Effect of Operator Experience on Ability to Place Sequential, 2-mm-thick Increments of Composite.

OBJECTIVE: To measure and compare the effect of operator experience in their ability to place composite in increments that are 2 mm thick. METHODS AND MATERIALS: Fifteen volunteers from each class of freshmen, sophomores, juniors, and senior dental students and 15 clinical faculty (total number of volunteers = 75) were asked to restore a Class I preparation that was 5 mm in diameter and 8 mm deep from the cusp tips using three increments of composite that were each to be 2 mm thick. Once completed, the models were sectioned, and the thickness of each increment was measured. A repeated-measures analysis of variance (pre-set α=0.05) was used to compare the mean increment thickness with respect to operator experience level and increment sequence number. In addition, the proportion of operators placing clinically acceptable increments (between 1.75 and 2.25 mm thick), as well as the proportions from each group who placed increments that either were thinner or thicker than this range, was determined using nonparametric analyses. RESULTS: Overall, there was an increasing trend for groups with a higher experience level to provide mean incremental thickness values close to 2 mm. However, the likelihood of placing an increment that was thicker or thinner than the manufacturer-recommended thickness was not significantly different. Regardless of the increment value, only about one-third of the increments placed fell within the desired range of 1.75 to 2.25 mm. CONCLUSIONS: Operator experience had no overwhelming significant influence on the ability to place increments of composite that were between 1.75 and 2.25 mm thick. An operator has only about one chance out of three to place a composite increment within this clinically acceptable range when using no external measurement system.

Diagnosis of Pit-and-fissure Caries Using Three-dimensional Scanned Images.

Diagnosis of the extent of pit-and-fissure caries has been subjective and thus difficult to teach and categorize for treatment planning. This in vitro study compares occlusal caries diagnosis of extracted posterior teeth (n=49) using three-dimensional (3D) scanned images vs visual examination, according to the International Caries Detection and Assessment System (ICDAS). The surfaces chosen for study represent all ICDAS classifications. Five experienced restorative faculty members examined scanned images for 60 seconds from a standardized series of views of each surface and scored them independently. One month later, the same teeth were examined visually by the same five raters with magnification and LED headlamps, with compressed air available. Intrarater and interrater agreement and validity were assessed using intraclass correlation coefficients (ICCs). The ICCs, ranging from 0.90 to 0.93, indicated excellent agreement between and within raters and between the raters and the gold standard ICDAS determination. This suggests that both photographs and 3D scans of pits and fissures are equally effective in diagnosing caries.

Tooth bleaching questions answered.

Tooth bleaching is an exciting treatment option for patients, which has many treatment options and considerations for the dentist. The purpose of this article is to answer questions in a Q&A fashion about different types of tooth bleaching and their applications to various clinical situations and patients' dental situations.

The critical barrier to progress in dentine bonding with the etch-and-rinse technique.

OBJECTIVES: The lack of durability in resin-dentine bonds led to the use of chlorhexidine as MMP-inhibitor to prevent the degradation of hybrid layers. Biomimetic remineralisation is a concept-proven approach in preventing the degradation of resin-dentine bonds. The purpose of this study is to examine the integrity of aged resin-dentine interfaces created with a nanofiller-containing etch-and-rinse adhesive after the application of these two approaches. METHODS: The more established MMP-inhibition approach was examined using a parallel in vivo and in vitro ageing design to facilitate comparison with the biomimetic remineralisation approach using an in vitro ageing design. Specimens bonded without chlorhexidine exhibited extensive degradation of the hybrid layer after 12 months of in vivo ageing. RESULTS: Dissolution of nanofillers could be seen within a water-rich zone within the adhesive layer. Although specimens bonded with chlorhexidine exhibited intact hybrid layers, water-rich regions remained in those hybrid layers and degradation of nanofillers occurred within the adhesive layer. Specimens subjected to in vitro biomimetic remineralisation followed by in vitro ageing demonstrated intrafibrillar collagen remineralisation within hybrid layers and deposition of mineral nanocrystals in nanovoids within the adhesive. CONCLUSIONS: The impact was realized by understanding the lack of an inherent mechanism to remove water from resin-dentine interfaces as the critical barrier to progress in bonding with the etch-and-rinse technique. The experimental biomimetic remineralisation strategy offers a creative solution for incorporating a progressive hydration mechanism to achieve this goal, which warrants its translation into a clinically applicable technique.

Leflunomide in rheumatoid arthritis: recommendations through a process of consensus.

OBJECTIVES: To determine, by consensus, the optimal use of leflunomide in rheumatoid arthritis (RA), using a multidisciplinary panel of experts and performing meta-analyses of available data. METHODS: A multidisciplinary panel of experts in RA was convened. Important questions, pertinent to the use of leflunomide in the treatment of RA, were defined by consensus at an initial meeting. Each question was allocated to subgroups of two or three members, who worked separately to prepare a balanced opinion, based on published literature, data from individual patients taking part in phase II and phase III clinical trials provided by Aventis, and data from a USA-based medical claims database (AETNA). The full group then reconvened to agree on an overall consensus statement. Recommendations concerning efficacy and tolerability versus comparator drugs and placebo were derived from two new meta-analyses. RESULTS: Leflunomide was at least as effective as sulphasalazine and methotrexate, and equally well tolerated on meta-analysis of trial data. Overall withdrawal rates for all adverse events were similar for all three drugs. Avoidance of the loading dose reduces 'nuisance' side-effects (e.g. nausea), but probably delays the onset of action. Adverse events could usually be managed by dose reduction and/or symptomatic therapy. CONCLUSIONS: On the basis of efficacy, safety and cost, leflunomide should be considered in patients with RA who have failed first-line DMARD drug therapy. In refractory cases, leflunomide may be used in combination with, for example, methotrexate before biological agents. Therapy should be initiated by a specialist, but repeat prescribing in general practice on a shared care basis is acceptable using agreed protocols. Clear mechanisms are required to monitor toxicity, with good communication between the patient and rheumatologist to manage nuisance side-effects and avoid unnecessary discontinuation of leflunomide.