ART restorations for occluso-proximal cavities in primary molars: a two-year survival and cost analysis of an RCT comparing two GIC brands

Abstract There are many glass ionomer cements available on the Brazilian market for Atraumatic Restorative Treatment (ART), however, there is still a gap in the literature regarding their cost-effectiveness. Objectives To evaluate the influence of restorative materials (Ketac Molar, 3M ESPE; and Vitro Molar, Nova DFL) in the two-year survival rate and cost-effectiveness of occluso-proximal ART restorations in primary molars. Methodology A total of 117 children (aged four to eight years) with at least one occluso-proximal carious lesion in primary molars were selected and randomly divided in treatment groups (KM or VM) in this parallel randomized controlled trial. Treatments followed ART premises and were conducted in public schools by trained operators in Barueri, Brazil. A trained, calibrated, and blinded examiner performed the evaluations after two, six, 12, and 24 months (k=0.92). Kaplan-Meier survival analysis was used to estimate restoration survival and Cox regression was used to test the association with clinical factors (α=5%). For cost analysis, material and professional costs were considered. Monte Carlo analysis was used to generate a cost-effectiveness plane and bootstrapping was used to compare material costs over the years. Results The overall survival rate was 36.9% after two years (48.6% for KM and 25.4% for VM). Restorations with VM failed more than those with KM (HR=1.70; 95% CI=1.06-2.73; p=0.027). VM presented lower initial cost, but no difference was observed between groups considering the two-year incremental cost. Conclusion After a two-year evaluation, KM proved to be a better option than VM for occluso-proximal ART restorations in primary molars. ClinicalTrials.gov: NCT02267720

Clinical wear of approximal glass ionomer restorations protected with a nanofilled self-adhesive light-cured protective coating

Abstract High viscous glass ionomer cement (GIC) has gained popularity as a restorative material; however, high wear is pointed as one of the major drawbacks of this material. Protective surface coatings were developed to protect GIC from water contamination with the additional advantage of occluding any surface cracks or porosities commonly found in this material, possibly resulting in an increased wear resistance of the restorations. Objective: The objective of this study was to investigate the clinical wear of GIC approximal restorations in primary molars protected either with a nanofilled self-adhesive light-cured protective coating (NPC) or with petroleum jelly. Material and Methods: Approximal caries lesions in primary molars from 32 schoolchildren previously enrolled in another clinical trial were included in this investigation. GIC restorations were performed according to the Atraumatic Restorative Treatment approach and protected with either petroleum jelly or a NPC. Impressions of the restored hemiarch were done after 1 day and 6, 12, 24 and 36 months. The impressions were scanned in a 3-D appliance and the obtained images were superimposed using an appropriate computer software. Two-way ANOVA for repeated measures and Tukey's post-hoc test were used to analyze the wear of restorations (α=5%). Results: A significant difference was found between the two groups, with a wear protection offered by the application of a NPC. Conclusion: These results suggest that the application of a NPC has a protective effect on the clinical wear of approximal GIC restorations in primary teeth.

Epidemiological study of traumatic dental injuries in 5- to 6-year-old Brazilian children

Monitoring traumatic dental injury (TDI) in primary teeth through epidemiological cross-sectional surveys provides descriptive information relevant to the development of public policies focused on the prevention of such injuries for the target population. The aim of this study was to assess the prevalence of TDI in 5- to 6-year-old Brazilian children and its association with biological and socioeconomic factors. A total of 684 children aged 5 to 6 years old, from 11 public schools in the city of Barueri (Brazil) were evaluated. Clinical examinations were carried out in the schools, by two trained and calibrated examiners. Gauze and a mouth mirror were used for the examinations. The reported TDIs were classified according to the Andreasen (2007) criteria for primary teeth. The results showed that 52.3% of the children had TDI. Enamel fracture (63.4%) was the most frequently observed sign of TDI, and the most affected teeth were the primary maxillary central incisors (26.9% maxillary right central incisor and 24% maxillary left central incisor). There was no association between the presence of TDI and biological or socioeconomic factors. In conclusion, the prevalence of TDI was high and had no statistically significant association with biological and socioeconomic factors.

Low-cost glass ionomer cement as ART sealant in permanent molars: a randomized clinical trial

Clinical trials are normally performed with well-known brands of glass ionomer cement (GIC), but the cost of these materials is high for public healthcare in less-affluent communities. Given the need to research cheaper materials, it seems pertinent to investigate the retention rate of a low-cost GIC applied as atraumatic restorative treatment (ART) sealants in two centers in Brazil. Four hundred and thirty-seven 6-to-8-year-old schoolchildren were selected in two cities in Brazil. The children were randomly divided into two groups, according to the tested GIC applied in the first permanent molars. The retention rate was evaluated after 3, 6 and 12 months. Kaplan-Meier survival analysis and the log-rank test were performed. The variables were tested for association with sealant longevity, using logistic regression analyses (α = 5%). The retention rate of sealants after 12 months was 19.1%. The high-cost GIC brand presented a 2-fold-more-likely-to-survive rate than the low-cost brand (p < 0.001). Significant difference was also found between the cities where the treatments were performed, in that Barueri presented a higher sealant survival rate than Recife (p < 0.001). The retention rate of a low-cost GIC sealant brand was markedly lower than that of a well-known GIC sealant brand.

Effect of insertion method on knoop hardness of high viscous glass ionomer cements

The aim of this study was to assess the Knoop hardness of three high viscous glass ionomer cements: G1 - Ketac Molar; G2 - Ketac Molar Easymix (3M ESPE) and G3 - Magic Glass ART (Vigodent). As a parallel goal, three different methods for insertion of Ketac Molar Easymix were tested: G4 - conventional spatula; G5 - commercial syringe (Centrix) and G6 - low-cost syringe. Ten specimens of each group were prepared and the Knoop hardness was determined 5 times on each specimen with a HM-124 hardness machine (25 g/30 s dwell time) after 24 h, 1 and 2 weeks. During the entire test period, the specimens were stored in liquid paraffin at 37ºC. Significant differences were found between G3 and G1/G2 (two-way ANOVA and Tukey's post hoc test; p<0.01). There was no significant difference in the results among the multiple ways of insertion. The glass ionomer cement Magic Glass ART showed the lowest hardness, while the insertion technique had no significant influence on hardness.

O objetivo deste estudo foi avaliar a microdureza Knoop de três cimentos de ionômero de vidro de alta viscosidade: G1 - Ketac Molar; G2 - Ketac Molar Easymix (3M ESPE) and G3 - Magic Glass ART (Vigodent). Adicionalmente, como um co-objetivo, três diferentes formas de inserção do Ketac Molar Easymix foram avaliadas: G4 - espátula conventional; G5 - seringa comercial (Centrix) e G6 - seringa de baixo custo. Dez corpos de prova de cada grupo foram preparados e a microdureza Knoop foi determinada com 5 indentações por espécime com o aparelho HM-124 (25 g/30 s tempo de identação) após 24 h, 1 e 2 semanas. Durante todo o período de teste, os espécimes foram mantidos em parafina líquida a 37ºC. Diferenças estatísticas significantes foram encontradas entre G3 e G1 / G2 (ANOVA a 2 critérios e teste de Tukey post hoc; p<0,01). Não houve diferença nos resultados no que se refere às diferentes formas de inserção. O cimento de ionômero de vidro Magic Glass ART apresenta os valores mais baixos de dureza enquanto o método de inserção não influencia nos resultados de dureza.

Efetividade do aparelho de fluorescência a laser no monitoramento da desmineralização e remineralização de lesões de cárie em superfície oclusal: estudo in situ / Effectiveness of laser fluorescence device in monitoring demineralization and remineralization of occlusal caries lesions: in situ study

Introdução - O objetivo deste estudo in situ foi avaliar a efetividade do aparelho de fluorescênciaa laser (FL-DIAGNOdent) no monitoramento da des/remineralização de lesões de cárie iniciais em superfícies oclusais. Material e Métodos - Oito voluntários utilizaram um dispositivo intrabucal contendo quatro blocos de superfícies oclusais hígidas de pré-molares, sob tela para promover retenção de placa. As superfícies oclusais foram submetidas à medição com o FL. Os voluntários gotejaram solução de sacarose a 20%, oito vezes ao dia, durante 14 dias. Após esse período, foi realizada nova medição com o FL e dois blocos foram removidos dos dispositivos. Os voluntários continuaram a utilizar os aparelhos durante mais vinte e oito dias, higienizando as amostras no dispositivo sem a tela, com dentifrício fluoretado de 1100 ppm. Foi realizada a remoção dos blocos, e nova medição com FL. Todas as superfícies oclusais foram seccionadas e submetidas ao teste de dureza Knoop de seção transversal. Foi realizada ANOVA e teste de Tukey, além de teste de correlação de Pearson para os valores de dureza e do FL. Resultados - Em relação ao teste de dureza, houve diferença estatisticamente significante entre os grupos de desmineralização (261,6 ±29,9 KNHx?m) e remineralização (302,1 ± 32,2 KNHx?m, p = 0,016). Não houve diferença nos valores do FL (des:3,9 ± 2,2; re: 3,8 ± 2,0, p > 0,05) e não houve correlação significante entre as medidasdo FL e de dureza (r = ?0,145). Conclusão - Pode-se concluir que o aparelho FL não é eficaz em monitorar o processo de remineralização utilizando um estudo in situ.

Introduction - The aim of this in situ study was to evaluate the effectiveness of the laser fluorescence device (DIAGNOdent) in monitoring the demineralization and remineralization of occlusal caries surfaces. Material and Methods - Eight volunteers were selected for the study, and used an intrabucal appliance with four sterilized blocks of occlusal sound surfaces from premolar teeth.The occlusal surfaces were measured with a DIAGNOdent laser. During a period of fourteen days the volunteers drop a 20% sucrose solution on the blocks eight times a day, and used non-fluoride dentifrice. After this period, a new measurement with the DIAGNOdent was carried out and twoblocks were removed for Knoop microhardness test to verify surface demineralization. The volunteers brushed the remaining surfaces with fluoride dentifrice (1100 ppm) in the device without the plastic mesh for more twenty eight days. After this period, new measurement of the remaining surfaces in the device were carried through with DIAGNOdent. The surfaces were removed after that. All the occlusal surfaces were submitted to the Knoop cross-sectional microhardness test. Results - The effectiveness of the DIAGNOdent in monitoring the demineralization and the remineralization was evaluated. In Knoop hardness test, there was statistically significant difference between demineralization and remineralization groups (p = 0,016). There was negative correlation (r = ?0,1448) between the DIAGNOdent values and the Knoop hardness test. Conclusion - It was concluded that remineralization process was efficient in this study, although the DIAGNOdent laser can not monitor little mineral alterations.

Tratamento restaurador atraumático em cavidades atípicas / Atraumatic restorative treatment in atypical cavities

O tratamento restaurador atraumático tem sido bem difundido entre os profissionais da área de Odontopediatria. Essa técnica restauradora está inserida na filosofia de mínima intervenção e é considerada como uma das mais conservadoras, pois há somente a realização da remoção do tecido dentinário infectado. Além disso, o tratamento restaurador atraumático mostra-se menos doloroso que a técnica convencional, sendo a anestesia raramente requerida. Após a remoção do tecido dentário infectado, realiza-se o preenchimento das cavidades com o cimento ionômero de vidro, material que possui capacidade antimicrobiana, bom selamento marginal e liberação e recarga de flúor constante. Apesar do aumento no número de estudos sobre esse tratamento, somente trabalhos com restaurações em cavidades oclusais mostram evidências científicas sobre a técnica. O objetivo deste trabalho é relatar o caso clínico de um paciente com grandes destruições nos dentes decíduos, o qual foi submetido ao tratamento restaurador atraumático e observar o resultado da técnica após um ano de acompanhamento clínico e radiográfico.

The atraumatic restorative treatment has been widely divulged among professionals in the area of Pediatric Dentistry. This restorative technique is included in the philosophy of Minimal Intervention and is considered one of the most conservative treatments, because only the layer of infected dentin caries is removed. Moreover, the atraumatic restorative treatment has been shown to be less painful than conventional approaches, and local anesthesia is rarely required. After the removal of the infected dentin, the cavities are filled with glass ionomer cement, a material that has antimicrobial capacity, good marginal sealing and constant fluorine release and recharge. In spite of the increasing number of studies about atraumatic restorative treatment, only studies related to restorations in occlusal cavities have shown scientific evidences about the technique. The aim of this study was to evaluate the feasibility of atraumatic restorative treatment in cavities with 3 or more surfaces involved, by means of a clinical case report of a patient with extensive dstruction in primary teeth, who was submitted to atraumatic restorative treatment, and observe the result of the treatment after one year of clinical and radiographic control.

Tratamento pulpar indireto em molar decíduo com resina composta: importância do diagnóstico e acompanhamento de três anos / Indirect pulp treatment of primary molar with composite resin: diagnosis importance and three years follow-up

O tratamento pulpar indireto é uma alternativa conservadora viável para manutenção da integridade pulpar. Entre os materiais indicados para essa técnica destacam-se o hidróxido de cálcio, por sua ação bacteriostática e bactericida e o cimento de ionômero de vidro, por sua ação antimicrobiana, adesão à estrutura dentária e liberação de flúor. O sistema adesivo é mais uma alternativa para proteção do complexo dentino-pulpar, pois proporciona um bom selamento marginal na interface dente-restauração. O objetivo deste estudo foi avaliar clínica e radiograficamente o tratamento pulpar indireto em molar decíduo com sistema adesivo e resina composta, após observação da indicação clínica. Após três anos de acompanhamento observou-se sucesso clínico eradiográfico o que faz com que essa técnica seja indicada como uma alternativa conservadora de tratamento para lesões de cárie profundas.

Indirect pulp treatment is a viable conservative alternative for keeping the integrity of the pulp. Among the indicated materials for this technique, calcium hydroxide presents bacteriostatic and bactericide action, glass ionomer presents antimicrobial capacity, adhesion dental structure and fluorid release. The adhesive system is another alternative to protect the dentin-pulp complex therefore it provides good marginal seal at the interface tooth-restoration. The aim of this study was to evaluate clinic and radiographic indirect pulp treatment in deciduous teeth with adhesive system and composite resin. After three years of surviving, the results shows clinic and radiographic success, what makes this technique indicated for a conservative alternative treatment.

Clareamento em dente decíduo vitalizado: caso clínico / Bleaching in vital deciduous teeth - a clinical case

A preocupação e a busca pela beleza e harmonia estética têm crescido consideravelmente nos últimos anos. Essas preocupações não fazem parte somente da vida dos adultos, mas também das crianças. Dentre as substâncias utilizadas para clarear as estruturas dentais, as que mais se destacam são aquelas cujo princípio ativo baseia-se no peróxido de hidrogênio. O presente trabalho relata um caso clínico de uma criança de quatro anos de idade, gênero feminino, que sofreu traumatismo dentário no elemento 61 com conseqüente alteração de cor do mesmo, porém sem alteração da vitalidade pulpar. A queixa principal do paciente e dos responsáveis era estética e, portanto foi realizado um clareamento dental externo, utilizando o Opalescence Xtra® (Ultradent), em duas sessões com intervalo de um mês. O clareamento externo de consultório foi o tratamento de escolha devido à vitalidade do dente, a idade do paciente e a presença de apenas um elemento dental escurecido. Após as sessões de clareamento observou-se melhora do escurecimento, sendo que a criança e os responsáveis ficaram satisfeitos com o resultado estético.

There has been growing concern and search for esthetic beauty and harmony over the last few years. This concern does not form part ofadults? lives only, but also of children?s. Among the substances used for bleaching dental structures, the most outstanding are those whose active principle is hydrogen peroxide-based . The present study reports a clinical case of a 4-year-old girl that suffered trauma of tooth 61with consequent color alteration, but with no alteration in pulp vitality. The main complaint by the patient and her guardians concerned esthetics, therefore external dental bleaching was performed, using Opalescence Xtra® (Ultradent), in two sessions with an interval of one month between them. External in office bleaching was the treatment of choice, due to the tooth vitality, patient?s age and presence of only one darkened tooth. After the bleaching treatments an improvement in the darkening was observed, and both the child and her guardians were satisfied with the esthetic result.

Avaliações clínica e radiográfica do selamento de lesões de cárie / Sealing dentinal caries lesion clinical and radiographic assessment

O objetivo do presente estudo in vivo foi verificar o efeito da aplicação do selante de fóssulas e fissuras no controle de lesões cariosas oclusais em metade externa de dentina comparado ao tratamento restaurador com resina composta. Trinta e seis dentes decíduos foram selecionados e divididos aleatoriamente em: Grupo 1 - aplicação de selante resinoso e Grupo 2 - restauração com resina composta, após remoção parcial de tecido cariado. Os dentes foram avaliados clínica e radiograficamente nos períodos de seis, 12 e 18 meses após o tratamento. Os resultados demonstraram, após a análise dos dados com o teste Wilcoxon, que não houve diferença estatística entre os períodos analisados (p>0,05), assim como, após a utilização do teste de Mann Whitney, não houve diferença entre G1 e G2 (p>0,05). Concluiu-se que os selantes de fóssulas e fissuras constituem uma alternativa conservadora ao tratamento restaurador, propiciando a paralisação de lesões de cárie que atingem a metade externa de dentina, concomitante a preservação de tecido dental hígido.

Evaluation of the dental structure loss produced during maintenance and replacement of occlusal amalgam restorations

The aim of this in vitro study was to evaluate four different approaches to the decision of changing or not defective amalgam restorations in first primary molar teeth concerning the loss of dental structure. Ditched amalgam restorations (n = 11) were submitted to four different treatments, as follows: Control group - polishing and finishing of the restorations were carried out; Amalgam group - the ditched amalgam restorations were replaced by new amalgam restorations; Composite resin group - the initial amalgam restorations were replaced by composite resin restorations; Flowable resin group - the ditching around the amalgam restorations was filled with flowable resin. Images of the sectioned teeth were made and the area of the cavities before and after the procedures was determined by image analysis software to assess structural loss. The data were submitted to ANOVA complemented by the Student Newman Keuls test (p < 0.05). The cavities in all the groups presented significantly greater areas after the procedures. However, the amalgam group showed more substantial dental loss. The other three groups presented no statistically significant difference in dental structure loss after the re-treatments. Thus, replacing ditched amalgam restorations by other similar restorations resulted in a significant dental structure loss while maintaining them or replacing them by resin restorations did not result in significant loss.

Avaliação do selamento de lesões de cárie comparado à restauração com resina composta em dentes decíduos / Sealing dentinal caries lesion and restoring treatment in deciduous teeth: a longitudinal evaluation

O objetivo do presente estudo “in vivo" foi verificar o efeito do selante de fóssulas e fissuras no controle de lesões cariosas oclusais comparado ao tratamento restaurador. Vinte dentes decíduos foram selecionados e divididos em: grupo I – selante resinoso e grupo II –restauração com resina composta, após remoção parcial de tecido cariado. Após 12 meses, 8dentes foram excluídos da pesquisa. Os resultados demonstraram que 83% dos dentes do grupoI apresentaram retenção completa do material e em 100% dos casos observou-se ausência de progressão da lesão. 100% dos molares pertencentes ao grupo II apresentaram retenção completa do material, e em 100% dos casos houve ausência de progressão da lesão. Concluiu-se queos selantes de fóssulas e fissuras constituem uma alternativa conservadora ao tratamento restaurador, propiciando a paralisação de lesões de cárie em estágio inicial em dentina, além de preservação da estrutura dental.

The aim of this “in vivo" study was to verify the effect of pit and fissure sealants to control the initial caries injuries compared with the restorative treatment. Twenty deciduous teeth had been selected and divided in: group I – resinous sealant and group II – restoration with composite resin, after the partial removal of the carious dentin. After 12 months of attendance 8 teeth were excluded of the research. The results showed that 83% of the deciduous molars from group I presented complete material retention and in 100% of cases a non-progression ofinjury was observed. For group II, complete material retention was observed in 100% of theteeth and in 100% of the cases there were non-progression of the injury. We conclude that thepit and fissures sealants constitute a more conservative treatment then restoration, propitiating the stoppage of injuries of initial caries lesions and preservation of the dental structure.

Avaliação da resistência de união de resina composta ao esmalte bovino clareado com peróxido de carbamida / A microshear test to measure bond strengths of composite resin to bovine enamel bleached with carbamide peroxide

O objetivo deste estudo in vitro foi avaliar a resistência de união de cilindros de resina composta Z250, confeccionados em superfícies de esmalte bovino, submetidas previamente ou não (controle) a tratamento clareador (8 horas/dia durante 14 dias) com gel de peróxido de carbamida (Opalescence PF), em concentrações de 10%, 15% ou 20%, por meio de teste de microcisalhamento. Os cilindros foram executados 12 horas (12h) ou 1 semana (1 sem) após o término do clareamento após o término do clareamento e a adesão da resina composta ao esmalte foi feita com sistema adesivo de frasco único Single Bond (SB) ou autocondicionante Clearfil SE Bond (CF). Para cada adesivo, havia um grupo controle (con) que não recebeu aplicação de peróxido. As médias dos valores de adesão, em MPa, para os grupos foram: SB/con: 28,65; CF/con: 29,10; SB/10%/12h: 19,36; SB/15%/12h: 19,17; SB/20%/12h: 19,34; CF/10%/12h: 21,59; CF/15%/12h: 21,82; CF/20%/12h: 21,70; SB/10%/1 sem: 25,71; SB/15%/1 sem: 25,83; SB/20%/1 sem: 24,17; CF/10%/1 sem: 26,77; CF/15%/1 sem: 26,33; CF/20%/1 sem: 26,63. Concluiu-se que o clareamento de esmalte bovino com gel de peróxido de carbamida, independente da concentração utilizada, fez com que os valores de resistência adesiva dos cilindros confeccionados 12h após o término do clareamento fossem estatisticamente menores (p<0,05) que os valores observados nos grupos controle, independente do sistema adesivo utilizado. Os valores de resistência adesiva dos cilindros confeccionados uma semana após o término do clareamento, independente da concentração do peróxido, foram estatisticamente semelhantes (p>0,05) aos dos respectivos grupos controle para os dois tipos de sistema adesivo utilizados.