The dilemma of selecting suitable proximal carious lesions in primary molars for restoration using ART technique.

OBJECTIVE: To determine the examiner's accuracy in selecting proximal carious lesions in primary molars for restoration using the atraumatic restorative treatment (ART) approach. BASIC RESEARCH DESIGN: Intervention study. CLINICAL SETTING AND PARTICIPANTS: A total of 804 six to eight year-olds from 30 rural schools in Kenya participated in the study. INTERVENTION: Three examiners selected a total of 1,280 suitable proximal carious lesions in primary molars after examining 6,002 children from 30 schools randomly selected out of 142 schools in two divisions. Seven operators randomly paired on a daily basis with eight assistants restored the lesions. An explanation was provided for any cavity that was not restored. Pre-and post-operative radiographs of the cavities were also taken for evaluation. MAIN OUTCOME MEASURES: The examiner's choice of suitable proximal cavities restorable using the ART approach was related to the decision made to either restore or not during the operative stage. The radiographic findings of the selected cavities were also compared to the decision made by the operator. The results obtained were used to determine the examiner's accuracy in selecting suitable proximal cavities for restoration using the ART approach. RESULTS: The majority of the children recruited in the study were excluded due to absenteeism, pulpal-exposure or anxiety during the operative stage. Only 804 children received one restoration in their primary molars. The examiner's accuracy in selecting suitable ART-restorable cavities clinically was 94.9% and based on radiographic analysis was 91.7%. CONCLUSIONS: A trained and diligent examiner has a very good chance of selecting proximal carious lesions restorable with the use of ART approach, without the threat of dental pulpal-involvement during the excavation of caries.

[Caries: diagnostics, monitoring and guidance in good oral health behaviour. A reorientation]. / Cariës: diagnostiek, monitoren en begeleiden naar goed mondzorggedrag. Een heroriëntatie.

Caries is a dynamic process which can develop either progressively or regressively under the all-determining influence of oral health behaviour. Management of caries therefore involves first of all: diagnostics, monitoring and preventive care and treatment which result in good oral health behaviour. The oral care provider should recognize all phases ofprogression of the caries process, and should be able to differentiate the symptoms which indicate an active or inactive process. A well maintained patient dossier is necessary to monitor this process over time. Following this procedure, the oral care provider is in a position to guide the patient with relevant information in order to achieve the final objective, good oral health.

Two-year survival of glass ionomer sealants placed as part of proximal atraumatic restorative treatment restorations.

OBJECTIVE: To evaluate after two years, the survival rate of glass ionomer cement (GIC) sealants placed in primary molars of six to eight year-olds and as part of proximal atraumatic restorative treatment (ART) restoration. DESIGN: A longitudinal clinical study. SETTING: Matungulu/Kangundo rural divisions, Machakos district, Kenya. SUBJECT: A total of 804 six to eight year-olds from rural Kenya received a sealant as part of a proximal restoration placed in a primary molar using the atraumatic restorative treatment (ART) approach. RESULTS: The two-year cumulative survival of the sealants was 10.9%, and the survival of the sealants was not significantly affected by the GIC material brand and the tooth-isolation method used. However, slightly more sealants survived when Fuji IX and rubber dam tooth- isolation method were used. CONCLUSION: The two-year survival rate of the sealants was poor and was not significantly influenced by the GIC material or the tooth-isolation method used.

[Principles of oral health care for children]. / Uitgangspunten van mondzorg voor kinderen.

In this article the principles of child oral health care in the Netherlands and the consequences of cariological principals of oral health care delivery to children are described. First of all the age of the child plays a very significant role in decisions concerning prevention and restoration. In addition, the combination of a positive attitude on the part of the dentist and a pain-free treatment can prevent fear of treatment and avoidance behaviour of the children. In the treatment of carious lesions, moreover, the oral health care provider should consider to what extent the problem is related to behaviour and fits in the multi-factorial caries model. Restorative treatments should be considered as supporting prevention, reducing caries activity and eliminating the effects of neglected oral health care. Prevention has to be seen as an essential element of the treatment model and it should start early from the standpoint of habit formation and the rapid demineralization process in the deciduous dentition which results from failed preventive care.

Caries prevalence in Suriname schoolchildren.

OBJECTIVES: The aim of this study was to establish the oral health status of children living throughout the Interior of Suriname in order to define needs for dental care in line with WHO goals and guidelines. BASIC RESEARCH DESIGN: In this cross sectional study, dental caries was recorded according to the criteria of the WHO. Decayed, missing and filled (DMF)-teeth (T) and surfaces (S) indices for caries prevalence were used. A total of 951 children from four different regions and between 5-15 years of age, were examined. There was an approximately equal distribution of boys and girls. The children were divided into three age categories. RESULTS: The mean dmfs in the youngest children (5-7.5 yrs) was 11.81 (SD 11.19) and the mean dmft 5.16 (SD 3.93). 17.2% of the children was caries free. Statisticaly significant regional, racial and gender differences were found The mean dmfs of children in the middle age category (7.5-10 yrs) was 5.37 (SD 6.42) and the mean DMFS was 0.84 (SD 1.30). A mean DMFS of 2.31 (SD 4.97) was recorded in the oldest children. No regional, racial or gender differences were found in the last two categories. CONCLUSIONS: The results indicate that caries prevalence in young children in the Interior of Suriname is high according to the criteria of the WHO. In contrast, children in older age groups were found to experience low to moderate caries levels. This finding has consequences for the organisation and planning of future oral health care which should be focused on young children.

Host and microbiological factors related to dental caries development.

Studies on dental caries suggest that in severe cases it may induce a systemic immune response. This occurs particularly when caries progresses into pulpal inflammation and results in abscess or fistula formation (AFF). We hypothesized that severe dental caries will affect the general health of children. The acute phase proteins alpha-1-acid glycoprotein (AGP), C-reactive protein (CRP) and the cytokine neopterin were chosen as parameters to monitor general health. Also, a polymorphism in the bacterial ligand CD14 (-260) was studied to investigate the relationship between genotype sensitivity for bacterial infections and AFF. In Suriname, children aged 6 years were recruited and enrolled into a dental care scheme, randomly assigned to 4 groups with different treatment strategies and monitored longitudinally. 348 children were included in the present study. Blood and saliva samples were taken at baseline and 1 year, and concentrations of serum AGP, CRP, neopterin, salivary Streptococcus mutans and CD14-260 C>T polymorphism were determined. There was no significant association between different treatment strategies and the serum parameters. Binary logistic regression analyses revealed a significant association between AFF as the outcome variable and the CD14 genotype and the concentrations of CRP and of neopterin as factors (p < 0.05). A significant negative association was found between the CD14-260 TT and AFF (p = 0.035, OR = 3.3) for the whole population. For children who had 4 or more carious lesions at baseline, the significance increased (p = 0.005, OR = 4.8), suggesting that the CD14-260 TT genotype was protective for AFF as a consequence of dental caries.

The effect of different dental treatment strategies on the oral health of children: a longitudinal randomised controlled trial.

The aim of the present study is to verify which strategy is the most effective in the treatment of dental decay of the deciduous dentition in a moderate to high caries child population under remote field conditions. This study was carried out in the rain forest of Suriname. Three hundred and eighty schoolchildren, mean age 6.1 years (SD 0.5, range 5.1-7.1 years), were randomly assigned to four different groups: full dental treatment, only extractions, only restorations (ART) and no treatment. Parameters for oral health were defined as caries prevalence (dmft), caries increment, sequela to dental caries and dental pain. Restorative dental care of the primary dentition, by means of ART, resulted in a caries increment from a dmft of 5.48 (SD 3.2) at baseline to 6.35 (SD 2.6) after 2 years (p < 0.001). Extensive dental treatment, performing only extractions, or no treatment did not render significant changes in the caries prevalence of children (p > 0.05). Full dental treatment should be the strategy of choice whenever oral health care programmes are developed. However, when priorities are required due to situational, practical or economical reasons, extraction of severely decayed teeth is an effective treatment strategy.

[Needle breakage during mandibular block anaesthesia: prevention and retrieval]. / Naaldbreuk tijdens mandibulaire blokanesthesie. Preventie en behandeling.

Disposable needles for dental local anaesthesia do not break easily. Still, needle breakage does occur, and is mainly caused by unexpected movements of the patient or pre-use bending of the needle by the dentist. If a dental needle breaks while administering local anaesthesia, the dentist should prevent panic. If the patient opens his mouth wide the needle might still be visible. If so, the needle is removed. If the needle is no longer visible, the site where the needle has penetrated the mucosa should be marked with a permanent marker. The dentist will contact a maxillofacial surgeon for immediate consultation. The maxillofacial surgeon will try to retrieve the broken dental needle under general anaesthesia.

Effectiveness of single-surface ART restorations in the permanent dentition: a meta-analysis.

Over the past few years, there has been an increase in the number of studies reporting on various aspects of the Atraumatic Restorative Treatment (ART) approach. Five randomized clinical trials in which ART restorations with glass ionomers were compared with amalgam restorations in permanent teeth for a maximum period of 3 yrs constituted the database. This meta-analysis divided the publications into 'early' (1987-1992) and 'late' (1995-) studies on the basis of improvements in the approach. The analysis showed that, in the 'early' studies, single-surface amalgam restorations survived statistically significantly longer than comparable ART restorations after 1, 2, and 3 yrs. This trend did not continue into the late group of studies; no statistically significant difference between the 2 types of restorations was found. Based on the available data, it appears that there is no difference in survival results between single-surface ART restorations and amalgam restorations in permanent teeth over the first 3 yrs.

Observer variation in the assessment of resin composite.

OBJECTIVES: The aim of this study was to compare the type of information obtained from log-linear modelling vs Cohen's kappa statistics on observer variation in the assessment of marginal adaptation in composite inlays and amalgam restorations. METHODS: Marginal adaptation of Class II resin composite inlays and amalgam restorations was clinically assessed by two observers, four years after placement. Each of 52 patients received 4 different restorations, three composite (Herculite XR, Clearfil CR Inlay and Visiomolar) inlays and one Tytin restoration. The results were evaluated by Cohens Kappa statistics and log-linear modelling. RESULTS: The overall Cohen's kappa was 0.45, ranging from poor to good for the four materials. Log-linear modelling confirmed that the observers agreed beyond chance but this agreement depended on the performance of the material. Marginal adaptation of Visiomolar (ESPE) inlays was somewhat inferior compared to the other materials. The assessment of Clearfil CR (Kuraray) inlay was difficult using this clinical evaluation procedure. SIGNIFICANCE: Using log-linear modelling it is possible to look at observer agreement and material performance at the same time. This combined approach is important because agreement may depend on material performance.

Is ART really atraumatic?

Atraumatic restorative treatment (ART) is an approach to the management of carious lesions that uses only hand instruments to remove carious tissue and to restore the tooth involved. The name ART implies that the approach is atraumatic to both the patient and the tooth. This study set out to evaluate whether ART is atraumatic in terms of both patient discomfort and tooth tissue conservation. Three hundred and fifty-nine patients were divided in two groups: one group was treated with hand instruments and the other with rotary equipment. Each patient received two restorations: one using amalgam and one using glass ionomer as the restorative material, placed without the use of anaesthesia. Less discomfort was reported with the ART approach compared to conventional restorations made using rotary instruments and amalgam. Moreover, preparations with hand instruments were smaller than those produced with rotary instruments. Reported discomfort was associated with the size of the preparation, although the influence of the operator on both criteria was considerable. A patient effect was also observed since patients who reported discomfort during the first treatment were more likely to report discomfort after the second treatment. In conclusion, the choice of the term "ART" as an atraumatic procedure is defensible.

Atraumatic perspectives of ART: psychological and physiological aspects of treatment with and without rotary instruments.

Atraumatic Restorative Treatment, ART, is a method of minimal caries intervention that uses only hand instruments. The aim of the present study was to explore a possible difference between the extent of discomfort experienced during dental treatment according to the ART approach and a method using rotary instruments. The study was performed in Indonesia. A total of 403 children were randomly divided in two groups. In each child, one class II restoration in a deciduous molar was made. One group received treatment using rotary instruments (750 r.p.m.). The other group was treated according to the ART approach. Glass ionomer cement was used for restoration in both groups. Discomfort scores were determined using both physiological measurements (heart rate) and behavioral observations (Venham) on specific moments during the treatment. Venham scores showed a marked difference between the two groups at most time points. Heart rate measurements were different at deep excavation. Also, a clear relation between Venham scores and heart rate measurements could be found at all time points. Confounding could be shown for operating dentist, gender of the patient and initial anxiety, not for age. No effect modification could be shown. It can be concluded that children treated according to the ART approach using hand instruments alone experience less discomfort than those treated using rotary instruments.

Cost-effectiveness of composite resins and amalgam in the replacement of amalgam Class II restorations.

OBJECTIVES: The replacement of an old amalgam Class II restoration is a common treatment and will remain so for decades. In addition to effectiveness, possible adverse health effects and esthetics, the costs of the treatment options will play a role in the choice of material. The aim of this study was to yield information on the relative cost-effectiveness of the use of composite resins and amalgam for the rerestoration of amalgam Class II restorations. METHODS: As part of a larger randomized clinical trial, treatment effectiveness and treatment costs were estimated in 73 composite and amalgam Class II posterior re-restorations. The main treatment outcome was longevity. Secondary outcomes included need of repair and quality of the margin while in situ. Costs were analyzed from the perspective of dentistry, assuming a treatment strategy aimed at offering 'value for money'. From this perspective, differential costs were based on personnel costs as approximated by treatment time. RESULTS: Replacing an amalgam Class II restoration with amalgam is associated with lower costs than replacing with a composite resin. A sensitivity analysis, considering type of composite, increasing proficiency with the material, and time needed for future removal of material, demonstrated that these differences are fairly robust. The materials performed equally well for the first 5 years after placement with respect to longevity. Differences in secondary outcomes were minor and not all in favor of the same material. CONCLUSIONS: It is tentatively concluded that amalgams are more cost-effective than composites for replacing existing Class II amalgam restorations.

Long-term evaluation and rerestoration of amalgam restorations.

In this study, 1544 class-II amalgam restorations were made and evaluated for 10 yr and the reasons for rerestoration were registered. Two categories of failure could be established: failures due to poor restorative technique (true failures) and those not due to poor restorative technique (false failures). After 10 yr, 1415 restorations were evaluated. Only 120 restorations (8.5%) had been replaced, most of these replacements being true failures (105 = 87.5%), which could be divided into: isthmus fracture (37), fracture of the enamel cusp (25), recurrent caries (16), partial fracture of the restoration (9), severe marginal breakdown (5), pulpal pathology (7) and others (6). The false failures (15) could only be classified into: caries elsewhere in the tooth (15). Origins of the true failures were the operator, the material (amalgam) and the type and size of the restoration. In this study, there were significantly more replacements of larger restorations than of smaller ones and more replacements in molars than in premolars. There is also a significant difference among the replacements by the various operators but not between the various types of amalgam. Origins of the false failures seem to be more related to patient factors like caries activity, caries susceptibility and oral hygiene, but chewing habits (bruxism) may also play a role.

Dentist's ratings of child dental-patients' anxiety.

This study investigates the extent to which dentists giving treatment are able to evaluate the (changes in) child patients' levels of fear, based on a comparison between direct behavior observations of a group of highly anxious children during sequential dental visits and video observations of the same group made by two independent evaluators using the measuring instrument described by Venham et al. (9). A significant difference was found between the fear scores given by the two dentists giving treatment and also between their fear scores and those by the independent observers. Both the fear and behavior scores of the two dentists giving treatment, however, clearly correlated with the fear scores of the observers. It is concluded that in this study the two dentists giving treatment were unable to award an unbiased fear score for each treatment given to a child but it was not possible to show that the bias was caused by experiences from previous sessions with the same child. After video training dentists giving treatment are capable of giving a picture of changes in children's fear levels during sequential dental visits.

Replacement risk of amalgam treatment modalities: 15-year results.

OBJECTIVES: This paper reports on the replacement risk of different treatment modalities for Class II amalgam restorations in a clinical trial of 15 years duration. METHODS: The performance of 1117 conventional Class II amalgam restorations in a controlled, longitudinal study were analysed using logistic regression with a random component. Primary variables regarding replacement risk were the treatment modality (cavity wall treatments) and alloy (conventional versus high copper). Secondly, the operator, type of tooth and type of restoration (MO/DO vs MOD) were considered. RESULTS: Over 15 years, 17% of the restorations were replaced (true failures). The application of copalite varnish or silver suspension and the type of alloy did not reduce the replacement risk. Reduced risks were observed by providing a 90-degree cavosurface angle combined with a cavity wall finish. The operator and the type of restoration determine replacement risk to a significant extent. CONCLUSIONS: Additional treatment modalities do not necessarily reduce replacement risks of Class II amalgam restorations within 15 years, while clinical variables affect the risk of replacement to a certain degree.

The analysis of restoration survival data in split-mouth designs.

OBJECTIVE: To report methodological difficulties with restoration survival data in controlled clinical trials on Class II amalgam restorations using a split-mouth design. The advantages and disadvantages of different ways of handling these data are described. METHODS: Three statistical methods (Kaplan-Meier estimation, logistic regression with random component and Friedman's statistic) are compared using data from a controlled clinical trial in which cavosurface angle (regular or non-standard) and cavity wall finish (applied or not applied) determine four treatment modalities of New True Dentalloy restorations. RESULTS: In this study logistic regression with a random component yields the best interpretable results. Cavity wall finish in combination with a regular cavosurface angle is indicated as the worst and cavity wall finish in combination with a non-standard cavosurface angle as the best treatment when the criterion is replacement or not within 15 years. CONCLUSIONS: The dependency between restorations within a patient needs to be taken into account. Logistic regression with a random component may be a valuable alternative to very advanced statistical survival modelling when restricting the research question to replacement within a certain time interval is not a major problem.

Dental caries under glass ionomer restorations.

The Atraumatic Restorative Treatment (ART) technique has two potential limitations. Because only hand instruments are used, dental caries can be left during cavity preparation. Beyond this limitation, the glass ionomer filling material currently used has some unfavorable mechanical properties with respect to its strength, wear resistance, and shrinkage during setting. The purpose of this paper is to provide an overview of changes that can be expected in carious dentin when a glass ionomer restoration is placed. Restriction of the substrate supply and the release of different components from the glass ionomer have an inhibiting effect on cariogenic microorganisms. Whether this influence is sufficient to completely arrest the caries process is doubtful. The influence of glass ionomers on the remineralization of carious dentin needs further research.

[ART or conventional restorations? A final evaluation of proximal restorations in deciduous molars]. / ART of conventioneel? Onderzoeksresultaten van proximale restauraties in tijdelijke molaren.

In this article the success rate of class 2 ART and conventional (prepared with a bur) restorations in deciduous molars is described. In 1999 approximately 200 ART and 200 conventional restorations were made in deciduous molars in Bandung, Indonesia. The restorations were evaluated after 1.5 month, half a year, 1 year, 2 years and 3 years. The three-year evaluation took place in October 2003. Results show that after 3 years 31% (ART) and 33.6% (conventional) of the restorations were successful (no significant difference). There was a significant difference between the operators. If keeping the element until shedding is the only criterion, the success rate increased to 53.

[Occult dentine lesions under a clinically intact enamel surface. A bacteriological investigation]. / Occlusale dentinelaesies onder een klinisch ogenschijnlijk intact glazuuroppervlak. Een bacteriologisch onderzoek.

Dentine samples of teeth from patients with occlusal lesions beneath an apparently intact enamel surface were bacteriologically examined. For this purpose two dentine samples, one from the dentinoenamel junction (A) and one just before all caries appeared to be removed clinically (B), were taken under aseptic conditions. In most cases the A and B samples contained considerable numbers of mutans streptococci and lactobacilli, while the dentine after opening was soft with a light colour. These results suggest that one is dealing with active caries lesions, which should be treated as such. Comparison of the saliva data from the patients group with the saliva data of a control group showed no significant differences concerning the numbers of mutans streptococci, secretion rate and buffer capacity.