WITHDRAWN: Operative caries management in adults and children.

BACKGROUND: The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006. OBJECTIVES: To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included. DATA COLLECTION AND ANALYSIS: Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration. MAIN RESULTS: In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I2 = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I2 = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I2 = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I2 = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies. AUTHORS' CONCLUSIONS: Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Infected Dentine Revisited.

Dentine becomes infected as a result of caries lesion formation on root surfaces and when lesions progress following cavitation of enamel lesions. However, this infection is unimportant because the driving force for lesion formation and progression is the overlying biofilm. This explains why root surface caries can be controlled by mechanical plaque control and fluoride, and restorations are not needed to arrest these lesions. Similarly, the infected dentine in cavitated coronal lesions does not have to be removed to arrest the lesion. If the lesion is either accessible or opened for cleaning by the patient or parent, the lesion can be arrested. Sealing of infected dentine within the tooth, either by a Hall crown in the primary dentition or by partial caries removal prior to placing a well-sealed filling, will also arrest the lesion. When restoring deep lesions in symptomless, vital teeth, vigorous excavation of infected dentine is likely to expose the pulp and make root canal treatment necessary. Thus complete excavation'is not needed and should be avoided. CPD/CLINICAL RELEVANCE: Root surface caries can be arrested by cleaning and fluoride application. Restorations are not essential. Vigorous excavation of softened dentine in deep cavities of symptomless, vital teeth is contra-indicated. It is not needed and increases the risk of pulp exposure.

Changing concepts in cariology: forty years on.

UNLABELLED: The caries lesion is a sign or symptom resulting from numerous pH fluctuations in biofilms on teeth. The lesion may or may not progress and lesion progression can be controlled, slowed down or arrested. Control of the biofilm is the treatment of caries, the most important measure being to disturb the biofilm mechanically using a fluoride-containing toothpaste. The informed patient controls caries and the role of the dental professional is to advise how this should be done. This is the non-operative treatment of caries and it is worthy of payment. It should be mandatory as part of any operative treatment to ensure that the patient understands, and is able to perform, adequate plaque control. CLINICAL RELEVANCE: It is very unfortunate that the current remuneration scheme (Unit of Dental Activity) in Health Service practice in England and Wales prevents practitioners adopting a modern biological approach to caries control.

Operative caries management in adults and children.

BACKGROUND: The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006. OBJECTIVES: To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included. DATA COLLECTION AND ANALYSIS: Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration. MAIN RESULTS: In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I(2) = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I(2) = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I(2) = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I(2) = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies. AUTHORS' CONCLUSIONS: Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Should deciduous teeth be restored? Reflections of a cariologist.

UNLABELLED: Whether deciduous teeth should be restored has caused controversy for at least 150 years and the argument rages on. Dental caries is a controllable process. The role of operative dentistry and restorations, as far as caries control is concerned, is to make cavitated, uncleansible lesions accessible to plaque control. However, deciduous teeth are exfoliated and perhaps non-operative treatments (plaque control, fluoride, diet) are all that are required to take cavitated teeth pain-free to exfoliation. Are such techniques child-friendly, obviating the need for anaesthesia or the use of handpieces? Alternatively, are they wanton neglect? This paper is written by a cariologist who never treated children, to present alternative managements and rehearse these arguments from a cariological perspective. CLINICAL RELEVANCE: This paper might serve as a discussion document for a group of dentists deciding practice policy with regard to the management of caries in deciduous teeth.

The implications of the new paradigm of dental caries.

The caries process is the ubiquitous, natural metabolism in the biofilm that causes numerous fluctuations in pH. The interaction of this biofilm with the dental tissues may result in a caries lesion. However, lesion formation and progression can be controlled, particularly by disturbing plaque regularly with a fluoride containing toothpaste. This paradigm implies that everyone with teeth is at risk to lesion development. Treatment of caries is principally non-operative, involving plaque control, fluoride and a sensible diet. Operative dentistry repairs un-cleansable cavities and is part of plaque control. A diagnosis is a mental resting place on the way to a treatment decision. The relevant diagnostic features with respect to caries are lesion activity (active lesions require active management) and un-cleansable cavities. When teaching undergraduates, it is important that they are credited for the non-operative treatment of caries as well as for operative dentistry. This is equally important in dental practice where an appropriate skills mix of the dental team is required to deliver dental health cost-effectively. Training more dentists may be an expensive mistake as far as disease control is concerned. It is ironic that dentists make most money from operative care and specialist treatment when disease control could be delivered relatively cheaply. The key to dental health is regular and effective plaque control with a fluoride containing toothpaste, from cradle to grave.

Clinical threshold for carious tissue removal.

There would appear to be little logic in the current practice of caries removal. Biologically, it would appear to be potentially damaging even to attempt to remove all infected dentin in a symptomless, vital tooth. It is neither possible nor necessary to achieve this. The evidence would seem to show that, provided a restoration is placed that seals the cavity, infected dentin may be left. It does not prejudice pulpal health, and the caries lesion does not progress.

Caries control from cradle to grave.

UNLABELLED: Caries is a ubiquitous, natural process occurring in the biofilm. The interaction of the biofilm with the dental tissues may result in a caries lesion, the reflection of the process being the consequence that can be seen. However, lesion formation and progression are not inevitable because the process in the biofilm can be controlled by plaque control, fluoride and a sensible diet. This paper summarizes caries control in note form and it questions how these measures are to be carried out under the current Unit of Dental Activity payment system used within the NHS Dental Services in England and Wales. CLINICAL RELEVANCE: Caries control is the non-operative management of the ubiquitous, natural process in the biofilm so that lesions do not form, or established lesions are arrested. This paper seeks to present these caries control measures in note form as checklists to aid the dental team.

Practical Suggestions for Implementing Caries Control and Recall Protocols for Children and Young Adults.

Caries is a ubiquitous, natural process occurring in the biofilm. Lesion formation can be controlled by plaque control, fluoride and a sensible diet. Diagnosis is a mental resting place for a treatment decision. Active lesions require active management, including non-operative measures to arrest the lesion, supplemented with operative dentistry to facilitate cleaning of cavities. The diagnosis of active lesions is the best measure of caries risk and should determine recall intervals. The paper describes a clinical sequence of oral hygiene instruction, followed by a clinical examination of clean, dry teeth and then fluoride varnish application .

Effect of biofilm growth on expression of surface proteins of Actinomyces naeslundii genospecies 2.

The predominant surface proteins of biofilm and planktonic Actinomyces naeslundii, a primary colonizer of the tooth surface, were examined. Seventy-nine proteins (the products of 52 genes) were identified in biofilm cells, and 30 of these, including adhesins, chaperones, and stress-response proteins, were significantly up-regulated relative to planktonic cells.

The treatment of deep dentine caries lesions.

UNLABELLED: This paper discusses the excavation of deep caries lesions, focusing on indirect pulp-capping and the stepwise excavation approach. The concept of a modified and less invasive stepwise excavation is presented, based on considerations of caries pathology. The aim of the first excavation is primarily to make a change within the cariogenic environment, and not to remove carious dentine close to the pulp because this risks an iatrogenic pulp exposure. Microbiological and clinical studies have shown that the number of bacteria decrease during stepwise excavation procedures, and that lesions clinically arrest. The active, soft-yellowish, demineralized dentine turns into a darker, harder and drier demineralized dentine, resembling a slowly progressing lesion, where the carious dentine is easier to remove at the final visit. The final excavation has two aims: (i) to verify that arrestation has taken place, ie a clinical control of the tooth reactions and (ii) to remove the slowly progressing but still slightly infected discoloured demineralized dentine, before carrying out the permanent and final restoration. CLINICAL RELEVANCE: Knowledge of guidelines for treatment of deep dentine caries may reduce the risk of pulpal exposure.

Relationship between S. mutans and the autofluorescence of carious dentin.

PURPOSE: To investigate the relationship between the presence of S. mutans and the autofluorescent signal detected in carious dentin, using confocal laser-scanning microscopy. METHODS: Experiment 1:15 visually caries-free freshly extracted premolars were coated with varnish except for two 2 mm x 2 mm windows; five were subjected to a 15-day bacterial artificial caries system using Streptococcus mutans while 10 underwent a 7-day controlled, lactic acid (0.5 M, pH 2.7) demineralization protocol. At the end of both periods, all teeth were longitudinally sectioned and the 20 bacterial and 40 acid-induced artificial lesions were examined by confocal laser-scanning microscopy. The media containing the S. mutans was also examined for autofluorescence. Experiment 2: 20 750 microm-thick caries-free coronal dentin disks were prepared from 10 healthy premolars. Ten underwent a demineralization protocol using 0.1 M EDTA (pH 4.8) for 21 days. All 20 were finally subjected to the same artificial bacterial caries system as above for 15 days and then examined for autofluorescence using confocal laser-scanning microscopy. RESULTS: Experiment 1 results showed that acid-demineralized lesions did not generate any autofluorescence. Lesions created by the bacterial system did exhibit autofluorescence. The media with or without S. mutans did not exhibit autofluorescence. Experiment 2: bacteria-induced lesions on dentin that had previously been acid-demineralized generated a visibly stronger autofluorescence signal than those lesions grown on sound dentin. It is hypothesized that dentin demineralization during the carious process exposes more matrix to a bacteria-matrix interaction, thus generating or refining the matrix chromophore responsible for the autofluorescence signal detected in carious dentin.

Effect of the environment on genotypic diversity of Actinomyces naeslundii and Streptococcus oralis in the oral biofilm.

The genotypic diversity of Actinomyces naeslundii genospecies 2 (424 isolates) and Streptococcus oralis (446 isolates) strains isolated from two sound approximal sites in all subjects who were either caries active (seven subjects) or caries free (seven subjects) was investigated by using the repetitive extragenic palindromic PCR. The plaque from the caries-active subjects harbored significantly greater proportions of mutans streptococci and lactobacilli and a smaller proportion of A. naeslundii organisms than the plaque sampled from the caries-free subjects. These data confirmed that the sites of the two groups of subjects were subjected to different environmental stresses, probably determined by the prevailing or fluctuating acidic pH values. We tested the hypothesis that the microfloras of the sites subjected to greater stresses (the plaque samples from the caries-active subjects) would exhibit reduced genotypic diversity since the sites would be less favorable. We found that the diversity of A. naeslundii strains did not change (chi2 = 0.68; P = 0.41) although the proportional representation of A. naeslundii was significantly reduced (P < 0.05). Conversely, the diversity of the S. oralis strains increased (chi2 = 11.71; P = 0.0006) and the proportional representation of S. oralis did not change. We propose that under these environmental conditions the diversity and number of niches within the oral biofilm that could be exploited by S. oralis increased, resulting in the increased genotypic diversity of this species. Apparently, A. naeslundii was not able to exploit the new niches since the prevailing conditions within the niches may have been deleterious and not supportive of its proliferation. These results suggest that environmental stress may modify a biofilm such that the diversity of the niches is increased and that these niches may be successfully exploited by some, but not necessarily all, members of the microbial community.

In vitro validation of carious dentin removed using different excavation criteria.

PURPOSE: To compare directly the extent of cavity preparation instigated by either clinical hardness or a caries detector dye. Caries removal was histologically validated against the autofluorescence of carious dentin within the same samples. METHODS: 50 human molars were sectioned longitudinally through occlusal lesions, color photomicrographs obtained and the pre-excavation autofluorescent signatures captured using a confocal laser scanning microscope (488 nm excitation, > 515 nm emission). The hydrated lesions were excavated using sterile hand instruments until the dentin cavity surface was hard to a dental probe. Color photomicrographs were obtained and then caries detector dye was then placed in the cavities and excavation continued until no pink stain was visible. Final color photomicrographs were obtained. RESULTS: Digital image superimpositions indicated that the extent of cavities prepared using the clinical hardness criterion correlated closely to the corresponding autofluorescent signal outlines of the original lesions. Caries detector dye-assisted excavation resulted in over-prepared cavities by as much as 58.2% relative to the validating autofluorescence outline. In conclusion, the use of caries dyes can lead to clinically significant over-preparation of cavities when compared to those prepared using clinical hardness.

Minimally Invasive Dentistry--concepts and techniques in cariology.

The concept 'Minimally Invasive Dentistry' can be defined as maximal preservation of healthy dental structures. Within cariology, this concept includes the use of all available information and techniques ranging from accurate diagnosis of caries, caries risk assessment and prevention, to technical procedures in repairing restorations. Dentists are currently spending more than half their time replacing old restorations. The main reasons for restoration failures are secondary caries and fractures, factors that are generally not addressed in the technical process of replacing a restoration. Prevailing concepts on minimally invasive dentistry seem to be 'product or technique-motivated', challenging one technique or product with another, rather than focusing on a general concept. New knowledge of caries progression rates has also led to substantial modification of restorative intervention thresholds and further handling of the disease. New diagnostic tools for caries lesion detection, caries risk assessment and focused preventive treatments have decreased the need for early restorative interventions. In parallel to this, new techniques for cutting teeth and removing decay have evolved. This paper focuses on describing minimally invasive dentistry in cariology from a conceptual perspective, relating to clinical caries diagnosis, restorative intervention thresholds and operative procedures, with special reference to survival of tunnel and slot restorations and to repair vs. replacement of defective restorations.

The effect of medicated chewing gums on oral health in frail older people: a 1-year clinical trial.

OBJECTIVES: To determine the effects of a medicated chewing gum on the oral health of frail older people. DESIGN: A controlled, double-blind trial using three groups based on random allocation of residential homes. SETTING: Sixteen residential homes in West Hertfordshire, England. PARTICIPANTS: One hundred eleven dentate subjects aged 60 and older who completed the 12-month study. INTERVENTION: Subjects were assigned to a chlorhexidine acetate/xylitol gum (ACHX) group, a xylitol gum (X) group, or a no-gum (N) group. Subjects in the gum groups chewed two pellets for 15 minutes twice daily for 12 months. MEASUREMENTS: Primary outcome measures were salivary flow rate, denture debris score, prevalence of angular cheilitis, and denture stomatitis; secondary outcome measures were salivary levels of caries-associated microorganisms. A single examiner, who was blinded to group allocation, made all measurements at baseline before gum usage and at subsequent examinations after 3, 6, 9, and 12 months. Separate analyses were performed for subjects with dentures. RESULTS: Subjects in the three groups were similar in most of their baseline characteristics. The stimulated whole saliva flow rate +/- standard deviation increased significantly for the ACHX (1.4 +/- 0.7 mL/min) and X (1.6 +/- 0.9 mL/min) groups (P <.01) over baseline (ACHX = 0.9 +/- 0.6 mL/min, X = 0.8 +/- 0.6 mL/min) and N group levels (0.6 +/- 0.9 mL/min). The levels of mutans streptococci, lactobacilli, and yeasts significantly increased (P <.05) in the X and N groups. Denture debris status was significantly lower in the ACHX and X groups than at baseline or in the N group (P <.01). The reductions of 91% and 75% in denture stomatitis and angular cheilitis prevalence, respectively, that occurred in the ACHX group were significantly greater (P <.01) than the reductions in the X group (denture stomatitis 62%, angular cheilitis 43%). Prevalence of denture stomatitis and angular cheilitis were not significantly changed in the N group. CONCLUSION: The use of a medicated chewing gum significantly improved oral health in older occupants of residential homes. Chewing gums should be considered as a potential adjunct to other oral hygiene procedures in older subjects.