ferritin levels were associated with baseline ferritin concentrations, red meat intake, and difficulty purchasing food because of cost. Conclusions: Improvements in iron and iron-related nutritional status were observed post GA. Dental surgery for S-ECC may contribute to improved children's eating practices and resolve oral inflammation, thus leading to better nutritional status.

Postoperative complications in Chinese children following dental general anesthesia: A cross-sectional study

Dental general anesthesia (DGA) is a safe and high-quality restorative and preventive treatment option for children with severe early childhood caries (S-ECC), who require extensive dental treatment and exhibit anxiety and emotional or cognitive immaturity or are medically compromised. However, several postoperative complications have been reported in children under DGA. This study aimed to evaluate and analyze the prevalence of the relevant factors of postoperative complications in healthy Chinese children following DGA to provide a foundation for pre-, intra-, and postoperative overall health management for healthy and disabled children after DGA.A total of 369 systematically healthy Chinese children (36-71 months old) undergoing a DGA were studied. Data were collected on patients' histories, characteristics, anesthesia, and dental procedures. Parents or caregivers were interviewed before and 72 hours after the procedure. Data were analyzed using logistic regression.Approximately 94.86% of the enrolled children reported one or more complications. The most prevalent complication was postoperative pain (62.70%), followed by weariness, agitation, masticatory problems, drowsiness, oral bleeding, coughing, fever, sore throat, nausea, constipation, epistaxis, vomiting, excitement, and diarrhea. The long duration of the operation was a risk factor for postoperative pain and weariness. A high nutritional status could be a protective factor for postoperative fever.Prolonged operation means complex treatment, such as pulp therapy or extraction. We speculate that the longer the duration is, the more difficult the dental procedures are. The accumulation of discomfort leads to pain. We suspect that children in lower nutritional levels are more likely to suffer from bacteremia or dehydration, resulting in fever.Postoperative pain was the most prevalent complication after the DGA. A decrease in dental procedure duration might reduce the odds of postoperative pain and weariness. A high nutritional status could be a protective factor for postoperative fever. Children with low nutritional status could be more susceptible to postoperative fever.

A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees

IMPORTANCE

Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children's parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown.

OBJECTIVE

To determine whether access to CWF is associated with the prevalence of DGA.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state's Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020.

EXPOSURES

Access to CWF was determined by estimating the proportion of a county's total population that had access to a fluoridated public water system.

MAIN OUTCOMES AND MEASURES

The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables.

RESULTS

A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county's population access to CWF was associated with lower caries-related visit prevalence (-0.45 percentage points; 95% CI, -0.59 to -0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (-0.39 percentage points; 95% CI, -0.67 to -0.12 percentage points; P = .006) but not in adjusted analysis (-0.23 percentage points; 95% CI, -0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county's access to CWF by 10% was not associated with the prevalence of asthma-related exacerbations (-0.02 percentage points; 95% CI, -0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (-0.0003 percentage points; 95% CI, -0.0014 to 0.0009 percentage points; P = .66).

CONCLUSIONS AND RELEVANCE

This study extends our understanding of CWF's benefits for children's oral health. Specifically, these findings suggest that increasing a population's access to CWF's is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

Systematic Review and Meta-Analysis of Randomized Clinical Trials on Chemomechanical Caries Removal

OBJECTIVES

The aim of this review was to assess the methodologies used in previously published prospective randomized clinical trials on chemomechanical caries removal and to conduct a meta-analysis to quantify the differences in the excavation time between chemomechanical and conventional caries removal methods.

METHODS

An electronic search was performed using Scopus, PubMed, EBSCO host, and Cochrane Library databases. The following categories were excluded during the assessment process: non-English studies published before 2000, animal studies, review articles, laboratory studies, case reports, and nonrandomized or retrospective clinical trials. The methodologies of the selected clinical trials were assessed. Furthermore, the reviewed clinical trials were subjected to meta-analysis for quantifying the differences in excavation time between the chemomechanical and the conventional caries removal techniques.

RESULTS

Only 19 randomized clinical trials fit the inclusion criteria of this systematic review. None of the 19 reviewed trials completely fulfilled Delphi's ideal criteria for quality assessment of randomized clinical trials. The meta-analysis results revealed that the shortest mean excavation time was recorded for rotary caries excavation (2.99±0.001 minutes), followed by the enzyme-based chemomechanical caries removal method (6.36±0.08 minutes) and the the hand excavation method (atraumatic restorative technique; 6.98±0.17 minutes). The longest caries excavation time was recorded for the sodium hypochlorite-based chemomechanical caries removal method (8.12±0.02 minutes).

CONCLUSIONS

It was found that none of the current reviewed trials fulfilled all the ideal requirements of clinical trials. Furthermore, the current scientific evidence shows that the sodium hypochlorite-based (Carisolv) chemomechanical caries removal method was more time consuming when compared to the enzyme-based (Papacarie) chemomechanical and the conventional caries removal methods. Further prospective randomized controlled clinical trials evaluating the long-term follow-up of papain-treated permanent teeth are needed.

Dental cavity liners for Class I and Class II resin-based composite restorations

BACKGROUND

Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure. This is an update of the Cochrane Review first published in 2016.

OBJECTIVES

The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 12 November 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10) in the Cochrane Library (searched 12 November 2018), MEDLINE Ovid (1946 to 12 November 2018), Embase Ovid (1980 to 12 November 2018) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 12 November 2018). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs.

DATA COLLECTION AND ANALYSIS

We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification.

MAIN RESULTS

Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at 1 year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at 2 years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

Efficacy of erbium-doped yttrium aluminium garnet for achieving pre-emptive dental laser analgesia in children: A study protocol for a randomized clinical trial

INTRODUCTION

A current non-pharmacological mean for attaining painless conservative treatment is presented by laser analgesia (LA), considered as bio-photomodulation of pulp reactivity aiming reduction of nociceptive impulse formation. Currently no consensus is reached regarding a detailed protocol with laser parameter settings for pre-emptive LA. The purpose of this study is determining the efficacy of erbium-doped yttrium aluminium garnet (Er:YAG) laser in achieving pulpal analgesia and quantifying duration and extent of any effects assessed.

METHODS AND ANALYSIS

The proposed study is a double-blind placebo-controlled randomized split-mouth clinical trial with 2-way repeated measures design. Eligible patients of age 10 to 12 years undergo 2 single-visit treatments, receiving LA or placebo analgesia (PA) prior to caries ablation, randomized via computer-generated, permuted-block sequence. Primary outcome measure is pain felt during treatment, reported by patient on visual-analogue scale.

SECONDARY OUTCOMES

changes in pulpal sensibility to electrical and cold-stimuli; patient experience during LA/PA; pain-related behavior according to Faces, Legs, Activity, Cry, Consolabilty (FLACC) scale; heart-rate dynamics. Data will be analyzed with intention-to-treat concept by Student t test for paired samples, P < .05. Pre-test on 20 subjects resulted in n = 41 patients needing to be recruited.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Committee for Scientific Research Ethics, Medical University - Plovdiv, Bulgaria (Reference number P-8604, Protocol of approval N:6/23.11.2017) and registered on a publically accessible database. This research received institutional funding from the Medical University - Plovdiv, Bulgaria under project SPD-03/2017. Findings will be reported in scientific publications and at research conferences, and in project summary papers for participants.

TRIAL REGISTRATION

ClinicalTrials.gov (Registration number: NCT03412721).

A Comparison of Periodontal Health in Primary Molars Restored with Prefabricated Stainless Steel and Zirconia Crowns

Purpose: The purpose of this study was to compare the periodontal health and clinical success of restoring primary molars with a prefabricated stainless steel crown (SSC) or zirconia crown (ZC). Methods: Six- to nine-year-olds with at least two decayed primary molars were included. Teeth were restored with SSCs and ZCs. Intact contralateral primary molars were evaluated as controls. A simplified oral hygiene index (OHI-S), plaque index (PI), gingival index (GI), and clinical success criteria for the crowns were evaluated during follow-up. Friedman and Wilcoxon tests were used for statistical analysis. Results: Fifty-two teeth were evaluated in 13 children for 12 months. The OHI-S levels were not different at the follow-ups. Teeth restored with ZCs showed lower GI and PI scores than those restored with SSCs, even among controls. All SSCs were retained after 12 months, while two of the ZCs decemented. Minor staining in one ZC and a fracture on the surface of another ZC were observed. Conclusions: The gingival health and plaque accumulation performance of zirconia crowns were better than those of stainless steel crowns and controls. SSCs are highly retentive and viable restorative option, although they were associated with a decline in gingival health.

An Agreed Terminology for Carious Tissue Removal

Understanding the carious process as a biofilm disease rather than an infectious disease has changed lesion management focus towards less invasive options. This has led to new and ongoing changes in recommendations for practitioners. However, the lack of clarity over what to do, and when, is complicated by different teaching, research, and policy documents containing different terms and definitions for carious lesions and management strategies. Lack of clear messages and communication over recommendations hampers moving evidence into practice. The International Caries Consensus Collaboration (ICCC) recommendations on terminology are one part of improving communication for discussing the diagnosis and management of dental caries and dental carious lesions. The term dental caries is the name of the disease, its use being limited to situations involving control of the disease using preventive and noninvasive measures at the patient level. Carious lesion management should be used where management is directly related to disease symptoms at the tooth level. As terminology cannot be used to directly relate the visual appearance of the carious lesion to the histopathology, the terms have been based around the clinical consequences of the disease: soft, leathery, firm and hard dentine. The 3 main carious tissue removal options are described as: (1) selective removal of carious tissue (to both soft and firm dentine), (2) stepwise removal, and (3) non-selective removal to hard dentine (previously known as complete removal and no longer recommended). Use of these terms across clinicians, researchers, dental educators, and even with patients, will help improve understanding and communication.

Removing Carious Tissue: Why and How?

Caries is no longer seen as an infectious disease, and the aim of treating carious lesions is to control their activity, not to remove the lesion itself. Such control can be implemented by sealing off the lesion from the environment, with sealed bacteria being deprived from carbohydrates and thus inactivated. For cavitated lesions, controlling them usually involves the placement of restorations to rebuild the cleansability of the surface. In this case, dental practitioners have traditionally removed carious tissues prior to the restoration. This has historically been for a number of reasons, while today the main reason for restoring a cavity is to maximise restoration longevity. In shallow lesions, dental practitioners should aim to remove as much carious tissue as possible (to allow adequate depth for the restorative material) without unnecessarily removing sound or remineralisable dentine. This means removal to hard dentine around the periphery, to firm dentine centrally for optimising restoration longevity and allowing a tight cavity seal. For deep lesions in teeth with vital pulps (without irreversible pulpitis), maintaining pulp vitality is critical. Dental practitioners should aim to avoid pulp exposure, leaving soft or leathery dentine in pulpoproximal areas. Peripherally, hard tissue is left, again to ensure a tight seal and sufficient mechanical support of the restoration. As an alternative to the selective removal to soft dentine, stepwise removal can be used. With this approach, the soft dentine is temporarily rather than permanently sealed in, and removed in a second step after 6-12 months. Strategies where carious tissue in cavitated lesions is not removed at all, but sealed or managed non-restoratively, are currently restricted to primary teeth.

Clinical Recommendations on Carious Tissue Removal in Cavitated Lesions

Non-cleansable carious lesions where sealing is no longer an option should be restored in the vast majority of cases. Prior to restoring the cavity, carious tissue removal is performed, mainly to increase the longevity of the restoration. Such removal, however, should not be conducted in a way that the vital pulp is harmed. This means that in teeth with shallow or moderately deep lesions, selective removal to firm dentine is recommended, while in deep lesions (radiographically extending into the pulpal third or quarter of the dentine) selective removal to soft dentine should be performed. In permanent teeth, stepwise removal is a possible alternative, while in primary teeth the Hall Technique can be considered too. To assess carious tissue removal, the hardness of the dentine should be the primary criterion. Moisture, colour, and additional parameters (like fluorescence of bacterial porphyrins, etc.) might be used, but should be critically evaluated towards their validity and patients' benefit. There is insufficient evidence to recommend a specific single carious tissue removal method. However, hand or chemomechanical excavation seem useful, as they reduce pain and discomfort during treatment. Current evidence also does not support any specific restoration material or (bonding) strategy for restoring cavities resulting from different carious tissue removal strategies. Prior to restoring the cavity, cavity disinfection is not recommended any longer.

Sealing Carious Tissue in Primary Teeth Using Crowns: The Hall Technique

In line with reducing the invasiveness of interventions in permanent teeth and changes towards more biological approaches, there have also been moves away from traditional restorative approaches to managing primary teeth where carious dentine/lesions were completely excised and a restoration placed. The Hall Technique is a method for managing carious primary molar teeth where a preformed stainless-steel crown, also known as a preformed metal crown, is seated over a tooth, sealing in, and not removing carious tissue. This chapter discusses the rationale behind the Hall Technique, an outline of the clinical procedure to carry it out, its indications and contraindications, together with the evidence supporting its use. The Hall Technique has been found to be acceptable to children and preferred to more invasive treatment options. Like all dental treatment options, it requires careful case selection, precise carious lesion and pulpal status diagnosis (clinically and radiographically), good patient management, and excellent parental cooperation. The Hall Technique has been shown to be a durable (being likely to last the lifespan of the primary molar) and economical management option for primary molars with carious lesions, which in addition offers the benefit of full coronal coverage, reducing the risk of future carious lesion development. As part of our everyday armamentarium in paediatric dentistry, the Hall Technique is an effective management option for controlling carious lesions in primary molars.

Selective Removal of Carious Tissue

Describing and quantifying how much carious tissue should be removed prior to placing a restoration has been a long-debated issue stretching back as far as G.V. Black's "complete caries removal," now known as non-selective carious tissue removal. Originating in the 1960s and 1970s, from the differentiation between different layers of carious dentine, an outer contaminated ("infected") layer and an inner demineralised ("affected") layer, the former of which needed to be removed during cavity preparation and the latter not, selective carious tissue removal was born. Currently, it is termed selective removal to firm dentine. This chapter describes different selective carious tissue removal techniques (to firm, to leathery, to soft dentine) and how they can be achieved appropriately with conventional and novel techniques. Selective removal to firm dentine is recommended for shallow or moderately deep lesions, while for deep lesions (extending close to the pulp) in teeth with vital pulps, selective removal to soft dentine is recommended to avoid pulpal exposure and to preserve the health of the pulp. Leaving soft carious dentine beneath a restoration does, however, raise certain issues regarding how we truly assess pulpal health, what would other dental practitioners think if the patient moved practice, and how do we monitor such sealed residual caries in the future. These issues will all be discussed in this chapter but should at present not preclude dental practitioners from adopting such a minimally invasive evidence-based approach to carious tissue removal.

Evaluation of the marginal integrity of a bioactive restorative material

This in vitro study evaluated the marginal microleakage of a bioactive restorative with other restorative materials in standard Class V preparations. Sixty previously extracted, noncarious human molars were randomly assigned to 3 experimental groups (n = 20): a bioactive composite resin, a universal hybrid composite resin, and a resin-modified glass ionomer restorative. Class V cavities were prepared on the facial or lingual surface of each tooth so that coronal margins were located in enamel and apical margins in cementum (dentin). After the cavity preparations were restored with the appropriate material, the specimens were artificially aged in water baths. The root apices were sealed with utility wax, the tooth surfaces were coated with nail varnish to within 1 mm of the restoration, and specimens were immersed in 1% methylene dye solution for 8 hours. The teeth were invested in clear polymer resin, sectioned longitudinally, and examined under a stereomicroscope to assess dye penetration. Nonparametric scores indicated that microleakage was significantly greater at the apical margins than the coronal margins for all groups (P > 0.0001). The specimens restored with the bioactive material exhibited greater microleakage at both the coronal and apical margins than did specimens restored with the composite resin or resin-modified glass ionomer material, although the differences were not statistically significant (P > 0.05). Based on the results of the present study, the type of restorative material did not appear to have a significant influence on microleakage. Rather, the marginal position (coronal versus apical) of the restoration was the determining factor in microleakage.

Evaluation of Interfacial Gap Volume of Two Low-shrinkage Composites Using Micro-Computed Tomography

OBJECTIVES

To investigate the efficacy of X-ray micro-computed tomography (μCT) in the detection and quantification of interfacial gap formation in standardized Class I and Class II resin composite restorations, to compare the interfacial gaps for two low-shrinkage resin composites with a methacrylate composite material, and to determine any correlation between the cavity configuration factor (C-factor) and the volume of gaps formed.

METHODS AND MATERIALS

Sixty standardized Class I and Class II cavities were prepared and divided into six groups. Three types of composites, with their recommended self-etching adhesive systems, were used: Filtek Z250 XT; Estelite Sigma Quick; and Filtek P90. Each of the composite materials was placed in 10 Class I and 10 Class II cavities. The specimens were digitized using Skyscan 1172 μCT. They were examined for gap volume measurements, the thickness of the adhesive layer, and location of interfacial gaps.

RESULTS

There was a significant difference in the mean gap volume percentages of the three materials. The gap volume percent of Estelite Sigma quick was significantly lower than that of Filtek P90. No significant difference in the mean gap volume percentages of Class I and Class II restorations was found, except for Estelite Sigma Quick, in which the Class I gap volume percentage was higher than that of the Class II restorations.

CONCLUSIONS

μCT is an efficacious tool for the measurement of volumetric gaps formed at the tooth/restoration interface and for the evaluation of the adhesive layer. The differences in the C-factor do not always have a pronounced effect on the gap volumes of low-shrinkage composites.

A Clinical Study on the Effect of Injection Sites on Efficacy of Anesthesia and Pulpal Blood Flow in Carious Teeth

This randomized clinical trial evaluated the efficiency of maxillary infiltration anesthesia in carious teeth at two different injection sites and their impact on the laser Doppler recordings of pulpal blood flow (PBF) during a caries excavation procedure. The null hypothesis tested was that there are no differences in the efficiency of anesthesia and PBF reduction between maxillary infiltrations at the two injection sites. One hundred twenty patients were divided into three groups according to the degree of carious lesion of their maxillary left central incisors (moderate caries, deep caries, or no caries). Forty patients in each group randomly received infiltrations over the root apex of maxillary left central incisors (site X) or over the midpoint of the line connecting the root apexes of both maxillary left central and lateral incisors (site Y) using 0.9 mL 2% lidocaine with 1:100,000 adrenaline. Teeth were pulp tested at five-minute intervals after injection except for the period of cavity cutting, which was done 12 minutes after injection. The PBF changes after injection were monitored by laser Doppler flowmetry. The observation period in this study was 60 minutes. Success of anesthesia was defined as no or mild pain on cavity cutting by visual analog scale recordings. Deep caries group showed significantly higher baseline PBF ( p<0.05). All groups showed 100% success of anesthesia and similar duration time ( p>0.05). Subgroups that had the injection at site Y showed significantly less reduction of PBF ( p<0.05). Cavity-cutting procedures increased the amplitude of the PBF around the lowest value after injection. Independent of the cavity depth, carious anterior teeth anesthetized by infiltration further from the apex had significantly less reduction on the pulpal blood flow compared with teeth anesthetized by infiltration at the apex.

Performance of Universal Adhesive in Primary Molars After Selective Removal of Carious Tissue: An 18-Month Randomized Clinical Trial

PURPOSE

To evaluate the 18-month clinical performance of a universal adhesive, applied under different adhesion strategies, after selective carious tissue removal in primary molars.

METHODS

Forty-four subjects (five to 10 years old) contributed with 90 primary molars presenting moderately deep dentin carious lesions on occlusal or occluso-proximal surfaces, which were randomly assigned following either self-etch or etch-and-rinse protocol of Scotchbond Universal Adhesive (3M ESPE). Resin composite was incrementally inserted for all restorations. Restorations were evaluated at one, six, 12, and 18 months using the modified United States Public Health Service criteria. Survival estimates for restorations' longevity were evaluated using the Kaplan-Meier method. Multivariate Cox regression analysis with shared frailty to assess the factors associated with failures (P<0.05).

RESULTS

Estimated survival rates of the restorations were 100 percent, 100 percent, 90.6 percent, and 81.4 percent at one, six, 12, and 18 months, respectively. The adhesion strategy did not influence the restorations' longevity (P=0.06; 72.2 percent and 89.7 percent with etch-and-rinse and self-etch mode, respectively).

CONCLUSION

Self-etch and etch-and-rinse strategies did not influence the clinical behavior of universal adhesive used in primary molars after selective carious tissue removal; although there was a tendency for better outcome of the self-etch strategy.

Partial Pulpotomy in Immature Permanent Molars After Carious Exposures Using Different Hemorrhage Control and Capping Materials

PURPOSE

This study compared the outcome of partial pulpotomies with mineral trioxide aggregate (MTA) or calcium hydroxide (CH) following hemorrhage control with 2.5 percent sodium hypochlorite (SH) or 0.9 percent sterile saline (SS) solutions in cariously exposed immature permanent molars.

METHODS

Following removal of two to three mm of the pulp at the exposure site, 80 Class I cavities were randomly allocated to four groups according to the hemorrhage control agent and pulp-capping material used: (1) group one-SH plus MTA; (2) group two-SS plus MTA; (3) group three-SH plus CH; (4) group four-SS plus CH. Glass ionomer cement was applied over the pulp-capping material, and the teeth were later restored with composite resin. The patients were recalled at six, 12, 18, and 24 months.

RESULTS

After 24 months, simultaneous radiographic and clinical success rates were 94.4 percent, 100 percent, 95 percent, and 100 percent for groups one to four, respectively (P>.05). No significant correlation was found between marginal integrity scores of restorations and partial pulpotomy failure (P>.05).

CONCLUSIONS

Partial pulpotomy, performed with MTA or CH used as the pulp-capping material following hemostasis with SH or SS solutions, provided comparable and favorable outcomes in carious pulp exposures of immature permanent teeth.

Randomized Clinical Trial to Evaluate MTA Indirect Pulp Capping in Deep Caries Lesions After 24-Months

OBJECTIVE

This clinical study aimed to assess the efficacies of mineral trioxide aggregate (MTA) and calcium hydroxide [Ca(OH)₂] in the treatment of deep carious lesions by the direct complete caries removal technique.

METHODS AND MATERIALS

A total of 100 permanent molar/premolar teeth were capped with either Ca(OH)₂ (n=49) or MTA (n=51) and restored with composite resin in 73 patients. Periapical radiographs were acquired prior to the treatment as well as at six, 12, and 24 months posttreatment. Two calibrated examiners performed the clinical and radiographic assessment of the periapical pathology and pulpal symptoms. Intergroup comparisons of the observed values were performed using the Fisher exact test. Significance was predetermined at α = 0.05.

RESULTS

The recall rates were 100% at six and 12 months posttreatment and 98.6% at 24 months posttreatment. Four teeth capped with Ca(OH)₂ (two each at six and 12 months posttreatment) and two capped with MTA (one each at 12 and 24 months posttreatment) received endodontic emergency treatment because of symptoms of irreversible pulpitis, which were clinically and/or radiographically established. There were no significant differences in pulp vitality between the two pulp-capping agents at six, 12, or 24 months posttreatment (p=0.238, p=0.606, and p=0.427, respectively).

CONCLUSIONS

Both pulp-capping materials were found to be clinically acceptable at 24 months posttreatment.

Improvised Vacuum-Assisted Closure for severe neck infection in poorly equipped conditions

INTRODUCTION

Dental infections are common and are mainly due to dental caries. When left untreated, these infections can lead to severe life-threatening sepsis.

CASE REPORT

The authors reported a case of a severe odontogenic deep neck space infection in a 54-year-old male. The patient was a heavy smoker with incidentally discovered diabetes. He was successfully treated by surgical drainage combined with an improvised Vacuum-Assisted Closure (VAC) system. The results of surgical drainage followed by insertion of an improvised VAC system were spectacular. The abscess resolved in response to dual-agent antibiotic therapy on day 17 and blood glucose control was achieved with insulin. Full-thickness skin graft was performed to repair the necrotic zone of the neck.

DISCUSSION

The use of VAC can be a valuable alternative to conventional dressings and hyperbaric oxygen therapy in poorly equipped conditions. Public awareness campaigns remain the most effective form of prevention against these odontogenic infections.

Restorative Treatment Decisions in Posterior Teeth: A Systematic Review

PURPOSE

To determine the stage of caries in posterior permanent teeth at which dentists decide to intervene invasively.

MATERIALS AND METHODS

A search of the literature from January 1980 to November 2015 available in MEDLINE-PubMed, EMBASE, and the Cochrane Library was conducted. The main search terms used were decision-making, restorative treatment, dental caries lesion, occlusal surface, and approximal surface. The inclusion criterion was studies including dentists only. Three reviewers independently screened titles and abstracts to determine the eligibility of studies. Subsequently, the full texts of the papers deemed eligible were perused and included in the data extraction process.

RESULTS

The review encompassed 11 studies and the methodological quality was considered moderate. Most dentists would restore lesions confined to enamel and reaching the outer half of the dentin, irrespective of the surface involved. With regard to the occlusal surface, the percentage of dentists who restored enamel lesions ranged from 4.6% to 17.8%. Regarding dentin lesions (outer half), 50.2%-70.2% of the dentists opted for invasive treatment. For the approximal surface, the choice for invasive treatment of enamel lesions ranged from 5%-88%. In dentin lesions, 4.4%-94% of dentists restored lesions in the outer half of the dentin.

CONCLUSION

Despite the progress achieved in the understanding of the development and management of caries, dentists still recommend restorative treatment in its early stages.

A retrospective investigation of the oral health records of a cohort of preschool children who received extractions under general anaesthesia including cost analysis of treatment

Internationally, a considerable proportion of children aged five years and younger require extraction of teeth due to dental caries and frequently dental general anaesthesia (DGA) is the treatment of choice.

AIMS

To investigate the records of a cohort of preschool children (aged five years and younger) referred to the public dental service provided at Cork University Hospital (CUH), Cork, Ireland, for extractions under DGA between the years 2000 and 2002. To determine the characteristics of the sample: disadvantage; the presence of a significant medical history; and, fluoride status. To establish the pattern of appointments and care, before, during and after DGA, and the pattern of dental treatment required up to sixth class (aged 11 to 12 years).

METHODS

A retrospective review of dental records of a cohort of preschool-aged children referred for DGA in CUH during the years 2000-2002 was completed. Demographic and clinical data were collated and analysed using Statistical Packages for Social Sciences (SPSS). Costs were provided by CUH and the Health Service Executive (HSE). Data on costs relating to preventive programmes were obtained from information presented in the Irish Oral Health Services Guideline Initiative 2009.

RESULTS

A total of 347 children were included with a median age of.fQur years and a range of one to five years. Children with a disadvantage were more likely to require extractions under DGA than their- counterparts (50%, n=175). In total, 73% (n=253)~ of patients had a fluoridated water supply and 91% (n=316) had no adverse medical history. For 88% (n=306), their first dental visit was an emergency appointment. The primary indication for DGA was treatment of dental caries. A recall appointment was provided for 18% (n=63). One-quarter (n=86) required an extraction, antibiotic or referral for a second DGA at their first visit following DGA. In first class, referral for a second DGA or extraction under local anaesthetic (LA) was required for 23% (n=79) of patients. Over 60% (n=21 1) required either an extraction or a restoration in third class. In excess of 20% (n=69) of patients did not attend the sixth class dental inspection, the final assessment appointment in the public services.

CONCLUSIONS

A considerable number of preschool children require extractions under DGA due to dental caries. The results of this study indicate that such children progress to adolescence with poor oral health, as evidenced by the need for further restorations, extractions and repeat DGA. The average cost of DGA was E819 per child. This figure has been shown to be as much as eight times the cost of a preventive/oral health promotion prograrnme operating within a similar cohort. An integrated preventive programme targeting preschool-aged children should be considered in attempting to manage the hicih levels of dental caries within this age group.

In Vivo Effect of Calcium Hydroxide and Resin-modified Glass Ionomer Cement on Carious Dentin in Young Permanent Molars: An Ultrastructural and Macroscopic Study

PURPOSE

The purpose of this study was to evaluate macroscopically and ultrastructurally the effect of calcium hydroxide cement (CH) and resin-modified glass ionomer cement (RMGIC) compared with gutta percha (control) as a lining material on carious dentin after partial caries removal and sealing.

METHODS

Twenty-seven permanent molars with deep carious lesions underwent partial caries removal with the application of CH, RMGIC, or gutta percha (control) and were then sealed for three months. After a partial caries removal and sealing period, the dentin was macroscopically assessed (for color, consistency, and humidity) and further analyzed by scanning electron microscope to assess the ultrastructural changes in dentin (lumen size, mineralization of tubules, occlusion of tubules by cements, and bacterial ingress). The effect of treatment in each group was statistically analyzed.

RESULTS

Dentin darkening and hardening were observed after the sealing period in all groups. However, there was no difference in the color after treatment among the three groups. It was observed that RMGIC showed a significant reduction in the size of the lumen compared to CH and the control.

CONCLUSION

Partial caries removal and sealing resulted in dentin hardening, darkening, and dentin remineralization, irrespective of the dentin protection used.

Endodontic treatment

The Finnish guideline on endodontics emphasizes good quality of endodontic treatment and coronal seal of the restoration. For prevention of endodontic treatment need caries control is essential. For deep carious lesions stepwise excavation or partial caries removal are recommended. Partial pulpotomy can be used if bleeding can be controlled. The decision for root canal treatment is based on prognosis, occlusion and general health of the patient. The use of kofferdam is essential in aseptic working. Chemomechanical preparation with NaOCI and root canal filling within 0-2 mm from the apex improve prognosis. Healing should be controlled annually up to four years.

Exploring How U.S. Dental Schools Teach Removal of Carious Tissues During Cavity Preparations

Approaches for managing carious tissues during cavity preparations vary considerably among clinicians, which may reflect inconsistencies in the teaching of this subject by dental schools. The aims of this study were to investigate practices related to the preclinical and clinical teaching of caries removal at U.S. dental schools and the relationship between that teaching and requirements for U.S. dental licensure examinations. The electronic survey included questions about terminology, methods, instruments and materials, treatment planning, criteria for clinical exams, faculty calibration sessions, and licensure exams. The faculty members at U.S. dental schools responsible for teaching cariology were invited to participate; 54 of the 65 schools had identified a contact person at the time of the survey in October 2015. Of those 54 invited to participate, 43 completed the survey (response rate of 79.6%). Most of the respondents indicated that depth of carious lesions was a clinical determinant of the amount of carious dentin being removed in cavity preparations. Caries removal was used as a criterion in restorative clinical examinations by 95% of responding schools. Marked differences were observed regarding the criteria used for assessment and removal of carious tissues, management of deep carious lesions, and definition of "caries remaining at cavity preparations," which is considered a critical error on licensure exams. Faculty calibration sessions on caries removal were reported to occur in 65% of these schools and at different time frames. Overall, the study found a wide range of teaching practices related to caries removal. Best evidence in caries management needs to be aligned with teaching and the criteria used to calibrate faculty members and examiners.

Caries Removal by First-Year Dental Students: A Multisource Competency Assessment Strategy for Reflective Practice

Multisource assessment (MSA) uses multiple assessors to provide feedback. Little is known about the validity of using MSA feedback for improving students' ability to self-assess in a preclinical environment. Therefore, the aim of this study was to measure the validity of using a defined reflective process involving an MSA tool for building skill in dental students' self-evaluation of caries excavation on extracted teeth. As part of this process, 104 first-year students at one U.S. dental school used a self-generated study plan (SGSP) for structured reflection on MSA feedback during the 2013-14 academic year. Interrater agreement, determined through calculation of percentage-agreements in scoring, was measured among three assessor groups (self-, peer, and expert assessors) in formative assessment and between two assessor groups (self- and expert assessors) in summative assessment two weeks apart, allowing for reflective practice and completion of an SGSP between assessments. Validity for improving self-assessment was determined by measuring significance in positive shifts of agreement between self- and expert assessors. The results showed that interrater agreement between the self- and expert assessors increased significantly: from a 28% agreement in formative assessment to a 60% agreement in summative assessment. Significance in percentage shifts between assessments was demonstrated with a McNemar score of 0.26 (p<0.001). These results suggest that the described MSA tool and reflective process in an SGSP may be valid methods for improving skill in student self-evaluation of competence in caries excavation on extracted teeth.

Dental care in patients with antiphospholipid syndrome: two case reports

Antiphospholipid syndrome (APS) is a prothrombotic autoimmune disease that may be classified as primary or secondary. Treatment consists of oral anticoagulant, antiplatelet, and/or immunosuppressant drugs. This report describes the dental treatment of 2 women with APS and multiple dental concerns, including periodontal disease, caries, and missing teeth. The invasive dental procedures were performed in an outpatient setting with hematologic monitoring and use of local hemostatic measures. Neither interruption of anticoagulant medications nor administration of blood products was necessary. All of the procedures were performed without complications. To date, no recommendations for the dental care of patients with APS have been established, demonstrating a need to investigate the risks for bleeding and infection, among other concerns, during dental treatment of these patients.

Remote Dental Surgery as a Medical Civilian Assistance Program (MEDCAP): Helping Iraqi, Kurdish, and U.S. Forces Win Hearts and Minds in the Fight Against Daesh

Dr Ferreira discusses the work of the Humanitarian Aid and Security Forces (HASF) in providing volunteer dental services to a local Christian militia in Mosul, Iraq.

Dental cavity liners for Class I and Class II resin-based composite restorations

BACKGROUND

Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure.

OBJECTIVES

The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library (searched 25 May 2016), MEDLINE Ovid (1946 to 25 May 2016), Embase Ovid (1980 to 25 May 2016) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 25 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs.

DATA COLLECTION AND ANALYSIS

We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification.

MAIN RESULTS

Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at one year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at two years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

Three-Year Clinical Evaluation of Class I Restorations in Posterior Teeth. Effects of Two Adhesive Systems

This longitudinal study evaluated the clinical performance of 97 direct class I resin composite restorations after 3 years. The restorations were performed using 2 types of adhesive systems: (1) Adper™ Single Bond Plus (SB) (3M ESPE, 3mespe.com), which is a two-step etch-and-rinse system, and (2) Adper Scotchbond™ SE (SE) (3M ESPE), which is a two-step self-etching system. Two calibrated examiners evaluated the restorations using modified US Public Health Service criteria. The materials were applied following the manufacturer's instructions, and 15 patients received at least one of the two adhesive systems. The restorations were evaluated 7 days after placement (baseline) and again after 3 years. Statistical analysis was performed using a proportion t-test at a significance level of 5% (P < .05). At baseline, all restorations received an Alpha score for the variable marginal discoloration and marginal integrity. After 3 years, marginal discoloration received an Alpha score for 53.19% of the restorations performed with SB and 52.08% with SE. Marginal integrity was rated as Alpha for 65.96% and 68.75% of the restorations with SB and SE systems, respectively. The remaining restorations received Bravo scores for all variables. Eight restored teeth presented postoperative sensitivity at baseline (5 SB; 3 SE), but no sensitivity was found after 3 years. No secondary caries was verified. No statistically significant differences were observed between the teeth restored with the SB and SE systems for marginal discoloration (P = .7880) and marginal integrity (P = .8132) after 3 years. Direct class I resin composite restorations performed with a two-step etch-and-rinse and a two-step self-etching adhesive system demonstrated satisfactory clinical performance after 3 years.

An evidence-based review of dental matrix systems

The restoration of proximal surface cavities, originating from Class II carious lesions, to "normal" anatomical specifications is a fundamental objective for the dental practitioner. Cognitive interpretation of tooth morphology attained from evidence-based resources, together with the necessary psychomotor skills for correct design and completion, are considered essential strategies for restoration success. Also, the visualization of the original tooth structure, if present, should substantially benefit the dentist in the creation of a clinically satisfactory restoration. The purpose of this evidence-based review is to define the cause and effect of decisions based on optimum treatment standards of care for the patient. The concepts of form and function, as related to the oral environment, and the consequences of unsatisfactory dental restorative care will be scrutinized. This article will identify and explain the different challenges and solutions for restoration of dental proximal lesions and provide an overview of past, present, and future procedures.

Zirconia-Prefabricated Crowns for Pediatric Patients With Primary Dentition: Technique and Cementation for Esthetic Outcomes

Traditionally, many clinicians tend to forego esthetic considerations when full-coverage restorations are indicated for pediatric patients with primary dentitions. However, the availability of new zirconia pediatric crowns and reliable techniques for cementation makes esthetic outcomes practical and consistent when restoring primary dentition. Two cases are described: a 3-year-old boy who presented with severe early childhood caries affecting both anterior and posterior teeth, and a 6-year-old boy who presented with extensive caries of his primary posterior dentition, including a molar requiring full coverage. The parents of both boys were concerned about esthetics, and the extent of decay indicated the need for full-coverage restorations. This led to the boys receiving treatment using a restorative procedure in which the carious teeth were prepared for and restored with esthetic tooth-colored zirconia crowns. In both cases, comfortable function and pleasing esthetics were achieved.