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.

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.

Preoperative three-dimensional modelling and virtual reality planning aids nephron sparing surgery in a child with bilateral Wilms tumour.

Bilateral Wilms tumour (BWT) is a surgically challenging condition. Virtual reality (VR) reconstruction aids surgeons to foresee the anatomy ahead of Nephron Sparing Surgery (NSS). Three-dimensional (3D) visualisation improves the anatomical orientation of surgeons performing NSS. We herewith report a case of BWT where VR planning and 3D printing were used to aid NSS. Conventional imaging is often found to be inadequate while assessing the tumour-organ-vascular anatomy. Advances like VR and 3D printing help surgeons plan better for complex surgeries like bilateral NSS. Next-generation extended reality tools will likely aid robotic-assisted precision NSS and improve patient outcomes.

Preventive management of carious lesions: from non-invasive to micro-invasive operative interventions.

Understanding that dental carious lesions occur as a result of the action of micro-organisms in the dental plaque biofilm, where demineralisation on the tooth surface is the first sign of the disease, such incipient lesions can be treated using preventive, non-operative and minimally invasive operative dentistry. If the caries process is left unmanaged, the lesions progress towards cavitation, leading to more invasive treatments. This article discusses the principles of preventive, non-invasive and micro-invasive treatments of early carious lesions, outlining the clinical situations where these therapies can be applied.

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.

Minimum intervention oral care - incentivising preventive management of high-needs/high caries-risk patients using phased courses of treatment.

This paper demonstrates how person-focused, prevention-based, risk/needs-related, team-delivered, minimum intervention oral care (MIOC) principles and approaches can be integrated into the dental profession for the delivery of environmentally sustainable, optimal care to high-needs and high caries-risk/susceptibility patients. It highlights the potential for NHS remuneration for prevention-based, phased, personalised care pathways/plans (PCPs) within a reformed NHS dental contract system. It emphasises the importance of comprehensive and longitudinal patient risk/susceptibility assessments, prevention and stabilisation of the oral environment before considering more complex, definitive restorative work. This paper forms the first of several components of a suite of educational/information materials needed to instil confidence and implementation protocols within primary care clinical oral health care teams delivering MIOC through phased PCPs, especially when managing patients with high needs and/or disease susceptibility.

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.

The in-vitro development of novel enzyme-based chemo-mechanical caries removal agents.

OBJECTIVES: Bromelain is a potent proteolytic enzyme that has a unique functionality makes it valuable for various therapeutic purposes. This study aimed to develop three novel formulations based on bromelain to be used as chemomechanical caries removal agents. METHODS: The novel agents were prepared using different concentrations of bromelain (10-40 wt. %), with and without 0.1-0.3 wt. % chloramine T or 0.5-1.5 wt. % chlorhexidine (CHX). Based on the enzymatic activity test, three formulations were selected; 30 % bromelain (F1), 30 % bromelain-0.1 % chloramine (F2) and 30 % bromelain-1.5 % CHX (F3). The assessments included molecular docking, Fourier-transform infrared spectroscopy (FTIR), viscosity and pH measurements. The efficiency of caries removal was assessed by DIAGNOdent pen, measuring the excavation time and number of applications, followed by a morphological evaluation of the remaining dentine using scanning electron microscopy (SEM). The results were compared to Brix 3000 as a control. RESULTS: The chloramine and chlorhexidine were chemically compatible with bromelain without compromising the enzyme activity. All experimental formulations showed higher viscosity and pH in comparison to Brix 3000. The DIAGNOdent readings were <20 in all groups, and the lowest readings were observed in F2. The excavation time and number of applications were lowest in F2 and F1. Both F2 and F3 produced smooth dentine surfaces with less tissue debris, but more patent dentine tubules were observed in F1 and F2. CONCLUSIONS: The bromelain-contained formulations showed a potential to be used as chemomechanical caries removal agents in vitro. Further laboratory and clinical studies are needed to validate this claim. CLINICAL SIGNIFICANCE: The bromelain from pineapple stem has broad specificity for cleavage the peptide bonds in denatured protein to facilitate their removal. The study proved the efficiency of this enzyme to remove the dental caries chemomechanically when used alone or conjugated with chloramine and/or chlorhexidine to enhance the disinfecting and cleansing properties.

Release Kinetics of Monomers from Dental Composites Containing Fluoride-Doped Calcium Phosphates.

This study analyse the type of release kinetic of specific monomers from dental resin composites containing various fluoride-doped calcium phosphates. The release behavior of urethane dimethacrylate (UDMA), ethoxylated bisphenol-A dimethacrylate (bis-EMA) and 1.6-hexanediol ethoxylate diacrylate (HEDA) was evaluated over a period of 35 days. Two tailored calcium phosphates doped with different concentrations of fluoride salts (VS10% and VS20%) were prepared and incorporated in the dimethacrylate matrix at various concentrations to generate a range of experimental composites. The release kinetics were characterized using mathematical models such as zero-order, first-order, Peppas and Higuchi models. The results showed that the first-order model best described the release kinetics. UDMA and HEDA exhibited significant differences in release compared to bis-EMA from day 1, while no significant differences were observed between UDMA and HEDA, except on day 35, when UDMA exhibited a higher release rate than HEDA. When comparing the release of each monomer, VS20-R20% had the highest total release percentage, with 3.10 ± 0.25%, whereas the composite VS10-R5% showed the lowest release percentage, with a total of 1.66 ± 0.08%. The release kinetics were influenced by the composition of the resin composites and the presence of calcium fluoride and sodium fluoride in the calcium phosphate played a role in the maximum amounts of monomer released. In conclusion, the release of monomers from the tested resin composites followed a first-order kinetic behaviour, with an initial rapid release that decreased over time. The composition of the resin monomers and the presence of fluoride salts influenced the release kinetics. The VS10-R5% and VS10-R10% resin composites exhibited the lowest total monomer release, suggesting its potential favourable composition with reduced monomer elution. These findings contribute to understanding the release behavior of dental resin composites and provide insights for the development of resin-based bioactive dental materials.

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).

Should compromised first permanent molar teeth in children be routinely removed? A health economics analysis.

OBJECTIVE: To evaluate the cost-effectiveness of retaining one or more compromised first permanent molars (cFPMs) affected by dental caries or enamel hypomineralization, compared to timely extraction, in children aged 8 years. METHODS: A Markov model was developed to simulate the lifetime of a cFPM. Two management strategies were compared: extraction facilitating spontaneous space closure or maintenance of teeth with restorations. Ten health states were utilized to capture long-term outcomes including various tooth restorations, prostheses or a retained gap at the cFPM site. Outcomes were expressed as Quality Adjusted Tooth-Years (QATYs). The model was informed by survey data on patient preferences for treatment outcomes and UK data on costs. Discounted costs and QATYs were calculated over 62 years. RESULTS: Regardless of the number of cFPMs, retaining cFPMs was more effective than early removal, generating an additional 2.3 QATYs per cFPM. Early removal of one or two cFPM under general anaesthetic (GA) was more expensive than retention and hence never cost-effective. Retaining a cFPM was more expensive than early removal under local anaesthesia or where four cFPMs were extracted under GA. In these cases, retaining cFPMs was cost-effective if a QATY was valued at £100 or £35, respectively. Results were robust to sensitivity analysis. CONCLUSION: Preserving a cFPM was more cost-effective than the early loss of one, or two cFPMs under GA. Preservation of four cFPMs was cost-effective if sufficient value was placed on a QATY. These findings can guide clinical practice on management of cFPMs alongside patient/payer values on maintaining teeth.

Factor analysis of risk perceptions of using digital and social media in dental education and profession.

PURPOSE: This study explored how dental students and dental professionals perceive risks of using digital and social media (DSM) in a dental professional context and validated a questionnaire to measure DSM perceived risks specifically among dental students and dental professionals. METHODS: A cross-sectional survey study was carried out amongst dental students (undergraduate and postgraduate) and dental professionals at a dental school in the UK. Data were collected using a 38-item questionnaire developed using interviews, experts' evaluation, and previous perceived risks studies of internet services and social media. Risk factors were identified using exploratory factor analysis (EFA). The internal consistency of the extracted factors was determined by Cronbach's α-coefficient reliability test. RESULTS: A total of 301 dental students and dental professionals completed the questionnaire. EFA identified eight factors perceived by dental students and professionals as critical to their DSM use. Some identified perceived risks were associated with all DSM users in the general context (e.g., personal privacy, and negative impact on self-image), but others were specific to the dental professional context (e.g., breaches of patients' confidentiality, public deception, and reputational damage). The identified factors explained 63.55% of the variance with eigenvalues >1. Cronbach's alpha for the total questionnaire was 0.9. CONCLUSIONS: This study data has deepened the understanding of perceived risks that influence dental students and professionals' DSM use. This will help develop education, training, and guidance to mitigate and manage the risks associated with DSM use in the dental professional context.

Minimum intervention oral care: defining the future of caries management.

It is not uncommon that oral healthcare professionals and researchers interchange the use of the terms minimum/minimal intervention and minimally invasive dentistry. However, these terms apply to two different, but related, concepts. Minimum intervention dentistry, to be more appropriately addressed in this paper as minimum intervention oral care (MIOC), is an oral healthcare delivery framework that encompasses four interlinked clinical domains. These domains are: identifying disease - detection, longitudinal risk/susceptibility assessment, investigation, diagnosis and the development of a personalized care plan; prevention of lesions/control of disease - patient behaviour management, non-invasive remineralisation of the enamel and dentine, biofilm and diet control, micro-invasive sealants and infiltration techniques to arrest and reverse incipient lesions; minimally invasive operative procedures including selective carious dentine removal, the "5Rs" management of the tooth-restoration complex (review, refurbish, re-seal, repair and replace) amongst other restorative interventions; and tailored recall/review/re-assessment consultations. This framework includes that minimally invasive operative dentistry (MID), that although a critical operative clinical domain, should be viewed as one of the pillars of minimum intervention oral healthcare (MIOC), applied across all disciplines of restorative dentistry, not just caries management. The aim of this review is to clarify these differences and emphasize the importance of minimally invasive operative dentistry (MID) within the context of minimum intervention oral care (MIOC). MIOC is applicable to all disciplines within restorative dentistry, including clinical caries management.

Learning Clinical Skills Using Haptic vs. Phantom Head Dental Chair Simulators in Removal of Artificial Caries: Cluster-Randomized Trials with Two Cohorts' Cavity Preparation.

Dental task trainer simulators using haptics (virtual touch) offers a cost-effective method of teaching certain clinical skills. The purpose of this study is to evaluate students' performance in removing artificial caries after training with either a haptic dental chair simulator with virtual reality or a traditional dental chair simulator with a mannequin head. Cluster Randomized Controlled Trials in two cohorts, both Year 1 dental students. Students taught using traditional dental chair simulators were compared with students taught using haptic-based simulators on their ability to cut a cavity in a plastic tooth following training. Across both cohorts, there was no difference in the quality of cavity cut, though students' technique differed across the two simulator groups in some respects. No difference was seen across both cohorts in the quality of cavity cut for a simple preparation, though students in the haptic condition performed less well in the more demanding task. Moreover, students in the haptic group were also less likely to be perceived to be 'holding the instrument appropriately'. These findings suggest further investigation is needed into the differences in handling of instruments and level of clinical task difficulty between the simulators.