ORCA-EFCD consensus report on clinical recommendations for caries diagnosis. Paper II: caries lesion activity and progression assessment.

INTRODUCTION: This consensus paper provides recommendations for oral health professionals on why and how to assess caries activity and progression with special respect to the site of a lesion. METHODS: An expert panel was nominated by the executive councils of the European Organization for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD). The steering committee built three working groups that were asked to provide recommendations on 1) caries detection and diagnostic methods, 2) caries activity and progression assessment and 3) obtain individualized caries diagnoses. The experts of work group 2 phrased and agreed on provisional general and specific recommendations on caries lesion activity and progression, based on a review of the current literature. These recommendations were then discussed and refined in a consensus workshop followed by an anonymous Delphi survey to determine the agreement on each recommendation. RESULTS: The expert panel agreed on general (n=7) and specific recommendations (n=6). The specific recommendations cover coronal caries on pits and fissures, smooth surfaces, proximal surfaces, as well as root caries and secondary caries/ caries adjacent to restorations and sealants (CARS). 3/13 recommendations yielded perfect agreement. CONCLUSION: The most suitable method for lesion activity assessment is the visual-tactile method. No single clinical characteristic is indicative of lesion activity; instead, lesion activity assessment is based on assessing and weighing several clinical signs. The recall intervals for visual and radiographic examination need to be adjusted to the presence of active caries lesions and recent caries progression rates. Modifications should be based on individual patient characteristics.

ORCA-EFCD consensus report on clinical recommendations for caries diagnosis. Paper III: caries diagnosis at the individual level.

The aim of the present consensus paper was to provide recommendations for clinical practice on the individual etiological and modifying factors to be assessed in the individual diagnosis of caries, and the methods for their assessment, supporting personalized treatment decisions. The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups which were asked to provide recommendations on 1) caries detection and diagnostic methods, 2) caries activity assessment and 3) forming individualised caries diagnoses. The experts responsible for "individualised caries diagnosis" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous eDelphi survey. The threshold for approval of recommendations was determined at 70% agreement. Ten recommendations were approved and agreed by the whole expert panel, covering medical history, caries experience, plaque, diet, fluoride and saliva. While the level of evidence was low, the level of agreement was typically very high, except for one recommendation on salivary flow measurement, where 70% agreed. It is recommended that all aspects of caries lesion progression and activity, recent caries experience, medical conditions and medications, plaque, diet, fluoride and saliva should be synthesized to arrive at an individual diagnosis. The expert panel merged evidence from existing guidelines and scientific literature with practical considerations and provided recommendations for their use in daily dental practice.

Clinical and ex-vivo effect of LASERs on prevention of early-enamel caries: systematic review & meta-analyses.

To investigate the in vivo and in situ effect of different types of lasers in prevention of enamel demineralization in high caries risk cases (around orthodontic brackets, around restoration and in caries susceptible pits and fissures). PubMed was searched using the following keyword sequence; (Laser therapy OR laser irradiation OR laser application) AND (enamel caries prevention OR enamel demineralization OR enamel remineralization OR early enamel caries OR early-enamel caries OR enamel resistance OR enamel decalcification OR white spot lesions WSLs OR incipient lesion OR enamel decay OR enamel Dissolution OR enamel microhardness) AND (clinical trial OR Randomized clinical trial OR In situ study). The latest literature search was ended by "30 January 2023". PubMed was used as a primary data base for study selection. Scopus, EBSCO, and Google scholar are checked in our study after results of systematic search on PubMed. Only duplicates were found. Two meta-analyses were carried out. The first, clinical meta-analysis on incidence of white spot lesions (WSLs) following CO2 laser irradiation of enamel. The second meta-analysis on ex-vivo/in situ effect of CO2 laser on microhardness of enamel. In each meta-analysis three studies were included. Risk of bias was assessed. The search identified eight studies (four ex-vivo and four clinical trials). Regarding the clinical meta-analysis, the overall standardized mean difference was 0.21 [ 95% confidence interval (CI): 0.15-0.30, p < 0.00001]. This indicates that the incidence of new WSLs in patients who received low power CO2 laser treatment was highly significantly lower than placebo groups. The heterogeneity was considerable (I2 = 71%). In the second meta-analysis, the overall standardized mean difference was 49.55 [ 95% confidence interval (CI): 37.74, 61.37, p < 0.00001]. This indicates that microhardness of enamel receiving low power (0.4-5 W) CO2 laser irradiation is highly significantly lower than control untreated enamel. The heterogeneity was substantial (I2 = 48%). Within the limitations of this study, Low level laser therapy concept with CO2 laser seems to be effective in preventing enamel caries.Prospero registration number: CRD42023437379.

Longitudinal study of the role of salivary proteins on radiation-related caries onset in head and neck cancer patients using 5000 ppm fluoride dentifrice up to one-year post-intensity modulated radiotherapy.

OBJECTIVES: Longitudinal assessment of the role of specific proteins on radiotherapy caries (RC) onset in head and neck cancer patients(HNC) up to one-year post-IMRT using a 5000ppm fluoride paste daily. MATERIALS AND METHODS: Dental status/salivary protein data were obtained from 40 HNC patients pre-IMRT, six months (T1) and 12 months (T2) post-IMRT (ethical approval/consent). DMFT/salivary parameters were quantified, including flow rate, mucin 5B/7, Immunoglobulin A (IgA), cystatin S and α-amylase. RESULTS: 45% patients had at least one carious lesion at T2, a significant reduction in the number of remaining teeth (65% <21), salivary flow rate (< 50%) and, protein secretion (< 0.05) post-IMRT. T1 IgA concentration/secretion rate was associated with RC (p < 0.05). Finally, IgA and total protein concentration obtained at T1 could provide a predictive pattern (AUC 82.3%) for the patients more predisposed to developing RC at T2. CONCLUSIONS: This study demonstrated the significant association of RC with salivary proteins in HNC patients treated with IMRT, revealing the potential role of salivary proteins in the early diagnosis of RC. CLINICAL RELEVANCE: This research contributes to revealing salivary proteins association with RC, and its role in early diagnosis. Therefore, this could be the first step towards personalized medicine approaches to improve this group quality-of-life.

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I: caries lesion detection and depth assessment.

OBJECTIVES: The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection. MATERIALS AND METHODS: The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey. RESULTS: Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel. CONCLUSION: Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations. CLINICAL RELEVANCE: The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.

Analysis of the association between salivary proteins and oral mucositis in patients with head and neck cancer undergoing IMRT: a longitudinal study.

INTRODUCTION: This longitudinal study assessed the association between salivary protein composition and the clinical onset/severity of oral mucositis (OM) in patients with head and neck tumours treated with intensity-modulated-radiotherapy (IMRT). METHODS: Saliva samples/clinical data were obtained from 40 head and neck cancer patients treated at Guy's Hospital before -IMRT(T0) and after-IMRT (T1 = 6 m, T2 = 12 m) (ethics approval/consent). Salivary flow rate, total protein concentration, and secretion rate were determined from saliva samples and compared with pre-treatment values. OM was assessed, total/specific salivary proteins, including mucin 5B and 7, IgA, cystatin-S, albumin, and α-amylase, were quantified. RESULTS: 95% patients experienced OM during IMRT, with 33 subjects reaching grade 2&3. At T1, there was a significant reduction in salivary flow rate, total protein secretion rate, α-amylase and cystatin-S compared to baseline. Remarkably IMRT did not significantly alter mucin 5B and 7, or the IgA secretion rate at any time point. At T1, all the analyzed proteins were associated with the OM outcomes. In addition, there was a significant inverse correlation between IgA concentration at T0 and the severity of OM during IMRT. CONCLUSION: This study revealed significant associations between several salivary proteins and OM in patients with head and neck cancer undergoing IMRT. Further longitudinal studies are needed to confirm these results. CLINICAL SIGNIFICANCE: The study contributes to the understanding of certain salivary proteins association with OM. This could be the first step towards identifying potential salivary markers that could offer perspectives for personalized medicine approaches to improve their quality of life (QoL). RESEARCH QUESTION: What is the association between salivary proteins and the occurrence and severity of OM in head and neck cancer patients? AIM: To assess the association between salivary protein composition with the clinical onset/severity of oral mucositis (OM) in head and neck cancer patients treated with intensity modulated radiotherapy. NULL HYPOTHESIS: There is no association between salivary proteins and onset/severity of OM in HNC patients.

Feasibility of minimum intervention oral healthcare delivery for individuals with dental phobia.

BACKGROUND: People with dental phobia often present with more active dental caries and fewer teeth. Minimally Intervention oral Healthcare offers a possible solution to address the high care needs of this group. The aim was to determine this patient group's eligibility and willingness to participate and the effect of MIOC, compared to treatment as usual (TAU), on their oral health outcomes for planning a future randomised controlled trial (RCT). Minimum intervention oral healthcare (MIOC) comprises of four interlinked domains. In the first domain, we identified and diagnosed the disease status and participants' anxiety status (≥ 19 MDAS). In the second domain, an individualised prevention-based personalised care plan was designed. During this process, patients with dental phobia were exposed to the dental environment in a stepped manner ('graded exposure') and had their urgent care provided with conscious sedation. In the 3rd domain, we took a minimally invasive operative approach to restore teeth while preserving tooth substance and limiting the use of fear-provoking stimuli (e.g., rotary instruments) when possible. At the review and the recall appointment(s) (4th domain), the patients' oral health care behaviours, disease risk/susceptibility and fear levels were re-assessed. METHODS: This two-arm randomised feasibility trial (N = 44) allocated participants to the experimental arm (MIOC) or the control arm (treatment as usual [TAU]). The primary outcomes were the eligibility and willingness to participate and feasibility to conduct a trial of MIOC for people with dental phobia. The secondary outcomes were oral health status, oral health related quality of life and care completion. A written and verbal consent for participation and dental care provision were obtained. RESULTS: Forty-four people diagnosed with dental phobia were allocated randomly to the two study arms. At the six-month recall after completed care, the outcome of each study arm was assessed. It was feasible to conduct a clinical trial (eligibility rate [56%], completion rate [81%], declined to participate [12%]). The intervention group showed improvements in all health care outcomes, and oral health related quality of life. CONCLUSION: A clinical trial of MIOC vs TAU in people with dental phobia is feasible. Preliminary findings suggest that patients in the MIOC arm are more likely to successfully complete their course of treatment. The study was 'retrospectively registered' on 02/05/2018 (ISRCT15294714) with the International Standard Randomised Controlled Trial (ISRCT).

Management of compromised first permanent molars in a cohort of UK paediatric patients referred to hospital-based services.

BACKGROUND: There are diverse opinions among dentists about managing compromised first permanent molars (cFPMs) in children and a perceived lack of guidance to help them evaluate prognosis. AIM: To evaluate the current management of cFPM in children referred to a UK hospital centre and to report the severity of the affected teeth. DESIGN: A service evaluation was undertaken, based on case records of medically fit children (6-11 years) referred to for the management of cFPMs. The presence of hypomineralisation, post-eruptive breakdown and the proposed care plans were recorded. Radiographic signs of severity were scored using the ICDAS index (intra/inter-rater kappa 0.96/0.82). RESULTS: From 349 records screened over a 4-month period, 249 met the selection criteria. Almost 81% were planned to have extraction of at least one cFPM, whereas 19.3% were managed without extraction. More than half of the extraction cases (n = 105) had radiographic radiolucencies not exceeding the middle third of dentine in the worst-affected FPM. At the time of extraction, the mean age of the patients was 9.8 years (±0.9). GA was used in 196 (97.5%) cases, and 40.8% had not received previous treatment in any of their cFPMs. CONCLUSION: Potentially restorable cFPMs in children is, most of the time, in a cohort of UK patients referred for tier 3 services, being managed by timed extractions under general anasethesia.

A Decentralized Sensor Fusion Scheme for Multi Sensorial Fault Resilient Pose Estimation.

This article proposes a novel decentralized two-layered and multi-sensorial based fusion architecture for establishing a novel resilient pose estimation scheme. As it will be presented, the first layer of the fusion architecture considers a set of distributed nodes. All the possible combinations of pose information, appearing from different sensors, are integrated to acquire various possibilities of estimated pose obtained by involving multiple extended Kalman filters. Based on the estimated poses, obtained from the first layer, a Fault Resilient Optimal Information Fusion (FR-OIF) paradigm is introduced in the second layer to provide a trusted pose estimation. The second layer incorporates the output of each node (constructed in the first layer) in a weighted linear combination form, while explicitly accounting for the maximum likelihood fusion criterion. Moreover, in the case of inaccurate measurements, the proposed FR-OIF formulation enables a self resiliency by embedding a built-in fault isolation mechanism. Additionally, the FR-OIF scheme is also able to address accurate localization in the presence of sensor failures or erroneous measurements. To demonstrate the effectiveness of the proposed fusion architecture, extensive experimental studies have been conducted with a micro aerial vehicle, equipped with various onboard pose sensors, such as a 3D lidar, a real-sense camera, an ultra wide band node, and an IMU. The efficiency of the proposed novel framework is extensively evaluated through multiple experimental results, while its superiority is also demonstrated through a comparison with the classical multi-sensorial centralized fusion approach.

A systematic review and meta-analysis of the role of sugar-free chewing gum on Streptococcus mutans.

BACKGROUND: Preventive strategies targeting Streptococcus mutans may be effective in reducing the global burden of caries. The aim of the current systematic review of published literature was to determine the difference in level of Streptococcus mutans in adults and children who chew sugar-free gum (SFG), compared with those who did not chew gum, who chewed a control gum or received alternatives such as probiotics or fluoride varnish. METHODS: Systematic review (PROSPERO registration No. CRD42018094676) of controlled trials with adult and child participants where chewing of SFG was the main intervention. Databases searched (1 Jan 1946 to 31 August 2020): MEDLINE, EMBASE, PsycINFO, Scopus, Web of Science, Allied and Complimentary Medicine Database, Cochrane Central Register of Controlled Trials (CENTRAL), Open Grey, PROSPERO and the Cochrane library of systematic reviews. 'Search terms included Medical Subject Headings, and free text to cover the following range of constructs: chewing gum, sugar free, oral health, caries, xerostomia, periodontal disease. Data extraction and Risk of Bias assessment was undertaken by three researchers using a modified version of the Cochrane RoB tool (version 1). Data synthesis was conducted using meta-analysis in STATA. RESULTS: Thirteen studies of SFG with micro-organisms as outcomes were identified. The use of SFG significantly reduced the load of Streptococcus mutans (effect size - 0.42; 95% CI - 0.60 to - 0.25) compared to all controls. In seven of the 13 studies the confidence intervals of the effect size estimate included zero, suggesting no effect of the intervention. Twelve trials used xylitol gum only as the basis of the intervention; xylitol gum significantly reduced the load of Streptococcus mutans (effect size - 0.46; 95% CI - 0.64 to - 0.28) in comparison to all controls. There was a moderate level of heterogeneity across the included studies. No adverse effects were recorded. CONCLUSION: Chewing SFG reduces the load of Streptococcus mutans in the oral cavity in comparison to non-chewing controls. Considering the degree of variability in the effect and the moderate quality of the trials included, there is a need for future research exploring the use SFG as a preventive measure for reducing the cariogenic oral bacterial load.

Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care.

BACKGROUND: Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth. METHOD: This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes. DISCUSSION: SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN. TRIAL REGISTRATION NUMBER: ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: https://www.isrctn.com/ISRCTN76503940?q=ISRCTN76503940%20&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search .

How to Intervene in the Caries Process in Older Adults: A Joint ORCA and EFCD Expert Delphi Consensus Statement.

AIM: To provide recommendations for dental clinicians for the management of dental caries in older adults with special emphasis on root caries lesions. METHODS: A consensus workshop followed by a Delphi consensus process were conducted with an expert panel nominated by ORCA, EFCD, and DGZ boards. Based on a systematic review of the literature, as well as non-systematic literature search, recommendations for clinicians were developed and consented in a two-stage Delphi process. RESULTS: Demographic and epidemiologic changes will significantly increase the need of management of older adults and root caries in the future. Ageing is associated with a decline of intrinsic capacities and an increased risk of general diseases. As oral and systemic health are linked, bidirectional consequences of diseases and interventions need to be considered. Caries prevention and treatment in older adults must respond to the patient's individual abilities for self-care and cooperation and often involves the support of caregivers. Systemic interventions may involve dietary counselling, oral hygiene instruction, the use of fluoridated toothpastes, and the stimulation of salivary flow. Local interventions to manage root lesions may comprise local biofilm control, application of highly fluoridated toothpastes or varnishes as well as antimicrobial agents. Restorative treatment is often compromised by the accessibility of such root caries lesions as well as the ability of the senior patient to cooperate. If optimum restorative treatment is impossible or inappropriate, long-term stabilization, e.g., by using glass-ionomer cements, and palliative treatments that aim to maintain oral function as long and as well as possible may be the treatment of choice for the individual.

How to Intervene in the Caries Process in Children: A Joint ORCA and EFCD Expert Delphi Consensus Statement.

This paper provides recommendations for dentists for the treatment of dental caries in children, with an emphasis on early childhood caries (ECC), primary teeth, and occlusal surfaces in permanent teeth. A consensus workshop followed by an e-Delphi consensus process was conducted with an expert panel nominated by the European Organization for Caries Research (ORCA) and European Federation of Conservative Dentistry (EFCD)/German Association of Conservative Dentistry (DGZ) boards. Based on 3 systematic reviews and a nonsystematic literature search, recommendations were developed. The caries decline has led to a more polarized disease distribution in children and adolescents along social gradients which should be taken into account when managing the caries process at all levels, such as the individual, the group, or a population. The control or reduction of caries activity is the basis for successful caries management. In children, caries management requires adequate daily oral hygiene and fluoride application via toothpaste, ensured by caregivers, and especially for ECC prevention an emphasis on sugar intake reduction is needed. These noninvasive interventions are also suitable to arrest or control initial or even cavitated dentine caries lesions in the absence of irreversible pulpitis. Fluoride varnish or silver diammine fluoride can be added as supplementary agents. In pits and fissures, composite resin materials can be used as preventive sealants and for defect-oriented minimally invasive restorations. In primary molars, preformed metal crowns are more successful than multisurface fillings, especially in caries-active patients. With persisting high caries activity, multiple lesions, and limited cooperation, caries control should consist of robust measures with high success rates, even including extraction in selected cases. This applies especially to treatments performed under general anesthesia.

In vitro compressive strength and edge stability testing of directly repaired glass-ionomer cements.

OBJECTIVE: To study the repair potential of seven commercial glass-ionomer cements (GICs) using an in vitro edge compression test model. MATERIALS AND METHODS: A total of 448 normal and 192 repaired cylindrical specimens (6 × 4 mm) were produced from 6 GICs and one resin-modified GIC. Repaired samples consisted of a base aged for 1 month before repaired by an overlying layer. All samples were matured for 1 day, 1 week, 1 month or 3 months before compression, and edge tests were performed respectively on the whole surface (compressive strength, CS) or on the edge (edge stability, ES) using a universal testing machine. RESULTS: For normal specimens, Ketac Universal (KU) illustrated a significantly higher CS than other groups at all time points (p < 0.001). ES of KU was weaker than EQUIA Forte (EQF), FIX (Fuji IX) and RSC (Riva Self Cure) after 1 day, increasing after 1 week. Repaired specimens showed CS comparable to normal specimens (p > 0.05). Repaired KU significantly improved CS compared to repaired EQF and Fuji II (FII) after 1 day. No statistical difference was found in ES among these groups (p > 0.05). CONCLUSIONS: KU provided the fastest maturation and greatest CS and ES in both normal and repair models after short-term ageing. Repair of GICs could potentially be achieved directly onto the fractured substrate and the subsequent improved mechanical performance could be maintained for at least 3 months. CLINICAL RELEVANCE: This study provides a potential alternative in-vitro method to assess GIC restoration failure as well as provide insight into the mechanisms of GIC restoration repair.

Secondary caries: what is it, and how it can be controlled, detected, and managed?

OBJECTIVES: To assess how to control, detect, and treat secondary caries. This review serves to inform a joint ORCA/EFCD consensus process. METHODS: Systematic and non-systematic reviews were performed or consulted and narratively synthesized. RESULTS: Secondary (or recurrent) caries is defined as a lesion associated with restorations or sealants. While the restorative material itself has some influence on secondary caries, further factors like the presence and size of restoration gaps, patients' caries risk, and the placing dentist's experience seem more relevant. Current detection methods for secondary caries are only sparsely validated and likely prone for the risk of over-detection. In many patients, it might be prudent to prioritize specific detection methods to avoid invasive overtreatment. Detected secondary caries can be managed either by repair of the defective part of the restoration or its complete replacement. CONCLUSIONS: There is sparse data towards the nature of secondary caries and how to control, detect, and treat it. CLINICAL SIGNIFICANCE: Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries. Longer-term studies may be needed to identify differences in secondary caries risk between materials and to identify characteristic features of progressive lesions (i.e., those in need of treatment).

How to intervene in the caries process in adults: proximal and secondary caries? An EFCD-ORCA-DGZ expert Delphi consensus statement.

OBJECTIVES: To provide consensus recommendations on how to intervene in the caries process in adults, specifically proximal and secondary carious lesions. METHODS: Based on two systematic reviews, a consensus conference and followed by an e-Delphi consensus process were held with EFCD/ORCA/DGZ delegates. RESULTS: Managing an individual's caries risk using non-invasive means (oral hygiene measures including flossing/interdental brushes, fluoride application) is recommended, as both proximal and secondary carious lesions may be prevented or their activity reduced. For proximal lesions, only cavitated lesions (confirmed by visual-tactile, or radiographically extending into the middle/inner dentine third) should be treated invasively/restoratively. Non-cavitated lesions may be successfully arrested using non-invasive measures in low-risk individuals or if radiographically confined to the enamel. In high-risk individuals or if radiographically extended into dentine, for these lesions, additional micro-invasive (lesion sealing and infiltration) treatment should be considered. For restoring proximal lesions, adhesive direct restorations allow minimally invasive, tooth-preserving preparations. Amalgams come with a lower risk of secondary lesions and may be preferable in more clinically complex scenarios, dependent on specific national guidelines. In structurally compromised (especially endodontically treated) teeth, indirect cuspal coverage restorations may be indicated. Detection methods for secondary lesions should be tailored according to the individual's caries risk. Avoiding false positive detection and over-treatment is a priority. Bitewing radiographs should be combined with visual-tactile assessment to confirm secondary caries detections. Review/refurbishing/resealing/repairing instead of replacing partially defective restorations should be considered for managing secondary caries, if possible. CONCLUSIONS: An individualized and lesion-specific approach is recommended for intervening in the caries process in adults. CLINICAL SIGNIFICANCE: Dental clinicians have an increasing number of interventions available for the management of dental caries. Many of them are grounded in the growing understanding of the disease. The best evidence, patients' expectations, clinicians' expertise, and the individual clinical scenario all need to be considered during the decision-making process.

A curriculum for behaviour and oral healthcare management for dentally anxious children-Recommendations from the Children Experiencing Dental Anxiety: Collaboration on Research and Education (CEDACORE).

BACKGROUND: Dentists need training in the management of children's anxiety (DA), fear (DF) and behaviour management problems (DBMP) but little is known of their competence on this topic. AIM: To report dentists' opinions and attitudes about protective stabilisation and pharmacological techniques for the management of children with DA/DF/DBMP; to propose a postgraduate curriculum focussing on DA/DF/DBMP. DESIGN: A survey of 301 Brazilian dentists and later a modified Delphi process to outline the curriculum in two phases: (a) face-to-face discussions with 33 early career researchers mentored by six researchers, both from UK and Brazil; (b) online discussions by eight early and senior researchers on the knowledge, experience, and competencies necessary for a specialist in paediatric dentistry in Brazil that should be included in the core curriculum of postgraduate courses. RESULTS: Almost all (99.0%) of the survey respondents provide treatment to children with DA/DF/DBMP, and 91.2% do not systematically diagnose these conditions; 94.3% use protective stabilisation, and 20.0%-30.0% have training in pharmacological techniques. The four-domain framework supporting the proposed curriculum is as follows: DA/DF/DBMP assessment, non-pharmacological and pharmacological approaches, and decision-making. CONCLUSION: Dental curricula should be customised to solve the misconceptions and promote a comprehensive and positive attitude to DA/DF/DBMP by paediatric oral healthcare practitioners.

Evaluation of the efficacy of calcium silicate vs. glass ionomer cement indirect pulp capping and restoration assessment criteria: a randomised controlled clinical trial-2-year results.

OBJECTIVES: Assess calcium silicate cement (Biodentine™) vs. glass ionomer cement (Fuji IX™, control) as indirect pulp capping (IPC) materials in patients with reversible pulpitis after a 2-year follow-up. Evaluate the integrity of the overlying resin composite restorations using modified USPHS criteria and FDI criteria. Investigate the sensitivity of the modified USPHS criteria compared to the FDI criteria in the assessment of the restorations. MATERIALS AND METHODS: Seventy-two restorations (36 Biodentine™, 36 Fuji IX™) were placed randomly in 53 patients. Periapical radiographs were taken at pre-treatment (T0), 12-month (T12), and 24-month (T24) review. Restorations were assessed using the modified USPHS and FDI criteria at T12 and T24. RESULTS: At 24 months, 15 teeth had failed to maintain vitality (6 Biodentine™, 9 Fuji IX™). Clinical success rate of IPC for both materials was 72% and is related to the intensity of reversible pulpitis symptoms. No difference was found between T12 and T24 in the periapical (PA) radiographs and in the integrity of the resin composite restorations overlying Biodentine™ compared to Fuji IX™. There was no difference in the efficacy of the USPHS criteria compared to the FDI criteria in the assessment of the resin composite restorations. CONCLUSIONS: Biodentine™ and Fuji IX™ were clinically effective when used as IPC materials in teeth with reversible pulpitis at T24. Resin composite restorations overlying both materials performed well at T24. Using the USPHS or FDI criteria is equally efficient at T24; however, longer term follow-up is needed to establish whether there are sensitivity differences between these assessment criteria. CLINICAL SIGNIFICANCE: Teeth with deep carious lesions approaching the pulp and with signs of reversible pulpitis can be treated successfully by indirect pulp capping using either Biodentine™ or Fuji IX™. Using the USPHS or FDI criteria to assess restorations is equally effective at 2 years. TRIAL REGISTRATION: NCT02201641.

When to intervene in the caries process? An expert Delphi consensus statement.

OBJECTIVES: To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions. METHODS: Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference. RESULTS: Carious lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations will be placed for reasons of form, function and aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated carious lesions which are cleansable. Cavitated lesions which are not cleansable usually require invasive/restorative management, to restore form, function and aesthetics. In specific circumstances, mixed interventions may be applicable. On occlusal surfaces, cavitated lesions confined to enamel and non-cavitated lesions radiographically extending deep into dentine (middle or inner dentine third, D2/3) may be exceptions to that rule. On proximal surfaces, cavitation is hard to assess visually or by using tactile methods. Hence, radiographic lesion depth is used to determine the likelihood of cavitation. Most lesions radiographically extending into the middle or inner third of the dentine (D2/3) can be assumed to be cavitated, while those restricted to the enamel (E1/2) are not cavitated. For lesions radiographically extending into the outer third of the dentine (D1), cavitation is unlikely, and these lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds. CONCLUSIONS: Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions. CLINICAL RELEVANCE: Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.