[Caries: diagnostics, monitoring and guidance in good oral health behaviour. A reorientation]. / Cariës: diagnostiek, monitoren en begeleiden naar goed mondzorggedrag. Een heroriëntatie.

Caries is a dynamic process which can develop either progressively or regressively under the all-determining influence of oral health behaviour. Management of caries therefore involves first of all: diagnostics, monitoring and preventive care and treatment which result in good oral health behaviour. The oral care provider should recognize all phases ofprogression of the caries process, and should be able to differentiate the symptoms which indicate an active or inactive process. A well maintained patient dossier is necessary to monitor this process over time. Following this procedure, the oral care provider is in a position to guide the patient with relevant information in order to achieve the final objective, good oral health.

The dilemma of selecting suitable proximal carious lesions in primary molars for restoration using ART technique.

OBJECTIVE: To determine the examiner's accuracy in selecting proximal carious lesions in primary molars for restoration using the atraumatic restorative treatment (ART) approach. BASIC RESEARCH DESIGN: Intervention study. CLINICAL SETTING AND PARTICIPANTS: A total of 804 six to eight year-olds from 30 rural schools in Kenya participated in the study. INTERVENTION: Three examiners selected a total of 1,280 suitable proximal carious lesions in primary molars after examining 6,002 children from 30 schools randomly selected out of 142 schools in two divisions. Seven operators randomly paired on a daily basis with eight assistants restored the lesions. An explanation was provided for any cavity that was not restored. Pre-and post-operative radiographs of the cavities were also taken for evaluation. MAIN OUTCOME MEASURES: The examiner's choice of suitable proximal cavities restorable using the ART approach was related to the decision made to either restore or not during the operative stage. The radiographic findings of the selected cavities were also compared to the decision made by the operator. The results obtained were used to determine the examiner's accuracy in selecting suitable proximal cavities for restoration using the ART approach. RESULTS: The majority of the children recruited in the study were excluded due to absenteeism, pulpal-exposure or anxiety during the operative stage. Only 804 children received one restoration in their primary molars. The examiner's accuracy in selecting suitable ART-restorable cavities clinically was 94.9% and based on radiographic analysis was 91.7%. CONCLUSIONS: A trained and diligent examiner has a very good chance of selecting proximal carious lesions restorable with the use of ART approach, without the threat of dental pulpal-involvement during the excavation of caries.

Influence of Salvadora persica (miswak) extract on physical and antimicrobial properties of glass ionomer cement.

AIM: To investigate physical and antimicrobial properties of Glass Ionomer Cement (GIC) combined with Salvadora Persica Extract (SPE). METHODS: SPE was added to GIC (Fuji IX) in concentrations of 1%, 2% and 4% w/w. The compressive strength and diametral tensile strength were measured at 1 h, 24 h and 7 days. The antimicrobial effect was tested in agar dilution assay in blood agar plates with Candida albicans, Streptococcus mutans, Streptococcus sanguis, Streptococcus mitis, Streptococcus salivarius and Actinomyces naeslundii as test organisms. GIC containing 5% chlorhexidine served as positive control. RESULTS: Significant differences were found for the compressive strength and diametral tensile strength as a result of adding SPE to GIC (p<0.05). GIC with 2 or 4 % SPE was significantly weaker than the GIC control, while GIC with 1% SPE was not different from the control. The mean values for the 4% SPE-containing specimens and the GIC control group ranged from 108.7MPa to 141.1MPa for CS and from 8.2MPa to 12.5MPa for DTS. The 1% SPE-containing specimens were not different in physical properties compared to the control GIC specimens; the 2% SPE-containing specimens were statistically slightly less strong (p<0.05), but within an acceptable range. As compared with pure GIC the antimicrobial properties of the SPE-containing specimens were increased significantly (p<0.01). It has been found up to a 2-fold increased inhibition compared to the GIC with increasing concentrations of SPE. For most microorganisms tested the SPE group inhibited less than Chlorhexidine, but significantly better than pure GIC (p<0.01). CONCLUSION: SPE could be a promising natural material as an additive to GICs. Further studies should include in vivo tests and other antimicrobial and physical properties of this combination.

Short communication: Influence of preformed metal crowns (Hall technique) on the occlusal vertical dimension in the primary dentition.

AIM: This was to investigate the measure of propping, or occlusal interference and opening the bite after placement of preformed metal crowns (PMC) using the Hall technique and in how many days it took for the open bite to return to normal. METHODS: For this study school children living in the rain forest of Suriname were selected. The distance between the tip of the mandibular and maxillary primary canines was measured just before and after treatment with PMCs and again after 15 and 30 days. RESULTS: In 48 children the mean distance between the canine tips reduced from 2.45 mm before to 0.54 mm directly after treatment. After 15 days the distance increased again to 1.96 mm and after 30 days (with the remaining 8 patients) to 2.75 mm. The reduction of the overbite seems to be caused by intrusion of the crowned molar and its antagonist. CONCLUSION: Although the overbite had equilibrated after 30 days, additional research is necessary in a larger study to draw more decisive conclusions.

ART class II restoration loss in primary molars: re-restoration or not?

AIM: The purpose of this study was to find an answer as to what to do with Atraumatic Restorations (ART) failures: re-restore or leave the preparation further unfilled? STUDY DESIGN: Cross sectional study. METHODS: In 2006, 804 children in Kenya each had one proximal cavity treated using the ART approach. Out of the original group of 192 children, who had lost their restorations but still had the treated molars in situ, were selected for further study in 2008. The length of time that the restorations had been in situ was known while the colour, hardness and the extent of infected dentine was then evaluated and documented. STATISTICS: Analysis of the data obtained was conducted using SPSS 16.0. Chi Square tests were performed with the variables of hardness, colour and infected dentine, and a 5% confidence interval was used. The Spearman's Rank Correlation Coefficient was also calculated. RESULTS: The results showed that 66% of the molars that had lost restorations had hard dentine, 78% of the preparations showed dark dentine and 50.7% appeared to have no infected dentine. These percentages increased with the increase in the survival time of the restorations. CONCLUSIONS: It is not always necessary to re-restore primary molars after ART restoration loss. Further research is necessary to confirm these findings.

[Principles of oral health care for children]. / Uitgangspunten van mondzorg voor kinderen.

In this article the principles of child oral health care in the Netherlands and the consequences of cariological principals of oral health care delivery to children are described. First of all the age of the child plays a very significant role in decisions concerning prevention and restoration. In addition, the combination of a positive attitude on the part of the dentist and a pain-free treatment can prevent fear of treatment and avoidance behaviour of the children. In the treatment of carious lesions, moreover, the oral health care provider should consider to what extent the problem is related to behaviour and fits in the multi-factorial caries model. Restorative treatments should be considered as supporting prevention, reducing caries activity and eliminating the effects of neglected oral health care. Prevention has to be seen as an essential element of the treatment model and it should start early from the standpoint of habit formation and the rapid demineralization process in the deciduous dentition which results from failed preventive care.

Short communication: Influence of different isolation methods on the survival of proximal ART restorations in primary molars after two years.

AIM: This was to evaluate the influence of two methods of tooth-isolation on the survival rate of proximal ART restorations in the primary molars. METHODS: The study was conducted in two rural divisions in Kenya, with 7 operators randomly paired to a group of 8 assistants. A total of 804 children each had one proximal cavity in a primary molar restored using the ART approach. During restorations 2 isolation methods, rubber dam or cotton wool rolls, and 3 brands of glass ionomer cements were used by the operators. The restorations were then followed for a period of 2 years. STATISTICS: SPSS 14.0 was used to analyse and relate the data obtained to the method of isolation used. RESULTS: After 2 years 30.8% of the ART restorations had survived. Higher survival rates of the restorations were obtained when using rubber dam irrespective of the GIC material or the operator. CONCLUSION: Generally the survival rate of the proximal restorations in the present study was very low, but the use of rubber dam resulted in a higher survival rate of the restorations.

Two-year survival of glass ionomer sealants placed as part of proximal atraumatic restorative treatment restorations.

OBJECTIVE: To evaluate after two years, the survival rate of glass ionomer cement (GIC) sealants placed in primary molars of six to eight year-olds and as part of proximal atraumatic restorative treatment (ART) restoration. DESIGN: A longitudinal clinical study. SETTING: Matungulu/Kangundo rural divisions, Machakos district, Kenya. SUBJECT: A total of 804 six to eight year-olds from rural Kenya received a sealant as part of a proximal restoration placed in a primary molar using the atraumatic restorative treatment (ART) approach. RESULTS: The two-year cumulative survival of the sealants was 10.9%, and the survival of the sealants was not significantly affected by the GIC material brand and the tooth-isolation method used. However, slightly more sealants survived when Fuji IX and rubber dam tooth- isolation method were used. CONCLUSION: The two-year survival rate of the sealants was poor and was not significantly influenced by the GIC material or the tooth-isolation method used.

Influence of the experience of operator and assistant on the survival rate of proximal ART restorations: two-year results.

AIM: The objective of the study was to determine the influence of the experience of the operator and the assistant on the survival rate of proximal ART- restorations after 2 years when placed using two methods of tooth-isolation and three glass ionomer cement-brands. STUDY DESIGN: A clinical intervention study. METHODS: Each of 804 children aged 6-8 years received one proximal restoration in their primary molars. The restorations were placed by 'experienced/inexperienced' operators randomly paired with 'experienced/ inexperienced' assistants. The atraumatic restorative treatment (ART) approach was used with 3 brands of glass ionomer cements (GIC) and 2 tooth-isolation methods (rubber dam vs cotton rolls). Trained and calibrated evaluators evaluated the restorations, soon after placement and after 2 years. STATISTICS: The data collected were analyzed using SPSS 14.0, to determine and relate the survival rate of the restorations to the operator and assistant with respect to the other factors such as the restorative material used and the isolation method applied. RESULTS: After 2 years, the survival rate of the restorations was 30.8%. In general, there were no statistical significant differences in the survival rate of the restorations made by the 'experienced' vs 'inexperienced' operators, but individually, the operator with more experience was associated with a significantly higher survival rate of the restorations. The experienced assistants were associated with significantly higher survival rates of the restorations. The most 'experienced' operator paired with any 'experienced' assistant and using rubber dam tooth-isolation method, was associated with a significantly higher survival rate of the restorations. CONCLUSION: The combination of the 'experienced' operator and assistant using rubber dam tooth-isolation method had the best chance of survival for proximal ART restorations, irrespective of the material-brand used.

Physical-mechanical properties of glass ionomer cements indicated for atraumatic restorative treatment.

BACKGROUND: This study evaluated mechanical properties of glass ionomer cements (GICs) used for atraumatic restorative treatment. Wear resistance, Knoop hardness (Kh), flexural (F(s)) and compressive strength (C(s)) were evaluated. The GICs used were Riva Self Cure (RVA), Fuji IX (FIX), Hi Dense (HD), Vitro Molar (VM), Maxxion R (MXR) and Ketac Molar Easymix (KME). METHODS: Wear was evaluated after 1, 4, 63 and 365 days. Two-way ANOVA and Tukey post hoc tests (P = 0.05) analysed differences in wear of the GICs and the time effect. F(s), C(s), and Kh were analysed with one-way ANOVA. RESULTS: The type of cement (p < 0.001) and the time (p < 0.001) had a significant effect on wear. In early-term wear and Kh, KME and FIX presented the best performance. In long-term wear, F(s) and C(s), KME, FIX and HD had the best performance. Strong explanatory power between F(s) and the Kh (r(2) = 0.85), C(s) and the Kh (r(2) = 0.82), long-term wear and F(s) of 24 h (r(2) = 0.79) were observed. CONCLUSIONS: The data suggested that KME and FIX presented the best in vitro performance. HD showed good results except for early-term wear.

Caries prevalence in Suriname schoolchildren.

OBJECTIVES: The aim of this study was to establish the oral health status of children living throughout the Interior of Suriname in order to define needs for dental care in line with WHO goals and guidelines. BASIC RESEARCH DESIGN: In this cross sectional study, dental caries was recorded according to the criteria of the WHO. Decayed, missing and filled (DMF)-teeth (T) and surfaces (S) indices for caries prevalence were used. A total of 951 children from four different regions and between 5-15 years of age, were examined. There was an approximately equal distribution of boys and girls. The children were divided into three age categories. RESULTS: The mean dmfs in the youngest children (5-7.5 yrs) was 11.81 (SD 11.19) and the mean dmft 5.16 (SD 3.93). 17.2% of the children was caries free. Statisticaly significant regional, racial and gender differences were found The mean dmfs of children in the middle age category (7.5-10 yrs) was 5.37 (SD 6.42) and the mean DMFS was 0.84 (SD 1.30). A mean DMFS of 2.31 (SD 4.97) was recorded in the oldest children. No regional, racial or gender differences were found in the last two categories. CONCLUSIONS: The results indicate that caries prevalence in young children in the Interior of Suriname is high according to the criteria of the WHO. In contrast, children in older age groups were found to experience low to moderate caries levels. This finding has consequences for the organisation and planning of future oral health care which should be focused on young children.

Host and microbiological factors related to dental caries development.

Studies on dental caries suggest that in severe cases it may induce a systemic immune response. This occurs particularly when caries progresses into pulpal inflammation and results in abscess or fistula formation (AFF). We hypothesized that severe dental caries will affect the general health of children. The acute phase proteins alpha-1-acid glycoprotein (AGP), C-reactive protein (CRP) and the cytokine neopterin were chosen as parameters to monitor general health. Also, a polymorphism in the bacterial ligand CD14 (-260) was studied to investigate the relationship between genotype sensitivity for bacterial infections and AFF. In Suriname, children aged 6 years were recruited and enrolled into a dental care scheme, randomly assigned to 4 groups with different treatment strategies and monitored longitudinally. 348 children were included in the present study. Blood and saliva samples were taken at baseline and 1 year, and concentrations of serum AGP, CRP, neopterin, salivary Streptococcus mutans and CD14-260 C>T polymorphism were determined. There was no significant association between different treatment strategies and the serum parameters. Binary logistic regression analyses revealed a significant association between AFF as the outcome variable and the CD14 genotype and the concentrations of CRP and of neopterin as factors (p < 0.05). A significant negative association was found between the CD14-260 TT and AFF (p = 0.035, OR = 3.3) for the whole population. For children who had 4 or more carious lesions at baseline, the significance increased (p = 0.005, OR = 4.8), suggesting that the CD14-260 TT genotype was protective for AFF as a consequence of dental caries.

The effect of different dental treatment strategies on the oral health of children: a longitudinal randomised controlled trial.

The aim of the present study is to verify which strategy is the most effective in the treatment of dental decay of the deciduous dentition in a moderate to high caries child population under remote field conditions. This study was carried out in the rain forest of Suriname. Three hundred and eighty schoolchildren, mean age 6.1 years (SD 0.5, range 5.1-7.1 years), were randomly assigned to four different groups: full dental treatment, only extractions, only restorations (ART) and no treatment. Parameters for oral health were defined as caries prevalence (dmft), caries increment, sequela to dental caries and dental pain. Restorative dental care of the primary dentition, by means of ART, resulted in a caries increment from a dmft of 5.48 (SD 3.2) at baseline to 6.35 (SD 2.6) after 2 years (p < 0.001). Extensive dental treatment, performing only extractions, or no treatment did not render significant changes in the caries prevalence of children (p > 0.05). Full dental treatment should be the strategy of choice whenever oral health care programmes are developed. However, when priorities are required due to situational, practical or economical reasons, extraction of severely decayed teeth is an effective treatment strategy.

Three-year survival of single- and two-surface ART restorations in a high-caries child population.

The aim of this study was to evaluate the survival of single- and two-surface atraumatic restorative treatment (ART) restorations in the primary and permanent dentitions of children from a high-caries population, in a field setting. The study was conducted in the rainforest of Suriname, South America. ART restorations, made by four Dutch dentists, were evaluated after 6 months, 1, 2, and 3 years. Four hundred seventy-five ART restorations were placed in the primary dentition and 54 in first permanent molars of 194 children (mean age 6.09 +/- 0.48 years). Three-year cumulative survivals of single- and two-surface ART restorations in the primary dentition were 43.4 and 12.2%, respectively. Main failure characteristics were gross marginal defects and total or partial losses. Three-year cumulative survival for single-surface ART restorations in the permanent dentition was 29.6%. Main failure characteristics were secondary caries and gross marginal defects. An operator effect was found only for two-surface restorations. The results show extremely low survival rates for single- and two-surface ART restorations in the primary and permanent dentitions. The variable success for ART may initiate further discussion about alternative treatment strategies, especially in those situations where choices have to be made with respect to a well-balanced, cost-effective package of basic oral health care.

Iatrogenic damage to the adjacent surfaces of primary molars, in three different ways of cavity preparation.

AIM: A clinical study was carried out to compare three methods of preparing a cavity regarding the measure of damage to adjacent teeth: the ART method, the use of the latest version of Carisolv and as a control group the use of rotating instruments. METHODS: Preparations (217) were made by 2 Tanzanian dentists and 2 final year Dutch dental students at the Muhimbili University College of Health Science (MUCHS) in Dar es Salaam, Tanzania. Only children 7 years old, with one class II cavity in a primary molar and no dental experience were included in the study. After cavity preparation, partial impressions of the adjacent teeth were made, from which resin models were cast and later studied under a stereomicroscope. RESULTS: These showed damage of 91.7% in the Bur group, which was significantly greater than in the ART and Carisolv groups (62.7% and 59.5% respectively). CONCLUSION: Protection of the adjacent surfaces is necessary, for instance in the form of matrix band separation and by means of damage reducing techniques. More studies on the long term effect of the damage need to be conducted.

The influence of restorative treatment approaches and the use of local analgesia, on the children's discomfort.

AIM: The aim is to investigate possible differences in discomfort during treatment with the atraumatic restorative treatment (ART) or the Conventional restorative method with and without local analgesia (LA). METHODS: The study group consisted of 6 and 7 year old children with no dental experience (mean age 6.98, SD +/- 0.52) randomly divided into four treatment groups: Conventional method with and without LA and ART with and without LA. One or two proximal lesions in primary molars were treated. The heart rate and the behaviour (Venham) were measured. STATISTICS: Statistical analysis was performed in SPSS version 10.0. RESULTS: In a first session 300 children were treated and 109 children for a second time in the same way as at the first visit. During the first session ART without LA gave the least discomfort while the Conventional method without LA gave the most discomfort. During the second treatment the least discomfort was observed with ART without LA and the most discomfort in the Conventional way with LA. CONCLUSION: There is a constant preference for hand instruments; the bur is increasingly accepted. The experience with LA is the reverse.

Residual caries and marginal integrity in relation to Class II glass ionomer restorations in primary molars.

AIM: To assess the effectiveness of three treatment methods (ART, Carisolv(TM) and rotary instruments) in caries removal and sealing capability of hand-mixed glass ionomer in the management of proximal caries in deciduous molars. METHODS: In a clinical study 217 dentally naïve children (age 7.5, SD 0.57) were randomly divided in three treatment groups and among 4 operators. Each child received one class II glass ionomer restoration. Immediately after restoration bitewings were made. The dependent variables were: residual caries and marginal adaptation. Independent variables were operator effect, child's behaviour and time to remove caries. RESULTS: There was no statistical significant difference in residual caries between the three treatment methods (p < 0.05). In 33% of the cases a clear radiolucency underneath the restoration was visible on the bitewings. In 26% doubt existed on the presence of residual caries. A clear cervical gap was seen in 16% of the restorations, while in 18% signs of cervical gaps were less obvious. Between the four operators a significant difference in relation to residual caries (p = 0.015) was found as well as a significant difference between the operators for the preparation time in the three treatment methods (p < 0.05). The child's behaviour seems to have no influence on residual caries and marginal gaps. CONCLUSION: This study indicates that there is no preparation method superior to another, though the treatment methods seem to be sensitive for operator effects. Using hand-mixed glass ionomer cement resulted in considerable number of cervical gaps found.

Influence of residual caries and cervical gaps on the survival rate of Class II glass ionomer restorations.

AIM: To assess the influence of different variables on the survival of class II glass ionomer restorations a clinical study was carried out among 6-7 year old schoolchildren in and around Dar es Salaam, Tanzania. METHODS: 217 children were randomly divided into three groups. In the conventional group, Class-II cavities were excavated with burs, in the ART group they were excavated with hand instruments and in the Carisolv group excavation took place with a chemical solution and special blunt hand instruments. The preparations in all groups were restored with hand mixed glass ionomer cement (Fuji IX). Four operators were involved in the treatment phase. After restoration, residual caries and cervical gaps were assessed on bite-wings. The quality of the restorations was established and the survival rate determined in two subsequent evaluations. RESULTS: 195 children (90%) were present at the first evaluation which took place after 7 months and 194 (89%) were present at the second evaluation, after one year. At the first evaluation the survival rate of the ART-restorations was 38%, of the conventional restorations 50%, and of the Carisolv restorations 35%. Survival rates at the time of the second evaluation were 30%, 42% and 28% respectively. The differences between the three treatment groups were, however, not significant (p = 0.200 at t = 1 and p = 0.247 at t = 2). In the first evaluation 161 bitewings were available of the 195 restorations, while for the second evaluation 130 cases were available. There was no significant relation between residual caries and the success/failure rate (p = 0.140 at t = 1 and p = 0,201 at t = 2). Also cervical gaps appeared to have no relation with the failure rate (p = 0.057 at t = 1 and p = 0.833 at t = 2) However, together those variables have a significant influence on the survival rate (p = 0.025). CONCLUSION: The combination of two variables (residual caries and cervical gaps) has considerable influence on the survival rate of class II glass ionomer restorations compared to each variable alone.

[Needle breakage during mandibular block anaesthesia: prevention and retrieval]. / Naaldbreuk tijdens mandibulaire blokanesthesie. Preventie en behandeling.

Disposable needles for dental local anaesthesia do not break easily. Still, needle breakage does occur, and is mainly caused by unexpected movements of the patient or pre-use bending of the needle by the dentist. If a dental needle breaks while administering local anaesthesia, the dentist should prevent panic. If the patient opens his mouth wide the needle might still be visible. If so, the needle is removed. If the needle is no longer visible, the site where the needle has penetrated the mucosa should be marked with a permanent marker. The dentist will contact a maxillofacial surgeon for immediate consultation. The maxillofacial surgeon will try to retrieve the broken dental needle under general anaesthesia.

[ART or conventional restorations? A final evaluation of proximal restorations in deciduous molars]. / ART of conventioneel? Onderzoeksresultaten van proximale restauraties in tijdelijke molaren.

In this article the success rate of class 2 ART and conventional (prepared with a bur) restorations in deciduous molars is described. In 1999 approximately 200 ART and 200 conventional restorations were made in deciduous molars in Bandung, Indonesia. The restorations were evaluated after 1.5 month, half a year, 1 year, 2 years and 3 years. The three-year evaluation took place in October 2003. Results show that after 3 years 31% (ART) and 33.6% (conventional) of the restorations were successful (no significant difference). There was a significant difference between the operators. If keeping the element until shedding is the only criterion, the success rate increased to 53.