Costs and health-related quality of life in relation to caries.

BACKGROUND: Dental caries remains a common and expensive disease for both society and affected individuals. Furthermore, caries often affect individuals' health-related quality of life (HRQoL). Health economic evaluations are needed to understand how to efficiently distribute dental care resources. This study aims to evaluate treatment costs and QALY weights for caries active and inactive adult individuals, and to test whether the generic instrument EQ-5D-5 L can distinguish differences in this population. METHODS: A total of 1200 randomly selected individuals from dental clinics in Västerbotten County, Sweden, were invited to participate. Of these, 79 caries active and 179 caries inactive patients agreed to participate (response rate of 21.7%). Inclusion criteria were participants between 20 and 65 years old and same caries risk group categorization in two consecutive check-ups between 2014 and 2017. RESULTS: Treatment costs showed to be twice as high in the caries active group compared to the caries inactive group and were three times higher in the caries active age group 20-29 compared to the caries inactive age group 20-29. Differences between the groups was found for number of intact teeth according to age groups. In the EQ-5D-5 L instrument, more problems relating to the dimension anxiety/depression was seen in the caries active group. QALY weights showed tendencies (non-significant) to be lower in the caries active group. CONCLUSIONS: These findings highlight the need for efficient treatments and prevention strategies as well as adequate money allocation within dentistry. However, further research is needed to assess appropriate instruments for health economic evaluations.

Caries as experienced by adult caries active patients: a qualitative study.

Objective: In the western world, increased oral health has resulted in a skewed occurrence of caries disease where relatively few individuals now account for most caries disease. This study examines how adults with recurrent caries activity experience caries disease and treatment.Materials and methods: The study is based on qualitative data from individual interviews, which were subjected to qualitative content analysis. The interviews were semi-structured and thematic and an interview guide was used that consisted of two main areas with open ended questions. Meaning units were condensed and labelled with a code which preserved the core content of the reduced text. Codes were assigned to different subcategories according to their similarities or differences. Subcategories formed categories which describe the manifest content of the text.Results: The domain "experience with caries" consisted of four subcategories that formed the main category Caries - an unwelcomed acquaintance. The domain "experience with caries treatment" consisted of three subcategories that formed the category Caries treatment - pain for gain.Conclusion: Comprehensive non-operative treatment and close follow-ups should precede restorations; this would probably gain insight in how to avoid new cavities to a greater extent. If to be supportive, information and advice about self-care given to individuals with recurrent cavities should be delivered with respect to the patient's feelings about their experience of dental caries.

Reimbursement systems influence prosthodontic treatment of adult patients.

OBJECTIVE: To evaluate the influence of reimbursement system and organizational structure on oral rehabilitation of adult patients with tooth loss. MATERIALS AND METHODS: Patient data were retrieved from the databases of the Swedish Social Insurance Agency. The data consisted of treatment records of patients aged 19 years and above claiming reimbursement for dental care from July 1, 2007 until June 30, 2009. Before July 1, 2008, a proportionately higher level of subsidy was available for dental care in patients 65 years and above, but thereafter the system was changed, so that the subsidy was the same, regardless of the patient's age. Prosthodontic treatment in patients 65 years and above was compared with that in younger patients before and after the change of the reimbursement system. Prosthodontic treatment carried out in the Public Dental Health Service and the private sector was also analyzed. RESULTS: Data were retrieved for 722,842 adult patients, covering a total of 1,339,915 reimbursed treatment items. After the change of the reimbursement system, there was a decrease in the proportion of items in patients 65 years and above in relation to those under 65. Overall, there was a minimal change in the proportion of treatment items provided by the private sector compared to the public sector following the change of the reimbursement system. CONCLUSIONS: Irrespective of service provider, private or public, financial incentive such as the reimbursement system may influence the provision of prosthodontic treatment, in terms of volume of treatment.

A retrospective analysis of caries treatment and development in relation to assessed caries risk in an adult population in Sweden.

BACKGROUND: The Public Dental Service of Västerbotten County (Sweden) recommends using population-based prevention strategies combined with an individual strategy for high-risk patients to manage caries. To facilitate this management strategy, all patients are evaluated for their risk of developing caries in the coming year using defined criteria. Using caries risk scoring over a seven-year period, the present study evaluates prophylactic measures, caries development, and non-operative treatments in adult patients. METHODS: From all adult patients (25-65 years; n = 76 320) scored with a high caries risk in 2005 (baseline) and with a dental visit in 2011, 200 subjects were randomly selected. In addition, an equally sized control group with a no/low caries risk was selected. Information concerning dental status, counselling, treatments, visits, and costs were retrieved from dental records. RESULTS: Over the seven-year study period, subjects with high caries risk had significantly higher caries incidence in spite of shorter recall intervals, more dental appointments, and higher costs for dental care than subjects with no/low caries risk. Non-operative measures, such as additional fluoride and individual counselling on diet at baseline (2005), was higher in the high caries risk group, whereas information about basic prophylaxis and counselling on oral hygiene showed only small differences. The frequency of non-operative measures given during the seven-year study period to patients in the high caries risk group is considered to be remarkably low and improvement, determined as reclassification from high to no/low caries risk from 2005 to 2011, was seen in only 13% of the participants. CONCLUSIONS: This study formulated two major conclusions. First, adult patients with high or no/low caries represent different populations, that each contain distinct subpopulations, those who improve/impair or maintained their caries risk and disease progression. These groups need different strategies in disease treatment. Second, preventive measures and non-operative treatments were associated with improvements in caries risk and maintenance, but the extent to which such treatments were given to high caries risk subjects was unacceptably low. Improved adherence to the guidelines for caries treatment may reduce caries risk, visits to dental clinics, and costs for the patients.

Relationship between natural teeth and memory in a healthy elderly population.

The relationship between mastication and cognitive function remains unclear, but both animal and experimental human studies suggest a possible causal relationship. In the present study it was hypothesized that natural teeth are of importance for hippocampus-based cognitive processes, such as episodic long-term memory. A population-based sample of 273 participants (55-80 yr of age; 145 women) was investigated in a cross-sectional study. The participants underwent health assessment, completed a battery of cognitive tests, and took part in an extensive clinical oral examination. The number of natural teeth contributed uniquely and significantly to explaining variance (3-4%) in performance on measures of episodic memory and semantic memory over and above individual differences in age, years of education, gender, occupation, living conditions, and medical history. The number of natural teeth did not have an influence on the performance of measures of working memory, visuospatial ability, or processing speed. Within the limitations of the current study, a small, but significant, relationship between episodic memory and number of natural teeth is evident.

Qualitative studies of patients' perceptions of loss of teeth, the edentulous state and prosthetic rehabilitation: a systematic review with meta-synthesis.

OBJECTIVE: To conduct a systematic review and meta-synthesis of qualitative studies addressing patients' perceptions of loss of teeth, edentulism and oral rehabilitation. BACKGROUND: Qualitative studies can complement quantitative studies by achieving deep understanding of patients' subjective experiences of losing teeth and coping with edentulism. They can also explore the perception that the benefits of prosthetic rehabilitation extend far beyond primary clinical treatment goals of restoration of oral function. MATERIALS AND METHODS: The major data bases were searched extensively for relevant qualitative and quantitative studies, followed by manual searching of the reference lists of included publications. Two authors independently read all abstracts. Relevant papers were retrieved in full-text and included or excluded according to a specially designed protocol. The included articles were then appraised and rated for quality: high, moderate or low. Articles of low quality were excluded. RESULTS: The database search yielded 36 abstracts of qualitative studies; manual search disclosed one further article. All were read in full-text by two independent authors: 28 were excluded. Of the remaining nine, two (assessed as of low quality) were excluded for further analysis. Meta-synthesis, based on seven studies, disclosed two major themes: loss of quality-of-life associated with losing teeth and restored quality-of-life after oral rehabilitation. CONCLUSIONS: In this relatively new field of research, there are few published papers. Nevertheless, the studies to date show that loss of teeth is associated not only with compromised oral function, but also loss of social status and diminished self-esteem. Oral rehabilitation has broad positive implications, restoring quality of life and self-worth.

Oral rehabilitation of tooth loss: a systematic review of quantitative studies of OHRQoL.

PURPOSE: This study aimed to review published quantitative studies for evidence regarding the influence of oral rehabilitation following total or partial tooth loss on self-perceived oral health-related quality of life (OHRQoL). MATERIALS AND METHODS: Three databases were searched using specified indexing terms. The reference lists of relevant publications were also searched manually. Quality of evidence was classified according to GRADE guidelines as high, moderate, low, or very low. RESULTS: The search yielded 2,138 titles and abstracts, 2,102 of which were of a quantitative study design. Based on pre-established criteria, the full-text versions of 322 articles were obtained. After data extraction and interpretation, 5 publications of high or moderate study quality remained. The results of these 5 studies showed positive effects of oral rehabilitation on OHRQoL. Two studies showed substantial improvements. CONCLUSIONS: This is a relatively new field of research; there are very few quantitative studies of how patients perceive OHRQoL following tooth loss and subsequent rehabilitation. While this review indicates that treatment has positive effects on quality of life, the scientific basis is insufficient to support general conclusions about the influence of various interventions on the OHRQoL of patients who have experienced total or partial tooth loss. To achieve a more comprehensive analysis, it is recommended that future studies be based on a combination of quantitative and qualitative methods, ie, questionnaires and semi-structured interviews. The follow-up period must also be appropriate for the specific intervention studied.

Treatment of adult patients with edentulous arches: a systematic review.

PURPOSE: This study aimed to evaluate the outcomes of treatment methods used to rehabilitate adult patients with maxillary and/or mandibular edentulism after at least 5 years of follow-up. The risks, adverse effects, and cost effectiveness of these methods were also evaluated. MATERIALS AND METHODS: Three databases as well as the reference lists of included publications were searched using specified indexing terms. Publications that met the inclusion criteria were read and interpreted using pre-established protocols. Quality of evidence was classified according to the GRADE system (high, moderate, low, or very low). RESULTS: The search yielded 2,130 titles and abstracts. Of these, the full-text versions of 488 publications were obtained. After data extraction and interpretation, 10 studies with moderate study quality of evidence and 1 study with low quality of evidence regarding outcomes, risks, and adverse effects remained. Three studies on the economic aspects of treatment were also included (1 with moderate quality and 2 with low quality). Low-quality evidence showed that the survival rate of implant-supported fixed prostheses is 95% after 5 years in patients with maxillary edentulism and 97% after 10 years in patients with mandibular edentulism. The survival rate of implant-supported overdentures is 93% after 5 years (low-quality evidence). In implant-supported fixed prostheses, 70 of every 1,000 implants are at risk of failing in the maxilla after 5 years and 17 of every 1,000 implants in the mandible are at risk after 10 years. Regarding economic aspects, the evidence was insufficient to provide reliable results. CONCLUSIONS: Due to the low quality of evidence found in the included studies, further research with a higher quality of evidence is recommended to better understand the outcomes of treatment for patients with maxillary and/or mandibular edentulism.

Treatment of adult patients with partial edentulism: a systematic review.

PURPOSE: The purpose of this systematic review was to identify and critically appraise published studies of treatment methods used in general practice to rehabilitate adult patients with single tooth loss or partial edentulism, with special emphasis on outcomes reported after at least 5 years of follow-up. MATERIALS AND METHODS: Three databases were searched using specified indexing terms. Publications were included if the study design, research questions, and sample size satisfied pre-established criteria. Reference lists of relevant publications and systematic reviews were also searched. The quality of evidence was classified according to the GRADE system as high, moderate, low, or very low. RESULTS: The search yielded 7,675 titles, of which 1,130 were read in full text. A final total of 15 publications were deemed eligible for inclusion: 5 of moderate quality and 10 of low quality. The five studies of moderate quality were all related to implant-based treatment. The 5-year survival rates for implant-supported single crowns and prostheses were 91% and 94.7%, respectively (implant survival rates: 98.5% and 94.9%, respectively). The underlying scientific evidence was low in quality. No relevant publications were identified regarding the economic aspects of treatment. CONCLUSION: Due to the low scientific evidence of the included studies, it was not possible to compare various treatment methods used for rehabilitation of single tooth loss or partial edentulism.

Selection of dental materials and longevity of replaced restorations in Public Dental Health clinics in northern Sweden.

OBJECTIVES: To investigate the selection of direct restorative materials and longevity of replaced restorations in relation to operator and patients characteristics. METHODS: A cross-sectional study of treatment in practice, recording all new placements and replacements of direct restorations was performed during 2 weeks comprising all dentists within the Public Dental Health clinics in the county council of Västerbotten. RESULTS: A total of 2834 data collection sheets, one for each placed restoration, were received with a dropout of 10%. Restorations analyzed in the study were placed in permanent teeth in patients older than 15 years. First restorations placed due to primary caries were 671 and replacements 1536. Class II was the most frequently treated cavity followed by class I. The median longevity of replaced restorations was for amalgam, resin based composite and glass ionomer 16, 6 and 11 years, respectively. High caries risk patients showed shorter longevity for resin based composite restorations than low or moderate risk patients. Secondary caries as reason for failure for class II resin based composite restorations occurred significantly later than loss or fracture. Significantly longer longevity was observed for replaced restorations executed by more experienced dentists. CONCLUSIONS: The use of amalgam was negligible and the material was predominantly replaced by resin based composites in first and replaced restorations. Class II was the most frequent placed and replaced restorations. Caries risk and experience of operator influenced longevity of replacements.

Clinical long-term retention of etch-and-rinse and self-etch adhesive systems in non-carious cervical lesions. A 13 years evaluation.

OBJECTIVES: The aim of this study was to evaluate the clinical long-term retention to dentin of seven adhesive systems. METHODS: A total of 337 Class V restorations of three three-step etch-and-rinse, one two-step etch-and-rinse and three self-etch adhesive systems were placed in non-carious cervical lesions without intentional enamel involvement. The restorations were evaluated at baseline and then every 6 months during a 13 years follow-up. Dentin bonding efficiency was determined by the percentage of lost restorations. RESULTS: During the 13 years, 275 restorations could be evaluated. The cumulative loss rate at 13 years was 60.3%, with significant different failures rates for the different systems varying between 26.3 and 94.7%. Three materials fulfilled the ADA 18 months full acceptance criteria. Three systems showed already at 18 months or earlier catastrophical debonding rates. The annual failure rates for the three-step etch-and-rinse systems were: Allbond 2 4.1%, Clearfil LB 2.0% and Denthesive 7.3%. For the two-step etch-and-rinse Gluma 2000 6.5%, and for the self-etch systems ART 3.2%, Denthesive 2 5.7% and PUB 3 4.5% CONCLUSION: A continuous degradation of the resin-dentin bond was observed for all bonding systems during the follow-up expressed by the increasing loss rates. A wide variation of dentin bonding effectiveness was seen between the systems independent to adhesion strategy.

Clinical bonding of a single-step self-etching adhesive in noncarious cervical lesions.

PURPOSE: The aim of this study was to evaluate the clinical retention to dentin of a single-step self-etching adhesive system. MATERIALS AND METHODS: A total of 133 Class V restorations were placed with the self-etching primer Xeno III and a resin composite (Tetric Ceram) or a polyacid-modified resin composite (Dyract AP) in noncarious cervical lesions without intentional enamel involvement. The restorations were evaluated at baseline and then every 6 months during a 2-year follow-up. Dentin bonding efficacy was determined by the percentage of lost restorations. RESULTS: During the 2 years, 130 restorations could be evaluated. The cumulative loss rate at 2 years was 7.7%, with no significant differences between the two restorative materials. The self-etching adhesive fulfilled the 18-month full acceptance ADA criteria. CONCLUSION: The single-step self-etching adhesive showed acceptable clinical retention rates to dentin surfaces during the evaluation period independent of restorative material used.

Flowable resin composite as a class II restorative in primary molars: A two-year clinical evaluation.

OBJECTIVE: To evaluate the clinical durability of flowable resin composite and resin-modified glass ionomer cement when used as class II restoratives in primary molars. MATERIAL AND METHODS: A total of 190 restorations were placed in 61 children, age in the range of 5-11 years. The restoratives, Tetric Flow, in combination with the adhesives, Excite or Prompt-L-Pop and Vitremer, were used in class II cavities in primary molars. An intra-individual study design was used and the restorations were evaluated by modified USPHS criteria over a 2-year period. RESULTS: 146 of the restorations could be evaluated at 2 years. The cumulative failure rate was 10.6% for Vitremer and 13.6% for Tetric Flow. No statistically significant differences were found in failure rates between different materials or between bonding systems. The main cause of failure for Tetric Flow was secondary caries and for Vitremer wear and dissolution. CONCLUSIONS: Vitremer and Tetric Flow showed no significant difference concerning clinical durability at 2 years when used as class II restoratives in primary molars. Both materials demonstrated acceptable clinical results.

Fiber-reinforced packable resin composites in Class II cavities.

OBJECTIVE: To evaluate the 6-year performance of two glass fiber-reinforced packable resin composites in Class II cavities. METHODS: Sixty-three participants received 87 medium to large, cervically dentin bordered, Class II restorations of two fiber-reinforced resin composites, 42 Nulite F (N) and 45 Alert (A). The restorations were evaluated clinically, according to slightly modified USPHS criteria at baseline, after 6 months, and yearly during 6 years. RESULTS: At 2 years the cumulative failure frequencies for N and A were 4.8% and 2.2%, respectively, which increased at 6 years to 25.0% and 12.8%. Reasons for failure were secondary caries, material and cusp fracture. The majority of the failures occurred after 3 years. Secondary caries occurred between 4 and 6 years. The incorporation of fibers resulted in very rough surface characteristics. CONCLUSIONS: A rather high failure rate was observed for one of the fiber-reinforced resin composites, while the other fulfilled the ADA criteria. The occurrence of most failures after 3 years indicated the necessity of long-term evaluations of new materials.

A three year follow-up of posterior doxadent restorations.

A new direct restorative material, a calcium aluminate cement, was introduced in the year 2000 and sold under the name Doxadent (Doxa AB, Uppsala, Sweden). The aim of this study was to evaluate Doxadent used in class I and II cavities. A total of 63 restorations were evaluated clinically, according to sligthly modified USPHS criteria, at baseline, after 6 mths, 1, 2 and 3 yrs. Four of the patients reported post-operative sensitivity. At 3 yrs, 62 restorations were evaluated. At 6 mths 9.5% non-acceptable Doxadent restorations were observed, 17.5% at 12 mths, 24.2% at 2 yrs and 21% at 3 yrs, which resulted in a cumulative failure frequency of 72.6% at the end of the 3-years for the new restorative material. Main reasons for failure were material or tooth fracture. It can be concluded that Doxadent showed a non-acceptable clinical failure rate as a posterior restorative, especially in class II cavities.

A four-year clinical evaluation of a highly filled hybrid resin composite in posterior cavities.

PURPOSE: To evaluate the four-year performance of a highly filled resin composite in Class II and Class I cavities. MATERIALS AND METHODS: Each of 63 participants received at least one pair of restorations of the same size: one resin composite (Tetric Ceram) and one calcium aluminate cement. Seventy-one pairs were placed. The restorations were evaluated clinically according to slightly modified USPHS criteria at baseline, after 6 months, 1, 2, 3, and 4 years. At 3 years, the calcium aluminate cement material showed an inacceptable clinical cumulative failure frequency of 57% and its evaluation was discontinued. RESULTS: Postoperative sensitivity was reported for 5 restorations (2 resin composite, 3 calcium aluminate cement). At 4 years, a cumulative failure frequency of 7.5% was observed for the resin composite material. Reasons for failure were partial material fracture (2), cusp fracture (2) and endodontic treatment (1). CONCLUSION: An annual failure rate of 1.9% for the resin composite material provided a good clinical performance during the 4-year period, which fulfills the ADA criteria for posterior resin composite materials.

A calcium aluminate cement as restorative material in Class V cavities.

Recently a calcium aluminate cement (Doxa Certex, Uppsala, Sweden) has been developed intended to be used as direct restorative filling material. The aim of this study was to evaluate intra-individually the experimental calcium aluminate cement (CAC) and a resin composite (RC;Tetric Ceram) in Class V restorations. Each of 46 participants received at least one pair of restorations of the same size, one CAC and one RC. The 119 restorations were evaluated clinically, according to slightly modified USPHS criteria, at baseline, after 6 mths, 1, 2 and 3 yrs. None of the patients reported post-operative sensitivity. At 3 yrs, 111 restorations were evaluated. Significantly better clinical durability was shown for RC. Two non-acceptable CAC restorations were observed at 6 months, 3 CAC and 1 RC at 12 months, 5 CAC and 2 RC at 24 months, and 8 CAC at 36 months. This resulted in a cumulative failure frequency of 32% for the CAC material and 5% for the RC material. Main reason for failure for the CAC was total or partial lost restorations, and for the RC lost restorations. It can be concluded that the CAC showed a non-acceptable clinical failure rate for Class V restorations.

A two-year clinical evaluation of a new calcium aluminate cement in Class II cavities.

A calcium aluminate cement (Doxa Certex, Uppsala, Sweden) has recently been developed intended for use as direct restorative filling material for posterior restorations. The material is inorganic and non-metallic and the main components are CaO, Al2O3, SiO2, and water. The aim of this study was to evaluate intra-individually the experimental calcium aluminate cement (CAC) and a resin composite (RC) in Class II restorations. Each of 57 participants received at least one pair of restorations of the same size, one CAC and one RC (Tetric Ceram). Sixty-one pairs were performed. The restorations were evaluated clinically, according to slightly modified USPHS criteria, at baseline, after 6 months, 1, and 2 years. One-hundred-and-twenty restorations were evaluated at 2 years. Postoperative sensitivity was reported for 5 restorations (2 RC, 3 CAC). Significantly better clinical durability was shown for RC. Five non-acceptable CAC restorations (8.2%) were observed at 6 months, 10 CAC (16.7%) and 2 RC (3.3%) at 12 months, and 11 CAC (18.3%) at 24 months. This resulted in a cumulative failure frequency of 43.3% for the CAC material and 3.3% for the RC material. Main reasons for failure for the CAC were partial material fracture (7), cusp fracture (5), and proximal chip fracture (6). The CAC showed a non-acceptable clinical failure rate for Class II restorations, probably caused by its difficult handling and low mechanical properties.

Flexural strength and modulus of a novel ceramic restorative cement intended for posterior restorations as determined by a three-point bending test.

The aim of this study was to compare a new restorative cement intended for posterior restorations, Doxadent, with other types of tooth-colored materials as regards flexural strength and flexural modulus. The new restorative material consists mainly of calcium aluminate. Four hybrid resin composites, one polyacid-modified resin composite, one resin-modified glass ionomer cement, one conventional glass ionomer cement, one zinc phosphate cement, and an experimental version as well as the marketed version of Doxadent were investigated. Flexural strength and flexural modulus were tested according to ISO standard 4049 and determined after 1 d, 1 week, and 2 weeks. Together with the zinc phosphate cement, Doxadent had the lowest flexural strengths (13-22 MPa). The strongest materials were the resin composites and the polyacid-modified resin composite (83-136 MPa). The highest flexural modulus was found for Doxadent (17-19 GPa). The flexural strength of Doxadent decreased significantly from 1 week to 2 weeks, while flexural modulus remained unchanged. The other materials reacted in different ways to prolonged water storage. It can be concluded that the restorative cement Doxadent had significantly lower flexural strength and significantly higher flexural modulus than today's materials used for direct posterior restorations.

Surface roughness of a novel "ceramic restorative cement" after treatment with different polishing techniques in vitro.

The aim of this study was to determine the surface roughness of a novel calcium aluminate cement (CAC) intended for posterior restorations after treatment with different polishing devices in vitro. Forty-eight CAC specimens were polished with diamond burs at 15550 rpm or 27000 rpm, Sof-Lex discs, Jiffy points, Shofu silicone points, and Aaba universal polisher. Amalgam specimens were polished with Shofu silicone points and used as reference. Roughness was measured using a profilometer. The smoothest CAC surface was observed after use of the fine Sof-Lex disc (roughness average [Ra] 0.26 microm). Diamond burs at higher speed, points, and polisher gave rather similar results (Ra 0.58-0.72 microm). An increase in surface roughness could be seen from using diamond burs at lower speed (Ra 2.3 microm). Extra fine Shofu points and Sof-Lex discs as a final step reincreased surface roughness. Polished amalgam showed the smoothest surface in the study (Ra 0.17). It can be concluded that the smoothest CAC surfaces were obtained with the fine Sof-Lex discs. Different polishing points and diamond burs at higher speed, which are suitable polishing devices for posterior restorations, also gave relatively smooth surfaces.