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New caries detection technologies and modern caries management: merging the strategies.

Literature over the past decade has suggested that dental caries be treated as a curable and preventable infectious disease. The emphasis is placed on early detection and intervention, including chemical therapies and minimally invasive strategies. There are now new detection technologies commercially available to help detect carious lesions early; however, what seems to be lacking is a clear strategy on how to merge these new technologies in a way consistent with today's changing paradigm of caries management. There is a real danger that these early detection technologies may be used to unnecessarily and overaggressively "drill and fill" using Black's "extension for prevention" preparations. This paper will review the literature and key strategies for caries management and early detection and suggest one way (not necessarily the only way) in which they may be used in harmony. Two relatively new detection technologies (DIAGNOdent and DIFOTI) will be reviewed.

Anti-Infective Agents, Local↗

Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children.

Untreated dental caries in Chinese pre-school children is common. This prospective controlled clinical trial investigated the effectiveness of topical fluoride applications in arresting dentin caries. Three hundred seventy-five children, aged 3-5 years, with carious upper anterior teeth were divided into five groups. Children in the first and second groups received annual applications of silver diamine fluoride solution (44,800 ppm F). Sodium fluoride varnish (22,600 ppm F) was applied every three months to the lesions of children in the third and fourth groups. For children in the first and third groups, soft carious tissues were removed prior to fluoride application. The fifth group was the control. Three hundred eight children were followed for 30 months. The respective mean numbers of arrested carious tooth surfaces in the five groups were 2.5, 2.8, 1.5, 1.5, and 1.3 (p < 0.001). Silver diamine fluoride was found to be effective in arresting dentin caries in primary anterior teeth in pre-school children.

Analysis of Variance↗

Restoration of teeth with more-viscous glass ionomer cements following radiation-induced caries.

OBJECTIVE: To assess the suitability of more-viscous conventional restorative glass ionomer cements (GICs) in a high-caries risk group of patients. METHODS: Fifteen adult patients with radiation-induced caries were treated at a dental hospital by one dentist. Two encapsulated aesthetic GICs were used in each patient to restore 146 carious lesions in the exposed dentine and cementum of 93 teeth. The restorations were assessed directly over two years for their retention, secondary caries, anatomic form, marginal integrity, marginal discolouration, and surface texture. RESULTS: Both GICs were placed in similar sized cavities (P = 0.63). After two years, although 30.0% of Ketac-Molar Aplicap and 12.5% of Fuji IX GP restorations had been lost (P = 0.01), there were no instances of secondary caries. The remaining GICs showed ongoing marginal deterioration, but there were very few instances where this required the repair or replacement of the restorations. No restorations failed from surface erosion. CONCLUSIONS: In these high-caries risk patients the placement of more-viscous GICs appeared to prevent secondary caries, even when the restorations were subsequently lost.

Adult↗

[Dental caries prevalence in permanent teeth of schoolchildren in the Municipality of Sao Paulo, Brazil, 1970-1996].

OBJECTIVE: To assess the evolution of dental caries in permanent teeth of schoolchildren in S. Paulo City, Brazil, during the period of 1970-1996. METHODS: The World Health Organization methodology for oral health surveys was applied in 2,491 schoolchildren, both male and female from 103 public and private schools. A probabilistic sample stratified by age, school category, and city zones was obtained by the Education State Service data system. Computational resources were used. RESULTS: Data from the 1996 S. Paulo survey were compared with others data provided by studies such as the one conducted in the same city and the reference-population in the second half of the 20th century. In the 60s and 70s the DMF-T Index among 12-year-old schoolchildren was around 7.0. In 1986 it was 6.5 and in 1996 it was registered 2.1, a decline of 68%. CONCLUSION: Dental caries in permanent teeth among S. Paulo City 12-year-old schoolchildren changed from a "very high" to "low" prevalence.

Age Distribution↗

Xylitol in the prevention of oral diseases.

Special needs populations such as the mentally disabled or developmentally disabled present a unique challenge for the dental professionals providing dental treatment. Among those challenges is oral health promotion through primary prevention of dental caries and periodontal disease. There are many barriers to adequate oral care for these special needs patients that include cost, physical limitations, low levels of perceived need and lack of dental knowledge by residents and staff, if the person resides in an institution. Primary prevention to maintain oral comfort and function for these patients is a priority to support their quality of life. Typical oral health problems of these patients include hyposalivation, root-surface caries, poor oral hygiene, a high prevalence of periodontal disease and dental caries. The purpose of this paper is to review information for the inclusion of xylitol in primary preventive regimens as an adjunct for the prevention of oral diseases for special needs patients.

Cariostatic Agents↗

Irradiation effects on microhardness of fluoridated and non-fluoridated bovine dentin.

The objective of this study was to evaluate the effects of irradiation on microhardness of dentin. Dentin blocks from the cervical region of bovine incisors were treated as follows: (1) no irradiation; (2) irradiation of specimens up to 60 Gy (2 Gy/day, 5 days/week); (3) no irradiation, but fluoridation of specimens for 5 min/d; (4) irradiation of specimens and daily fluoridation. Knoop hardness number (KHN) of the control specimens was 62.63+/-14.75 (mean+/-SD). This was significantly different from the irradiated dentin samples (8.74+/-2.59 KHN). Hardness of the fluoridated dentin specimens was 11.19+/-1.95 KHN in the non-irradiated group and 10.03+/-2.76 KHN in the irradiated groups, respectively. Within the limitations of an in vitro study, it is concluded that dentin is severely affected by irradiation. This could be an explanation for the frequently observed side-effects of irradiation like loss of enamel, gap formation at the amelodentinal junction, and caries of the cervical region. Fluoridation with acidic gels decreases microhardness of dentin surface, and does not prevent softening due to radiation, when saliva is absent.

Animals↗

The periodontal response to cantilevered resin-bonded bridgework.

This study investigated 84 cantilevered resin-bonded bridges (CRBB) in 60 patients. These CRBB (single retainer, single pontic) had been in place for an average of 43.6 months. Periodontal health was assessed on abutment teeth and contralateral control teeth. Periodontal indices utilized were Plaque Index (PI), Gingival Index (GI), Bleeding Index (BI), Pocket Depth (PD) and mobility. The marginal adaptation, the gingival extension of the retainers and the presence or absence of caries around each retainer margin were also assessed. Information about the history of debonding was collected and a success rate of 93% was reported. PI, GI and mean PD compared statistically significantly, less favourably, with scores of the control teeth. Marginal adaptation of the retainers was of a high standard and caries did not appear to be a problem.

Adolescent↗

A clinical comparison of glass ionomer, resin-modified glass ionomer and resin composite restorations in the treatment of cervical caries in xerostomic head and neck radiation patients.

Controversy exists as to whether there is less secondary caries at the margins of glass ionomer restorations compared with other materials that do not release fluoride. This study examined the incidence of secondary caries for three types of restorative materials in Class V restorations in xerostomic patients. The study group consisted of 45 high caries-risk adult patients who had undergone head and neck irradiation for the treatment of cancer. All were substantially xerostomic and in need of at least three restorations in the same arch. Every patient received a restoration with each of the test materials, a conventional glass ionomer (GI), a resin modified glass ionomer (RMGI) and a resin composite (C). Patients were instructed in the daily use of a neutral pH sodium fluoride gel in custom trays. Recall appointments were made at 6, 12, 18 and 24 months, and the restorations were examined for material loss, marginal integrity and recurrent caries at the restoration margin. Fluoride compliance was determined at each recall period and recorded as the percentage of recommended use during that interval. Patients were categorized at the end of the study as fluoride non-users if their average compliance was 50% or less. Those with greater than 50% compliance were categorized as fluoride users. In the latter group, no recurrent caries was found for any of the restorations, whereas a material-dependent incidence of recurrent caries was found in the fluoride non-user group. None of the GI, one RMGI and eight C restorations failed due to recurrent caries. For the fluoride non-user patients, Fishers exact test (p=0.05) showed no statistical difference between GI and RMGI but statistical differences were found among those materials and resin composite at each recall period. Recurrent caries reductions for GI and RMGI relative to C were greater than 80% in xerostomic patients not using topical fluoride supplementation.

Adult↗

A model for producing caries-like lesions in enamel and dentin using oral bacteria in vitro.

Subsurface enamel lesions and root surface caries-like lesions were consistently produced in vitro using Streptococcus mutans FA1 cultured in thioglycollate broth containing 3.5% w/v dextrose and 2% w/v gelatin. When viewed in polarized light and after imbibition in water, the enamel lesions had a negatively birefringent surface zone and positively birefringent body of the lesion. Those lesions produced after six weeks, after imbibition in quinoline, exhibited a dark zone. The root surface caries-like lesions exhibited a less-radiolucent surface zone above a heavily demineralized body of the lesion. However, no reactionary dentin was seen in the in vitro lesions.

Dental Caries↗

Crown lengthening: the periodontal-restorative connection.

Crown lengthening procedures are based on biologic principles that can be determinants for successful treatment. These procedures are fixed on an understanding of the biologic width. A few of the indications for crown lengthening are caries beneath the gingival margin, fractured teeth with insufficient clinical crown exposure, and teeth with excessive occlusal or incisal wear. This article describes flap designs, the use of a new bur probe for precise measurement of clinical crown exposure, and suturing methods for flap stabilization. Clinical documentation of patients with various clinical situations requiring crown lengthening is presented.

Crown Lengthening↗

Critical evaluation of the composition and use of topical fluorides.

This report reviews the current status of various topical fluoride systems commonly used for caries prevention; these systems include professional fluoride applications, prophylaxis pastes, varnishes, rinses, gels, and dentifrices. Although the cariostatic benefits of professional applications are well-established from early studies, the magnitude of benefit relative to other preventive measures needs to be re-assessed under current conditions. Significant cariostatic benefits from fluoride prophylaxis pastes remain to be established, as does the relative efficacy of fluoride varnishes in comparison with other fluoride measures. The established cariostatic activity of fluoride rinses with supervised usage needs confirmation under normal home usage conditions. There is inadequate evidence to justify either increasing or decreasing the concentration of fluoride in conventional dentifrices whose efficacy is well-established. Based on limited clinical data and supportive laboratory data, fluoride appears to be effective for preventing root-surface caries.

Dental Caries↗

Rehabilitation of a bulimic patient using endosteal implants.

This article describes the dental rehabilitation of a bulimic patient using endosteal implants. Although the patient, a 31-year-old woman with a long history of bulimia nervosa, had been receiving medical and psychological treatment, the condition was not completely controlled. Clinical examination revealed multiple crowns with extensive cervical caries. The prognosis for all remaining teeth was poor. After extractions, implant therapy was implemented to provide support for fixed prostheses. After the implants were uncovered and during provisional therapy, the peri-implant tissue exhibited inflammation and lack of keratinized tissue requiring additional periodontal procedures before definitive restorations could be placed. Because of the difficulty in managing the peri-implant tissue during the many phases of implant therapy, treatment was challenging. One year after treatment, the patient's low self-esteem had improved substantially and her restorations provided satisfactory esthetics and function.

Adult↗

The use of ozone in dentistry and medicine.

There is growing interest in the use of ozone in oral healthcare and the National Institute for Clinical Excellence (NICE) is at present reviewing the evidence for its effectiveness in the management of occlusal and plain surface caries. These are only two of the clinical problems for which ozone can, and has, been used; it has also been employed for a wide variety of other purposes in both dentistry and medicine. This pale blue-coloured gas plays an important role as a natural constituent in the higher layer of the Earth's atmosphere. There is growing evidence that it can be employed as a useful therapeutic agent. This paper reviews its therapeutic uses to date and suggests its possible future clinical applications. Consumer demands for this strong oxidant may increase as the general public becomes increasingly aware of its therapeutic capacity and the non-invasive manner in which it can be administered.

Air Pollutants↗

Cervical compomer restorations: the role of cavity etching in a 48-month clinical evaluation.

Compomers are defined as polyacid-modified resin composites. They are supposed to combine the advantages of traditional glass-ionomer cements with resin composites. This study clinically evaluated a compomer in cervical cavities. Sixty cervical cavities in premolars and molars (24 with cervical caries and 36 with abrasions) randomly divided into two groups of 30 teeth (Group 1 and Group 2) were restored with Dyract (DeTrey-Dentsply, York, PA 17405-0872). The cavities of Group 2 were etched for 30 seconds with orthophosphoric acid before compomer application, while the Group 1 cavities received no treatment. All the restorations were evaluated every six months, up to 48 months: characteristics assessed according to USPHS-modified standards were retention, secondary caries, post-operative sensitivity, marginal adaptation and discoloration, color and wear. The Kaplan-Meier's survival analysis was performed. In both groups, retention was high without any statistically significant difference. No difference was found between the two groups for caries, post-operative sensitivity and wear--that all had a low incidence. Color was not perfectly matched, however, there was no statistically significant difference between the two groups. Marginal discoloration and marginal adaptation loss were significantly higher in non-etched group (p < 0.05). Clinically relevant failure required 17.2% of restorations in the non-etched group and 10% in the etched group to be replaced: this difference was not statistically significant. Dyract has an acceptable clinical behavior when used in cervical cavities. Its marginal adaptation is enhanced by etching.

Acid Etching, Dental↗

Simultaneous team approach of a crown-lengthening procedure and an operative restoration: technique and long-term effect.

Traditionally, crown-lengthening procedures to expose subgingival caries for operative restorative work are carried out in a two-stage approach. A disadvantage of this procedure is that the gingival margin associated with the treated tooth moves apically; this may create an esthetic problem. Resin-modified glass-ionomer cement has been demonstrated to have good biocompatibility with dental hard and soft tissues. Surgical and restorative procedures were combined at the same appointment in an effort to achieve a restoration with minimal change in the gingival margin. Four patients have been treated with this one-stage team approach and followed for 8 to 13 months. The clinical results demonstrated this team approach procedure is excellent for the dentition when esthetics is a consideration.

Adult↗

Criteria for caries removal at the enamel-dentine junction: a clinical and microbiological study.

In the UK cavity preparation at the enamel-dentine junction (EDJ) is considered complete when all soft and/or stained tissue is removed. The aim of the present work was to link the clinical criteria of dentine consistency and dentine colour with the microbiological status of the tissue. Cavities were prepared in 564 teeth. Under rubber dam, access to the EDJ was gained and the sample sites selected (n = 847). Their consistency was noted as hard or soft and wet or dry when probed. The colour of the site was noted as stain-free or stained. Dentine was sampled using a round bur. After microbiological processing the total anaerobic count and counts of mutans streptococci and lactobacilli were expressed as log10 [CFU per sample]. Soft sites harboured significantly more bacteria than hard sites (P < 0.001). Soft and wet sites harboured significantly more bacteria than soft and dry sites (P < 0.001). Stained and hard sites harboured more bacteria than stain-free and hard sites (P < 0.05) but this difference was not considered to be clinically relevant. The relatively simple clinical criteria used here correlated significantly with the microbial findings. All soft dentine must be removed at the EDJ to ensure minimal infection of the underlying hard dentine. However, it may not be necessary to continue preparation until the EDJ is also stain-free.

Adult↗

Effect of selected beta-blockers on supragingival calculus formation.

Supragingival plaque and calculus indices, salivary flow rates, pH, ionic and total calcium concentrations, total phosphate concentration, and the number of cervical restorations and caries lesions were measured in 29 subjects using systemic beta-(beta) blockers and in 28 subjects who were not taking any systemic medication. After 8 weeks of normal oral hygiene following an oral prophylaxis, a second comparison of each of the above quantities was made. With the exception of the calculus indices and the incidence of cervical restorations, no significant differences were found for any of the measured quantities between the medicated and non-medicated groups at either examination. The medicated group showed significantly lower mean calculus values than the non-medicated group at both examinations and a higher incidence of cervical restorations at the baseline examination, suggesting that beta-blockers decrease the rate of mineralization in the oral cavity. Since beta-blockers did not appear to alter stimulated salivary pH, flow rate, phosphate, ionic calcium or total calcium concentrations, their effect on the mineralization processes must be attributed to other mechanisms. Two hypotheses appear plausible: changes in salivary mineralization rates caused by either direct physico-chemical effects of the secreted beta-blockers in the saliva, or by alterations in the salivary protein/glycoprotein composition, enzymes and oral bacterial flora owing to systemic pharmacological effects of beta-blockers.

Adrenergic beta-Antagonists↗