Effect of mutanase and dextranase on biofilms of cariogenic bacteria: A systematic review of in vitro studies.

Matrix-degrading enzymes are promising non-biocidal adjuncts to dental biofilm control and caries prevention. By disrupting the biofilm matrix structure, enzymes may prevent biofilm formation or disperse established biofilms without compromising the microbial homeostasis in the mouth. This study reviewed whether treatment with mutanase and/or dextranase inhibits cariogenic biofilm growth and/or removes cariogenic biofilms in vitro. An electronic search was conducted in PubMed, EMBASE, Scopus, Web of Science, Cochrane, and LIVIVO databases. Manual searches were performed to identify additional records. Studies that quantitatively measured the effect of mutanase and/or dextranase on the inhibition/removal of in vitro cariogenic biofilms were considered eligible for inclusion. Out of 809 screened records, 34 articles investigating the effect of dextranase (n = 23), mutanase (n = 10), and/or combined enzyme treatment (n = 7) were included in the review. The overall risk of bias of the included studies was moderate. Most investigations used simple biofilm models based on one or few bacterial species and employed treatment times ≥30 min. The current evidence suggests that mutanase and dextranase, applied as single or combined treatment, are able to both inhibit and remove in vitro cariogenic biofilms. The pooled data indicate that enzymes are more effective for biofilm inhibition than removal, and an overall higher effect of mutanase compared to dextranase was observed.

Resin infiltration versus fluoride varnish for visual improvement of white spot lesions during multibracket treatment. A randomized-controlled clinical trial.

AIMS: This study aimed to evaluate the visual improvement of resin infiltration of white spot lesions (WSL) during orthodontic treatment with the multibracket appliance (MBA) compared to fluoride varnish. METHODS: Patients aged 12-17 years with at least one WSL with an International Caries Detection and Assessment System (ICDAS) score of 1-2 during an active MBA treatment were included and randomized to receive either resin infiltration (Icon) or fluoride application (Flairesse). Standardized digital images were obtained before, one-day, one-week, one-month, three-months and six-months after treatment using a DSLR camera and a matching polarization filter. A grey reference card was used for color standardization. A Matlab routine was used to measure the color difference between adjacent healthy enamel and treated WSL. The independent-samples t-test was used for intergroup and paired-samples t-test for intragroup comparison. RESULTS: Images of 116 teeth from 36 patients were analyzed. The ΔE for the "Icon" treated WSL was smaller (T1ICON = 5.0 ± 1.4) than in the fluoride group (T1Fluoride = 8.4 ± 3.2). Caries infiltration significantly improved the aesthetic appearance of WSL (p < 0.001), which remained satisfactory at six months (T5ICON = 5.2 ± 1.6). CONCLUSION: WSL infiltration management during orthodontic treatment was superior to topical fluoridation in not only arresting the enamel lesions but also significantly improving the aesthetic appearance of demineralized regions around the brackets. CLINICAL RELEVANCE: WSL treatment in orthodontic patients is usually initiated after debonding. Research has shown that the earlier WSL is treated, the better the aesthetic outcome. There is limited data on the efficacy of resin infiltration of WSL during orthodontic treatment.

Resin Infiltration of Non-Cavitated Proximal Caries Lesions in Primary and Permanent Teeth: A Systematic Review and Scenario Analysis of Randomized Controlled Trials.

The present study aimed to meta-analyze and evaluate the certainty of evidence for resin infiltration of proximal carious lesions in primary and permanent teeth. While resin infiltration has been shown efficacious for caries management, the certainty of evidence remains unclear. The protocol was registered with PROSPERO (CRD42018080895), and PRISMA guidelines have been followed. The databases PubMed, Embase, and Cochrane CENTRAL were systematically screened, complemented by hand searches and cross-referencing. Eleven relevant articles were identified and included, i.e., randomized controlled trials (RCTs) comparing the progression of resin infiltrated proximal caries lesions (combined with non-invasive measures) in primary or permanent teeth with non-invasive measures. Random-effects meta-analyses and trial sequential analyses (TSA) were performed for per-protocol (PP), intention-to-treat (ITT), and best/worst case (BC/WC) scenarios. Six included trials assessed lesions in permanent teeth and five trails assessed lesions in primary teeth. The trials had a high or unclear risk of bias. Risk of caries progression was significantly reduced for infiltrated lesions in the PP, ITT, and BC scenarios in both permanent teeth and primary teeth, but not in the WC scenario. According to the TSA, firm evidence was reached for all of the scenarios except the WC. In conclusion, there is firm evidence for resin infiltration arresting proximal caries lesions in permanent and primary teeth.

Older patients' perception of treating root caries with silver diamine fluoride - a qualitative study based on the Theoretical Domains Framework.

OBJECTIVES: Caries treatment with silver diamine fluoride (SDF) is effective, but often leads to irreversible tooth discoloration. This study aimed to investigate older patients' perceptions of root caries treatment with SDF and to identify factors that influence their decision process. METHODS: Fifteen interviews were conducted in older patients (mean, min/max: 83, 71/92 years) with root caries experience, following a semi-structured interview-guide based on the domains of the Theoretical Domains Framework (TDF) including three case vignettes of SDF treatment. Transcripts of the interviews were used to perform deductive and inductive content analysis along the TDF and Capability-Opportunity-Motivation-Behavior model (COM-B) to assess influential factors. RESULTS: All TDF domains and behavior determinants of the COM-B were covered, identifying twenty-two barriers, facilitators and conflicting themes. Main barriers for consenting to SDF treatment were patients' perceptions of permanent staining of visible root caries lesions, as well as preconceptions about those of others and lack of knowledge about root caries and SDF. Main facilitators were trust in advice given by dentists, especially regarding new treatment options, that aesthetics were less important in non-visible areas and the importance of tooth preservation and feasibility of treatments when immobile or in need of care. CONCLUSION: Permanent discoloration is an important barrier to older patients' acceptance of SDF treatment for visible root caries. However, patients appear to accept SDF treatment under certain conditions, including less visible lesions or in comparison to more invasive treatment options. CLINICAL SIGNIFICANCE: Our findings contribute to understanding both barriers and facilitators when treating root caries in older patients with SDF.

Accuracy of different approaches for detecting proximal root caries lesions in vitro.

OBJECTIVES: The objective was to evaluate the diagnostic accuracy of radiographic evaluation (XR), visual-tactile assessment (VT), laser-fluorescence (LF) (DIAGNOdent Pen/KaVo), and near-infrared-light transillumination (NILT) (DIAGNOcam/KaVo) on proximal root caries lesions in vitro. METHODS: Two-hundred extracted permanent premolars and molars with and without proximal root caries lesions were allocated to 50 diagnostic models simulating the proximal contacts between teeth and mounted in a phantom dummy head. Two independent examiners used the diagnostic approaches to detect any or advanced root caries lesions, with histologic evaluation of the lesions serving as reference. Receiver operating characteristic (ROC) curves were employed, and sensitivity, specificity, and the area under the ROC curve (AUC) are calculated. Significant differences in mean AUCs between approaches were assumed if p < 0.05 (two-sample t-test). RESULTS: NILT was not applicable for proximal root caries detection. The sensitivity/specificity to detect any lesions was 0.81/0.63 for XR, 0.76/0.88 for VT and 0.81/0.95 for LF, and the sensitivity/specificity to detect advanced lesions was 0.43/0.94 for XR, 0.66/0.99 for VT, and 0.83/0.78 for LF, respectively. For both, any and advanced root caries lesions, mean AUCs for LF and VT were significantly higher compared to XR (p < 0.05). For any root caries lesions, LF was significantly more accurate than VT (p = 0.01), but not for advanced root caries lesions (p = 0.59). CONCLUSIONS: Under the in vitro conditions chosen, LF and VT were more accurate than XR to detect proximal root caries lesions, with LF being particularly useful for initial lesion stages. CLINICAL RELEVANCE: LF might be a useful diagnostic aid for proximal root caries diagnosis. Clinical studies are necessary to corroborate the findings.

Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study.

OBJECTIVES: To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework. DESIGN: Qualitative correlational study to evaluate a national intervention programme. SETTING: Primary healthcare in two care homes in rural Germany. PARTICIPANTS: Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists. INTERVENTIONS: Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF. RESULTS: 860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health. PRIMARY OUTCOME: A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents. SECONDARY OUTCOMES: Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants. CONCLUSIONS: Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Glass Hybrid Versus Nanocomposite for Restoration of Sclerotic Non-carious Cervical Lesions: 18-Month Results of a Randomized Controlled Trial.

PURPOSE: To compare the clinical performance and treatment times between glass hybrid (GH; EQUIA Forte Fil/EQUIA Forte Coat, GC) and adhesive/nanofilled resin composite restorations (RC; OptiBond FL, Kerr/Filtek Supreme XTE, 3M Oral Care) of sclerotic non-carious cervical lesions (sNCCL). MATERIALS AND METHODS: This is an 18-month interim analysis of a 36-month cluster-randomized trial (ClinicalTrials.gov Identifier: NCT02631161). Eighty-eight patients (50-70 years) with 175 sNCCLs were randomized to receive GH or RC restorations. Restorations were placed without mechanical cavity preparation, and treatment time was recorded. After 18 months, restorations were evaluated using FDI criteria. Factors associated with restoration survival were evaluated using multi-level Cox-regression analysis. Generalized linear mixed modelling was used to analyze factors associated with treatment time. RESULTS: After a mean of 18 months (min/max: 8/25), 78 patients (160 restorations) were assessed. Fifteen restorations (18%) failed in GH, and 11 (12%) in the RC, without a significant difference in survival (p = 0.904/Cox). Retention loss was the most common reason for failure in both groups. Restorations placed in older patients showed lower risk of failure [OR (95% CI): 0.90 (0.81-0.99) per year], while mandibular teeth showed higher risks [2.89 (1.00-8.31)]. Treatment time was significantly shorter for GH (mean ± SD: 8.6 ± 4.3 min) than RC (11.7 ± 5.7 min; p < 0.001). CONCLUSIONS: GH may be a suitable alternative to RC for restoring sNCCLs, without any significant difference in survival between the two materials at this interim analysis. In addition, placing GH restorations required less chairtime than did placing RC restorations.

The impact of glass ionomer cement and composite resin on microscale pH in cariogenic biofilms and demineralization of dental tissues.

OBJECTIVE: Secondary caries is among the most frequent reasons for the failure of dental restorations. Glass ionomer cement (GIC) restorations have been proposed to protect the surrounding dental tissues from demineralization through the release of fluoride and by buffering the acid attack from dental biofilms. In contrast, the lack of buffering by composite resin (CR) restorations has been suggested as a promoting factor for the development of secondary caries. METHODS: The present study employed transversal microradiography and confocal microscopy based pH ratiometry to quantify mineral loss and map microscale pH gradients inside Streptococcus mutans biofilms grown on compound specimens consisting of enamel, dentin and either GIC or CR. RESULTS: Mineral loss in dentin was significantly lower next to GIC than next to CR, but no significant differences in local biofilm pH were observed between the two restorative materials. SIGNIFICANCE: The cariostatic effect of GIC relies predominantly on the provision of fluoride and not on a direct buffering action. The lack of buffering by CR did not affect local biofilm pH and may therefore be of minor importance for secondary caries development.

The Composite Quality Score (CQS) as a trial appraisal tool: inter-rater reliability and rating time.

OBJECTIVE: To establish the CQS inter-rater reliability and rating time and to compare both against that of the Jadad scale and Cochrane's Risk of Bias Tool (ROBT). MATERIAL AND METHODS: Four independent raters rated 45 trial reports. The inter-rater reliability was established by use of the Brennan-Prediger coefficient (BPC). The coefficients were compared using the two-sample z-test. Secondary analysis included comparison of the inter-rater reliability of the randomization component of all tools, as well as of the allocation concealment component of the CQS to that of the ROBT. The mean rating time with standard deviation (SD) for each tool was determined using one-way repeated measures analysis of variance. Post hoc comparisons were made using the Tukey-Kramer adjustment for three pair-wise multiple comparisons. RESULTS: The inter-rater reliability was significantly higher for the CQS (BPC, 95% CI: 0.95, 0.87-1.00) compared to Jadad (0.70, 0.58-0.82) (adjusted p = 0.0005) and most components of ROBT. The mean (SD) time to complete the CQS (4.0 (1.0) min) did not differ significantly from that of the Jadad scale 4.8 (1.1) min (adjusted p = 0.11), but was significantly shorter compared to that of the ROBT 15.3 (5.9) min (adjusted p < 0.0001). CONCLUSIONS: The results suggest the CQS to be a very reliable and fast trial appraisal tool. Clinical relevance The higher the inter-rater reliability, the higher the probability that trial results reflect therapeutic truth. The CQS will need to take further bias sources into consideration, in order to increase its utility.

Interventions for treating cavitated or dentine carious lesions.

BACKGROUND: Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC). OBJECTIVES: To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps. SEARCH METHODS: An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions). DATA COLLECTION AND ANALYSIS: Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions. MAIN RESULTS: We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT. AUTHORS' CONCLUSIONS: Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Implementation of COVID-19 Infection Control Measures by German Dentists: A Qualitative Study to Identify Enablers and Barriers.

OBJECTIVES: COVID-19 infection control measures have been recommended for dental practices worldwide. This qualitative study explored barriers and enablers for the implementation of these measures in German dental practices. METHODS: Semi-structured phone interviews were conducted in November/December 2020 (purposive/snowball sampling). The Theoretical Domains Framework (TDF) and the Capabilities, Opportunities and Motivations influencing Behaviors model (COM-B) were used to guide interviews. Mayring's content analysis was employed to analyze interviews. RESULTS: All dentists (28-71 years, 4/8 female/male) had implemented infection control measures. Measures most frequently not adopted were FFP2 masks, face shields (impractical), the rotation of teams (insufficient staffing) and the avoidance of aerosol-generating treatments. Dentists with personal COVID-19 experience or those seeing themselves as a role model were more eager to adopt measures. We identified 34 enablers and 20 barriers. Major barriers were the lack of knowledge, guidelines and recommendations as well as limited availability and high costs of equipment. Pressure by staff and patients to ensure infection control was an enabler. CONCLUSIONS: Dentists are motivated to implement infection control measures, but lacking opportunities limited the adoption of certain measures. Policy makers and equipment manufacturers should address these points to increase the implementation of infection control measures against COVID-19 and potential future pandemics.

Glass hybrid versus composite for non-carious cervical lesions: Survival, restoration quality and costs in randomized controlled trial after 3 years.

OBJECTIVE: This study compared survival, restoration quality and costs of glass hybrid (GH; EQUIA Forte Fil/EQUIA Forte Coat) and resin composite restorations (RC; OptiBond FL/Filtek Supreme XTE) of sclerotic non-carious cervical lesions. METHODS: This is a cluster-randomized trial (ClinicalTrials.gov: NCT02631161). 88 patients (50-70 years) with 175 sNCCLs were randomized to receive GH or RC. Restorations were placed without mechanical cavity preparation and followed for a mean 36 (min/max: 31/55) months (variable follow-up due to COVID-19 lockdown). Restoration quality was re-evaluated at 1-, 18- and 36-months using FDI-criteria. Survival was assessed using multi-level Cox-regression analysis. Costs were estimated from a payer's perspective in Germany. Initial costs were determined based on micro-costing using time recordings and hourly costs, and follow-up costs based on statutory insurance fee-item-catalogues. RESULTS: 88 patients (175 restorations) were treated; 43 received GH (83 restorations), 45 RC (92 restorations). 17  GH and 19 RC showed total retention loss, 5  GH were partially lost (p = 0.396/Cox). FDI ratings were not sufficiently different for any domain except surface luster, where RC showed higher score (p < 0.001). Costs were initially lower for GH (32.57; SD 16.36 €) than RC (44.25; SD 21.40 €), while re-treatment costs were similar (GH: 9.15; SD 15.70 €; RC: 7.35; SD 14.51 €), resulting in significantly lower costs for GH (GH: 41.72; SD 25.08 €) than RC (51.60; 26.17 €) (p < 0.001/GLM). CONCLUSIONS: While survival was not significantly different, GH was significantly less costly both initially and long-term than RC for restoring non-carious cervical lesions. CLINICAL SIGNIFICANCE: Within this trial, survival was not significantly different between GH and RC to restore sclerotic NCCLs. As GH was significantly less costly both initially and long-term than RC, using RC was only cost-effective for payers willing to invest high additional expenses per minimal survival gains.

Root Caries Preventive Effect of Varnishes Containing Fluoride or Fluoride + Chlorhexidine/Cetylpyridinium Chloride In Vitro.

Caries preventive varnishes containing only fluoride might differ from those containing a combination of fluoride and antimicrobial components in terms of mineralization properties and their impact on the cariogenic biofilm. We compared a fluoride and a fluoride + chlorhexidine (CHX)/cetylpyridinium chloride (CPC) varnish on root caries formation in vitro. One hundred bovine root dentin samples were allocated to five groups (n = 20/group): (1) 7700 ppm fluoride varnish (Fluorprotector S (F)), (2) experimental placebo varnish for F (F-P), (3) 1400 ppm fluoride + 0.3% CHX/0.5% CPC varnish (Cervitec F (CF)), (4) experimental placebo varnish for CF (CF-P), (5) untreated control. Cariogenic challenge was provided using a multi-station, continuous-culture 3-species (Streptococcus mutans (SM), Lactobacillus rhamnosus (LR), Actinomyces naeslundii (AN)) biofilm model for 10 days. Mineral loss (ΔZ) was evaluated using transversal microradiography and bacterial counts in the biofilm assessed as colony-forming units. Fluorescence in situ hybridization (FISH) and confocal microscopy were performed to assess the three-dimensional biofilm architecture. Mean ± SD (vol% × µm) ΔZ was significantly lower for F (9133 ± 758) and CF (9835 ± 1677) compared to control (11362 ± 919) (p < 0.05), without significant differences between F and CF. SM counts were significantly lower and LR counts significantly higher in F- and CF-biofilms compared to control. AN counts were significantly higher in the F-biofilms than in all other groups. According to FISH, SM and LR invaded dentinal tubules only in the control-group. In the CF-group, the basal biofilm layer did not contain SM and AN. Both F and CF varnishes had similar caries-preventive effects and a considerable impact on biofilm structure and composition.

Barriers and Enablers for Artificial Intelligence in Dental Diagnostics: A Qualitative Study.

The present study aimed to identify barriers and enablers for the implementation of artificial intelligence (AI) in dental, specifically radiographic, diagnostics. Semi-structured phone interviews with dentists and patients were conducted between the end of May and the end of June 2020 (convenience/snowball sampling). A questionnaire developed along the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities and Motivations influencing Behaviors model (COM-B) was used to guide interviews. Mayring's content analysis was employed to point out barriers and enablers. We identified 36 barriers, conflicting themes or enablers, covering nine of the fourteen domains of the TDF and all three determinants of behavior (COM). Both stakeholders emphasized chances and hopes for AI. A range of enablers for implementing AI in dental diagnostics were identified (e.g., the chance for higher diagnostic accuracy, a reduced workload, more comprehensive reporting and better patient-provider communication). Barriers related to reliance on AI and responsibility for medical decisions, as well as the explainability of AI and the related option to de-bug AI applications, emerged. Decision-makers and industry may want to consider these aspects to foster implementation of AI in dentistry.

The performance of balance exercises during daily tooth brushing is not sufficient to improve balance and muscle strength in healthy older adults.

BACKGROUND: High prevalence rates have been reported for physical inactivity, mobility limitations, and falls in older adults. Home-based exercise might be an adequate means to increase physical activity by improving health- (i.e., muscle strength) and skill-related components of physical fitness (i.e., balance), particularly in times of restricted physical activity due to pandemics. OBJECTIVE: The objective of this study was to examine the effects of home-based balance exercises conducted during daily tooth brushing on measures of balance and muscle strength in healthy older adults. METHODS: Fifty-one older adults were randomly assigned to a balance exercise group (n = 27; age: 65.1 ± 1.1 years) or a passive control group (n = 24; age: 66.2 ± 3.3 years). The intervention group conducted balance exercises over a period of eight weeks twice daily for three minutes each during their daily tooth brushing routine. Pre- and post-intervention, tests were included for the assessment of static steady-state balance (i.e., Romberg test), dynamic steady-state balance (i.e., 10-m single and dual-task walk test using a cognitive and motor interference task), proactive balance (i.e., Timed-Up-and-Go Test [TUG], Functional-Reach-Test [FRT]), and muscle strength (i.e., Chair-Rise-Test [CRT]). RESULTS: Irrespective of group, the statistical analysis revealed significant main effects for time (pre vs. post) for dual-task gait speed (p < .001, 1.12 ≤ d ≤ 2.65), TUG (p < .001, d = 1.17), FRT (p = .002, d = 0.92), and CRT (p = .002, d = 0.94) but not for single-task gait speed and for the Romberg-Test. No significant group × time interactions were found for any of the investigated variables. CONCLUSIONS: The applied lifestyle balance training program conducted twice daily during tooth brushing routines appears not to be sufficient in terms of exercise dosage and difficulty level to enhance balance and muscle strength in healthy adults aged 60-72 years. Consequently, structured balance training programs using higher exercise dosages and/or more difficult balance tasks are recommended for older adults to improve balance and muscle strength.

Secondary Caries Adjacent to Bulk or Incrementally Filled Composites Placed after Selective Excavation In Vitro.

OBJECTIVES: selective caries excavation (SE) is recommended for deep carious lesions. Bulk fill composites (BF) may be considered to restore SE-cavities. We compared the susceptibility for secondary caries adjacent to BF versus incrementally filled composites (IF) in SE and non-selectively excavated teeth (NS) in vitro. METHODS: in 72 extracted human premolars, artificial caries lesions were induced on pulpo-axial walls of standardized cavities. The lesions were left (SE) or removed (NS), and teeth were restored using two BF, GrandioSO x-tra/Voco (BF-Gra) and SDR/Dentsply (BF-SDR), and an IF, GrandioSO/Voco (IF-Gra) (n = 12/group for SE and NS). After thermo-mechanical cycling (5-55 °C, 8 days), teeth were submitted to a continuous-culture Lactobacillus rhamnosus biofilm model with cyclic loading for 10 days. Mineral loss (ΔZ) of enamel surface lesions (ESL), dentin surface lesions (DSL), and dentin wall lesions (DWL) was analyzed using transversal microradiography. RESULTS: ΔZ was the highest in DSL, followed by ESL, and it was significantly lower in DWL. There were no significant differences in ΔZ between groups in DSL, ESL, and DWL (p > 0.05). Regardless of lesion location, ΔZ did not differ between SE and NS (p > 0.05). CONCLUSIONS: BF and IF both showed low risks for DWL (i.e., true secondary caries) after SE in vitro, and surface lesion risk was also not significantly different between materials. SE did not increase secondary caries risk as compared with NS. CLINICAL SIGNIFICANCE: the risk of secondary caries was low after selective excavation in this study, regardless of whether bulk or incrementally filled composites were used.

Secondary caries risk of different adhesive strategies and restorative materials in permanent teeth: Systematic review and network meta-analysis.

OBJECTIVES: Secondary caries is a major long-term complication of dental restorations. Different adhesive strategies and restorative materials may affect secondary caries risk. We aimed to systematically review and synthesize the secondary caries risk of different adhesive strategies and restorative materials. SOURCES: Medline via PubMed 01/2005-10/2019. STUDY SELECTION: Randomized controlled studies with minimum 2 years follow-up, comparing different adhesive strategies and/or restorative materials in permanent teeth were included. Our outcome was the occurrence of secondary caries. Bayesian pairwise and network-meta-analysis were conducted. DATA: We included 50 trials; 19 assessing secondary caries depending on different adhesive strategies, 31 on restorative materials. Studies were published between 2005 and 2017, largely of unclear risk of bias, and included a mean of 40 (range: 8-90) participants and 46 (range: 14-200) placed restorations. Mean follow-up was 43 (range: 24-180) months. Secondary caries was a rare event; the majority of studies did not find any lesions. Network meta-analysis found great uncertainty. 3-step etch-and-rinse adhesives showed the lowest risk of secondary caries, 2-step etch-and-rinse the highest. For restorative materials, resin-modified glass ionomer showed the lowest risk of secondary caries. Most resin composites showed similar risks. CONCLUSION: Data from randomized trials comparing different adhesive strategies or restorative materials are extremely scarce. The differences between materials were limited over the observational period of the included studies. The yielded rankings should be interpreted with caution. CLINICAL SIGNIFICANCE: Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries from randomized trials. Longer-term studies may be needed to identify differences in secondary caries risk between materials.

Interventions to improve oral health of older people: A scoping review.

OBJECTIVES: A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care. DATA: We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention. SOURCES: Studies retrieved via MEDLINE, EMBASE, CINAHL. STUDY SELECTION: Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81). CONCLUSIONS: Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures. CLINICAL SIGNIFICANCE: While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.

Probiotic Effects on Multispecies Biofilm Composition, Architecture, and Caries Activity In Vitro.

While probiotics have been tested for their anti-caries effect in vitro and also clinically, there is a lack of understanding of their effects on complex dental biofilms. We assessed two probiotics, Lactobacillus reuteri and Streptococcus oligofermentans, on a continuous-cultured model containing Streptococcus mutans, Lactobacillus rhamnosus and Actinomyces naeslundii. Cariogenic biofilms were grown on bovine enamel specimens and daily challenged with L. reuteri or S. oligofermentans whole culture (LC/SC) or cell-free supernatant (LS/SS) or medium only (negative control, NC) (n = 21/group) for 10 days. Biofilm was assessed via counting colony-forming units, quantitative polymerase chain reaction, and fluorescence in situ hybridization. Caries activity was determined by pH measurements and by assessing mineral loss (ΔZ) using transverse microradiography. Both LC and SC significantly reduced total and strain-specific cariogenic bacterial numbers (p < 0.05). ΔZ was reduced in LC (mean ± SD: 1846.67 ± 317.89) and SC (3315.87 ± 617.30) compared to NC (4681.48 ± 495.18, p < 0.05). No significant reductions in bacterial numbers and ΔZ was induced by supernatants. Biofilm architecture was not considerably affected by probiotic applications. Viable probiotics L. reuteri and S. oligofermentans, but not their culture supernatants, could reduce the caries activity of multi-species biofilms in vitro.

Secondary caries: what is it, and how it can be controlled, detected, and managed?

OBJECTIVES: To assess how to control, detect, and treat secondary caries. This review serves to inform a joint ORCA/EFCD consensus process. METHODS: Systematic and non-systematic reviews were performed or consulted and narratively synthesized. RESULTS: Secondary (or recurrent) caries is defined as a lesion associated with restorations or sealants. While the restorative material itself has some influence on secondary caries, further factors like the presence and size of restoration gaps, patients' caries risk, and the placing dentist's experience seem more relevant. Current detection methods for secondary caries are only sparsely validated and likely prone for the risk of over-detection. In many patients, it might be prudent to prioritize specific detection methods to avoid invasive overtreatment. Detected secondary caries can be managed either by repair of the defective part of the restoration or its complete replacement. CONCLUSIONS: There is sparse data towards the nature of secondary caries and how to control, detect, and treat it. CLINICAL SIGNIFICANCE: Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries. Longer-term studies may be needed to identify differences in secondary caries risk between materials and to identify characteristic features of progressive lesions (i.e., those in need of treatment).