Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document.

PURPOSE: The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage deep carious lesions in primary teeth. METHODS: Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified. RESULTS: There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions. Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs) using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual failure rates. CONCLUSION: The management of deep carious lesions in primary teeth can be challenging and must consider the patient's compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing carious primary teeth as a mainstream rather than a compromise option.

Impact of operators' experience and patients' age on the success of nitrous oxide sedation for dental treatment in children.

AIM: To evaluate the success rates and potential influencing factors of nitrous oxide sedation for dental treatment in a specialised paediatric dental service. MATERIALS: Medical records of all children treated under nitrous oxide sedation in a specialised pedodontics clinic between 2012 and 2017 were analysed retrospectively for parameters such as age of the patient, experience and change of operating dentists, treatment procedure and success or failure regarding the sedation and treatment. CONCLUSION: Given the high overall success rate of over 90%, nitrous oxide sedation can be a highly effective treatment option for performing dental treatment in pre-cooperative and/or anxious children and adolescents. With age of the children and experience of the dentist, success rates increased.

Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review.

PURPOSE: This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research. METHOD: An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area. RESULTS: Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has significantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7-88%, respectively, over 3 years follow-up). CONCLUSION: Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.

Ten-year trends in DMF-S and DMF-T in a northeast German adult population.

OBJECTIVE: The aim of this study was to assess 10-year trends in coronal caries in adults aged 20-83 years using data from the two-representative population-based Studies of Health in Pomerania (SHIP-0/SHIP-Trend-0). METHODS: Repeated cross-sectional data from 4,286 SHIP-0 and 3,913 SHIP-Trend-0 participants were analysed. Carious, filled and missing teeth/surfaces were recorded in a half-mouth design and the DMF-T/S scores and sound surfaces/teeth were calculated according to WHO criteria. Trends in DMF-T/S scores and its single components were presented stratified by age group and sex. RESULTS: A statistically significant decline in coronal caries experience (DMF-T and DMF-S) in adults aged 20 to 83 years as well as for D-T/S components was observed. The proportion of edentulous participants was almost halved from 8.7% (SHIP-0) to 5.1% (SHIP-Trend-0), while the number of M-T declined from 4.4 to 3.5 revealing an overall clear shift to a higher retention rate of teeth. In younger adults (25-34 years) 3.8 more sound teeth (17.2 sound surfaces) were found in average in the mouth and in elderly (65-74 years) a clear shift from extracted to filled teeth was observed (M-T reduced by 5.4, while F-T increased by 4). Regarding sex differences, females had consistently on average higher MF-T/S values, but lower D-T/S values than males. CONCLUSION: A clinically relevant drop in the severity of coronal caries experience in all adult age groups in Northeast Germany shows that not only reductions in caries experience in adolescence translated into adulthood but also later improvements led to long-term oral health.

Treatment of Carious Lesions Using Self-Assembling Peptides.

Modern approaches in caries treatment involve lesion management without tissue removal. Regenerative medicine focuses on replacing damaged tissues with biologically similar tissues. This article discusses the scientific evidence and clinical results for self-assembling peptides in modern caries management. The biomimetic remineralization promoted by self-assembling peptide P11-4 has been proven in vitro as an effective therapy for initial caries. P11-4 was rationally designed to promote formation of hydroxyapatite on its surface. The formulation was optimized to ensure the ability of monomeric P11-4 to penetrate past the subsurface lesions and assembly into a biomatrix within. Furthermore, P11-4 has shown that it assembles into fibers within carious lesions, and promotes the remineralization thereof. In a recent clinical study, the safety and efficacy of P11-4 in treatment of initial caries were evaluated. The additional effect of the application of P11-4 (Curodont Repair) was compared to the application of fluoride varnish (Duraphat) alone in active occlusal initial caries lesions on erupting permanent molars. In the 3- and 6-month recalls, the test group showed, both in the laser fluorescence readings and in the clinical assessment of the caries stage and activity, significantly superior lesion regression compared to the control group. No adverse events, medical complications, or allergic reactions related to the treatments were reported. Clinical applicability of treatment was regarded as satisfactory. Patients were happy to receive noninvasive caries treatments. In conclusion, biomimetic mineralization facilitated by P11-4 in combination with fluoride may present a simple, safe, and effective noninvasive treatment for early carious lesions.

Self-assembling Peptide P11-4 and Fluoride for Regenerating Enamel.

Regenerative medicine-based approaches for caries treatment focus on biomimetic remineralization of initial carious lesions as a minimal invasive therapy. In vitro, self-assembling peptide P11-4 enhances remineralization of early carious lesions. To investigate the safety and clinical efficacy of P11-4 for treatment of initial caries, a randomized controlled single-blind study was conducted on children aged >5 y with visible active early caries on erupting permanent molars. Subjects were randomized to either the test group (P11-4 + fluoride varnish) or control group (fluoride varnish alone). Caries were assessed at baseline and at 3 and 6 mo posttreatment per laser fluorescence, a visual analog scale, the International Caries Detection and Assessment System, and Nyvad caries activity criteria. Intention-to-treat analyses were performed, and safety and clinical feasibility of the treatment approaches were assessed. Compared with the control group, the test group showed clinically and statistically significant improvement in all outcomes at 3 and 6 mo. The laser fluorescence readings (odds ratio = 3.5, P = 0.015) and visual analog scale scores (odds ratio = 7.9, P < .0001) were significantly lower for the test group, and they showed regression in the International Caries Detection and Assessment System caries index (odds ratio = 5.1, P = 0.018) and conversion from active to inactive lesions according to Nyvad criteria (odds ratio = 12.2, P < 0.0001). No adverse events occurred. The biomimetic mineralization facilitated by P11-4 in combination with fluoride application is a simple, safe, and effective noninvasive treatment for early carious lesions that is superior to the presently used gold standard of fluoride alone. By regenerating enamel tissue and preventing lesion progression, this novel approach could change clinical dental practice from a restorative to a therapeutic approach. This could avoid additional loss of healthy hard tissue during invasive restorative treatments, potentially enabling longer tooth life and thereby lowering long-term health costs ( ClinicalTrials.gov NCT02724592).

The Hall Technique 10 years on: Questions and answers.

It is ten years since the first paper on the Hall Technique was published in the British Dental Journal and almost 20 years since the technique first came to notice. Dr Norna Hall a (now retired) general dental practitioner from the north of Scotland had, for many years, been managing carious primary molar teeth by cementing preformed metal crowns over them, with no local anaesthesia, tooth preparation or carious tissue removal. This first report, a retrospective analysis of Dr Hall's treatments, caused controversy. How could simply sealing a carious lesion, with all the associated bacteria and decayed tissues, possibly be clinically successful? Since then, growing understanding that caries is essentially a biofilm driven disease rather than an infectious disease, explains why the Hall Technique, and other 'sealing in' carious lesion techniques, are successful. The intervening ten years has seen robust evidence from several randomised control trials that are either completed or underway. These have found the Hall Technique superior to comparator treatments, with success rates (no pain or infection) of 99% (UK study) and 100% (Germany) at one year, 98% and 93% over two years (UK and Germany) and 97% over five years (UK). The Hall Technique is now regarded as one of several biological management options for carious lesions in primary molars. This paper covers commonly asked questions about the Hall Technique and speculates on what lies ahead.

Caries management strategies for primary molars: 1-yr randomized control trial results.

Minimal invasive approaches to managing caries, such as partial caries removal techniques, are showing increasing evidence of improved outcomes over the conventional complete caries removal. There is also increasing interest in techniques where no caries is removed. We present the 1-yr results of clinical efficacy for 3 caries management options for occlusoproximal cavitated lesions in primary molars: conventional restorations (CR; complete caries removal and compomer restoration), Hall technique (HT; no caries removal, sealing in with stainless steel crowns), and nonrestorative caries treatment (NRCT; no caries removal, opening up the cavity, teaching brushing and fluoride application). In sum, 169 children (3-8 yr old; mean, 5.56 ± 1.45 yr) were enrolled in this secondary care-based, 3-arm, parallel-group, randomized clinical trial. Treatments were carried out by specialist pediatric dentists or postgraduate trainees. One lesion per child received CR, HT, or NRCT. Outcome measures were clinical failure rates, grouped as minor failure (restoration loss/need for replacement, reversible pulpitis, caries progression, etc.) and major failure (irreversible pulpitis, abscess, etc.). There were 148 children (87.6%) with a minimum follow-up of 11 mo (mean, 12.23 ± 0.98 mo). Twenty teeth were recorded as having at least 1 minor failure: NRCT, n = 8 (5%); CR, n = 11 (7%); HT, n = 1 (1%) (p = .002, 95% CI = 0.001 to 0.003). Only the comparison between NRCT and CR showed no significant difference (p = .79, 95% CI = 0.78 to 0.80). Nine (6%) experienced at least 1 major failure: NRCT, n = 4 (2%); CR, n = 5 (3%); HT, n = 0 (0%) (p = .002, 95% CI = 0.001 to 0.003). Individual comparison of NRCT and CR showed no statistically significant difference in major failures (p = .75, 95% CI = 0.73 to 0.76). Success and failure rates were not significantly affected by pediatric dentists' level of experience (p = .13, 95% CI = 0.12 to 0.14). The HT was significantly more successful clinically than NRCT and CR after 1 yr, while pairwise analyses showed comparable results for treatment success between NRCT and CR (ClinicalTrials.gov NCT01797458).

Predicting caries by measuring its activity using quantitative light-induced fluorescence in vivo: a 2-year caries increment analysis.

The aim of this study was to analyse the predictive power of several clinical baseline parameters and the de-/remineralisation properties of in vivo etched sites measured with quantitative light-induced fluorescence (QLF) for subsequent 2-year caries increment. At baseline, in 44 children (8.23 ± 1.5 years) two areas (diameter 2 mm) of the buccal surface of a primary posterior tooth were etched with 36% phosphoric acid gel for 1 and 4 min, respectively. The etched sites were analysed immediately after etching (ΔQ1) and 24 h (ΔQ2) later by QLF. Additionally, caries status (deft/DMFT and initial caries), approximal plaque, bleeding on probing, and the patient's current use of fluorides were recorded. In the 2-year follow-up, 29 children were re-assessed. After clinical examination, the caries increment was calculated (ΔDMFT) and correlated with the baseline clinical variables and the QLF readings. Results showed a significant positive correlation between ΔQ(1 min) and the ΔDMFT (r = 0.44, p = 0.02). The ΔDMFT was significantly correlated with the baseline deft (r = 0.56, p = 0.002), cavitated active caries lesions (r = 0.52, p = 0.003), and filled teeth (r = 0.53, p = 0.003). In a regression analysis the use of fluoridated salt (SC = -0.10) and fluoride gel (SC = -0.14) were negatively associated with ΔDMFT. In conclusion, these findings suggest that the demineralisation properties of the etched sites and the outcome of the 24-hour measurements with QLF are significantly associated with caries increment. Previous caries experience strongly correlated with caries increment in this group of children.

Dental fluorosis, dental caries, and quality of life factors among schoolchildren in a Colombian fluorotic area.

OBJECTIVE: To assess dental fluorosis, dental caries and quality of life factors associated with dental fluorosis among schoolchildren living in a Colombian endemic dental fluorosis area. METHOD: 110 12-year olds were visually examined for dental caries (ICDAS) and dental fluorosis (TF) and a self-administered quality of life and fluorosis questionnaire was applied. RESULTS: The prevalence of dental fluorosis reached 100% in this sample with most children falling within the TF 3 severity category. Varying degrees of severity were observed as follows for TF 1 to 6: 1%, 16%, 62%, 16%, 4%, 2%. The prevalence of caries experience (DF-S2) was 54%. The DF-S2 mean was 4.4 (sd 4.3). The principal contributor to the DF-S2 outcome was the decayed component. When initial caries lesions were included (ICDAS-scores 1-3) the mean DF-S1,2 increased to 10 (sd 5.1). The association between fluorosis and dental caries was not statistically significant (p > 0.05). Children not only detected the presence of something abnormal in their teeth but also reported feeling embarrassed, and worried due to their dental appearance. Almost 60% of the children reported avoiding smiling because of their teeth's appearance. CONCLUSIONS: The high prevalence of dental fluorosis and dental caries combined with the schoolchildren's negative perception about their dental health reflects the need to propose effective dental public health policies to regulate multiple exposures to fluoride at an early age, and to improve health outcomes in a highly vulnerable population.

Sealing distal proximal caries lesions in first primary molars: efficacy after 2.5 years.

BACKGROUND: The prevalence of proximal caries in primary molar teeth is high in many countries. AIMS: (1) To study by means of a split-mouth design the 1- and 2.5-year efficacy of sealing proximal lesions vs. flossing instructions (control) on primary molar teeth. (2) To assess children's behaviour and pain perception during the procedure. METHODS: Ninety-one 4- to 6-year-old children from Bogotá, Colombia participated. Participants had to have at least two proximal lesions scored according to the following radiographic classification system: radiolucency (1) in enamel outer half, (2) restricted to enamel-dentine junction, or (3) restricted to dentine outer third. Baseline, 1- and 2.5-year follow-up bitewing radiographs were taken. Test and control lesions were randomly selected. After temporary separation test lesions were sealed (adhesive). Parents/caregivers received a flossing leaflet for their children. Progression of the lesions was assessed by means of independent reading of conventional bitewing radiographs. RESULTS: One-year (n = 73) test vs. control lesion progression was 27.4 vs. 50.7%, respectively (p < 0.01, McNemar's test), and 2.5-year (n = 56) test vs. control lesion progression was 46.4 vs. 71.4%, respectively (p < 0.01). The dropouts did not differ from those who remained in the study regarding relevant caries baseline data. More than 88% of the participants presented positive to definitively positive behaviour and very low or low pain intensity at both first and second appointments. CONCLUSION: The sealing technique was superior to flossing instructions both after 1 and 2.5 years of follow-up and the majority of the participants had no anxiety or pain during the treatment.

Sunflower hulls degradation by co-composting with different nitrogen sources.

The decomposition of sunflower hull and its mixtures was examined under mesophilic (M) and thermophilic (T) temperatures during 100 days. Thermophilic conditions were used to define the composting process. Vetch, alfalfa and ammonium nitrate were used as nitrogen co-substrates, in 6 treatments: sunflower hulls alone (C), sunflower hulls plus ammonium nitrate (CN), sunflower hulls plus alfalfa (CA), sunflower hulls plus alfalfa and ammonium nitrate (CAV), sunflower hulls plus vetch (CV), sunflower hulls plus vetch and ammonium nitrate (CVN). Total organic carbon (TOC), oxidizable carbon (OC), dry matter, ashes content, total nitrogen (N), cellulose, hemicellulose, lignin, pH, electrical conductivity and C to N ratio were measured to asses the efficiency of the composting process and to determine the best amendment. Results show that sunflower hulls (Sh) treatment with the organic amendments had a better response than the inorganic ones. This was concluded from the variation in the fiberfractions, the decrease in dry matter and the major decrease in C to N ratio.

Oral-health workshop targeted at 0-5-yr. old deprived children's parents and caregivers: effect on knowledge and practices.

One-session oral-health workshop was targeted at 770 parents and 60 caregivers of 0-5-year-old low-income children. Lower plaque scores (Silness & Löe-modified index) were observed in test-group-(TG) children after 1 and 6-months (Median=0) than control-group-(CG) (Median=1)(p<0.05), with a significant improvement from baseline among the TG (p<0.05). The questionnaire showed improvement in the TG parents/caregivers' knowledge after 1- 6-months regarding white-spot lesion visual recognition; with respect to the practices, these improved after 1-6 but decreased after 6-months.