How combining different caries lesions characteristics may be helpful in short-term caries progression prediction: model development on occlusal surfaces of primary teeth.

BACKGROUND: Few studies have addressed the clinical parameters' predictive power related to caries lesion associated with their progression. This study assessed the predictive validity and proposed simplified models to predict short-term caries progression using clinical parameters related to caries lesion activity status. METHODS: The occlusal surfaces of primary molars, presenting no frank cavitation, were examined according to the following clinical predictors: colour, luster, cavitation, texture, and clinical depth. After one year, children were re-evaluated using the International Caries Detection and Assessment System to assess caries lesion progression. Progression was set as the outcome to be predicted. Univariate multilevel Poisson models were fitted to test each of the independent variables (clinical features) as predictors of short-term caries progression. The multimodel inference was made based on the Akaike Information Criteria and C statistic. Afterwards, plausible interactions among some of the variables were tested in the models to evaluate the benefit of combining these variables when assessing caries lesions. RESULTS: 205 children (750 surfaces) presented no frank cavitations at the baseline. After one year, 147 children were reassessed (70%). Finally, 128 children (733 surfaces) presented complete baseline data and had included primary teeth to be reassessed. Approximately 9% of the reassessed surfaces showed caries progression. Among the univariate models created with each one of these variables, the model containing the surface integrity as a predictor had the lowest AIC (364.5). Univariate predictive models tended to present better goodness-of-fit (AICs < 388) and discrimination (C:0.959-0.966) than those combining parameters (AIC:365-393, C:0.958-0.961). When only non-cavitated surfaces were considered, roughness compounded the model that better predicted the lesions' progression (AIC = 217.7, C:0.91). CONCLUSIONS: Univariate model fitted considering the presence of cavitation show the best predictive goodness-of-fit and discrimination. For non-cavitated lesions, the simplest way to predict those lesions that tend to progress is by assessing enamel roughness. In general, the evaluation of other conjoint parameters seems unnecessary for all non-frankly cavitated lesions.

Do the ball-ended probe cause less damage than sharp explorers?-An ultrastructural analysis.

BACKGROUND: No evidence about damage caused by ball-ended probes on tooth is available. No study compared probing defects caused by ball-ended probes with sharp explorers during tactile examinations of primary teeth. This exploratory study aimed to compare ultrastructural defects caused by ball-ended probes with sharp explorers during tactile examinations of primary teeth. METHODS: Forty-nine primary extracted teeth were tactile examined as performed for caries activity assessment. Surfaces were randomly divided into groups based on probe type (ball-ended probe or sharp explorer). Two examiners probed different surfaces using the sharp explorer and the ball-ended probe. The order for examination was randomly determined. Images were captured using environmental scanning electron microscopy (ESEM) before and after probing. Two external examiners evaluated independently the ESEM images and scored them as: 0) no damage, 1) slight marks, 2) distinct marks, 3) marks with discontinuity, 4) enamel break-offs. Multilevel Poisson regression models were used to analyze associations between probing ultrastructural damage and surface type, baseline condition and probe type. Prevalence ratios (PR) were calculated with 95 % confidence interval (CI). RESULTS: The most common defects observed on the dental surfaces were probing marks without discontinuity (scores 1 and 2). Ball-ended probes caused significantly less severe damage than sharp explorers (PR: 0.28; CI: 0.11-0.76, p = 0.01). CONCLUSION: Ball-ended probes cause less damage than sharp explorers when probing gently dental surfaces of primary teeth.

Children's discomfort may vary among different treatments for initial approximal caries lesions: preliminary findings of a randomized controlled clinical trial.

BACKGROUND: Longer and more complex dental procedures could negatively affect patient's acceptability of minimal invasive techniques. AIMS AND METHODS: Therefore, this short communication aims to show the preliminary findings regarding children's discomfort reported after some minimal invasive treatments in treating initial caries lesions on approximal surfaces: flossing instruction, silver diamine fluoride (SDF) application and caries resin infiltration. RESULTS: Children allocated in the infiltration group showed higher levels of discomfort than those in the SDF and control groups. CONCLUSIONS: These findings suggest that the simplest interventions for approximal initial caries lesions cause less discomfort for children and should be applied where possible.

New proposal of silver diamine fluoride use in arresting approximal caries: study protocol for a randomized controlled trial.

BACKGROUND: Approximal surfaces are a challenge to caries lesions control. Silver diamine fluoride (SDF) is a simple,low-cost and promisor intervention for arresting caries lesions, but it has never been tested on approximal surfaces. Our aim is to evaluate the efficacy and cost-efficacy of SDF in arresting initial lesions compared to resin infiltration and exclusively flossing (control group). Our second aim is to assess discomfort and satisfaction regarding interventions. METHODS/DESIGN: This is a randomized clinical trial, double-blinded, placebo-controlled study. Children/adolescents presenting at least one approximal initial caries lesion in primary molars/permanent premolars and molars will be included. Surfaces with advanced dentine lesions identified by radiography and participants who refuse to participate or present negative behaviors will be excluded. A minimum sample size of 504 surfaces will be required for each subgroup. Individuals will be randomly allocated in three groups of interventions: SDF, resin infiltration, and control group. Depending on the allocation, the patients will receive the active treatment and respective placebo therapies. All patients will be oriented to daily flossing the included surfaces. Our primary outcome will be caries progression by clinical and radiographic examinations. Appointments will be timed and costs of materials will be considered to calculate cost-efficacy. Patient discomfort will be assessed after interventions. Parent and patient satisfaction with the treatment will be collected after treatment and in the last follow-up visit. Individuals will be assessed at 1 and 3 months after treatment to evaluate dental biofilm and at 6, 12, and 24 months to assess caries progression by visual examination and/or radiography. Multilevel analyses will be used to verify if the type of treatment influenced on the tested outcomes. Costs will be compared and analyses of cost-efficacy will be performed. Poisson analysis will test the association between intervention and reported discomfort and satisfaction. DISCUSSION: Our hypothesis is that SDF is the most cost-efficacious option from all tested interventions. If our hypothesis is confirmed, the use of SDF in private and public contexts could represent an easier and effective option in the treatment of enamel approximal caries in children/adolescents. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01477385), Initial release: 11/16/2011: last update: 06/02/2014.

Diamino fluoreto de prata - uma nova proposta para o tratamento não operatório de lesões proximais em molares decíduos: estudo clínico randomizado / Silver diamine fluoride - a new proposal for the non-operative treatment for approximal caries lesions in primary molars: randomized clinical trial

Este ensaio clínico randomizado, cego e controlado com placebo teve como objetivo principal avaliar a eficácia do diamino fluoreto de prata (DFP) a 30% no tratamento não operatório de lesões de cárie em superfícies proximais de molares decíduos e compará-la a eficácia do infiltrante resinoso e a do controle do biofilme interproximal pelo uso do fio dental. Além disso, também avaliou a custo-eficácia e o desconforto dos tratamentos e a satisfação dos participantes quanto ao tratamento recebido. Para isso, foram selecionadas 141 crianças entre 3 e 10 anos de idade, que apresentavam pelo menos uma superfície proximal com lesão de cárie clinicamente em esmalte. A alocação dos participantes foi aleatória, de acordo com o tratamento: DFP a 30%, infiltrante resinoso de cárie e orientação para o uso diário do fio dental (controle). Todos os participantes receberam o tratamento ativo para os quais foram alocados e também o placebo dos tratamentos realizados nos outros grupos. Os custos dos materiais utilizados nos tratamentos foram registrados. Ao final da consulta de tratamento, foi aplicada aos participantes a Escala Facial de Wong-Baker para avaliação do desconforto. Os responsáveis pelos participantes, que concluíram o seguimento da pesquisa, responderam a um questionário de satisfação sobre o tratamento recebido. As crianças foram examinadas após 1 mês para avaliação de higiene bucal e também de presença de biofilme nas superfícies tratadas

Análises de regressão foram realizadas para verificar se os grupos de tratamento influenciaram os desfechos testados após 12 e 24 meses de seguimento (análise por protocolo - Poisson multinível e análise de sobrevida). Valores pontuais de custo-eficácia dos tratamentos foram calculados e, para comparar a custo-eficácia da implementação do uso do DFP em relação às outras opções testadas foi utilizada a razão de custo-eficácia incremental. Análises de regressão de Poisson foram utilizadas para verificar a associação entre o desconforto e variáveis explicativas. A satisfação dos participantes e seus responsáveis foi explorada descritivamente. Um total de 316 superfícies proximais foram incluídas, sendo a maioria classificada como escore 2 do ICDAS (Sistema Internacional de Detecção e Avaliação de Cárie) associadas à ausência de imagem radiográfica (46,8%). As perdas de seguimento foram de 15% e 24% aos 12 e 24 meses, respectivamente. Não houve associação entre o grupo de tratamento e a progressão das lesões aos 12 e 24 meses, tanta pela análise por protocolo como pela análise de sobrevida. A taxa de progressão clínica das lesões para cavidade em dentina foi de 2,5% aos 12 meses e de 5,6% aos 24 meses

This randomized, blinded and placebo-controlled clinical trial aimed to evaluate the efficacy of 30% silver diamine fluoride (SDF) as a non-operative treatment of the approximal surfaces of primary molars and to compare it with the efficacy of resin infiltration and the mechanical control of the interproximal biofilm by flossing. We also evaluated the cost-efficacy and the discomfort of the treatments as well as the parent's satisfaction regarding treatments. One hundred forty-one, 3-to-10-year-old, children were included. They must present at least one caries lesion clinically into enamel sited on an approximal surface of primary molar. Participants were randomly allocated to the following groups according to active treatment to be received: 30% SDF, caries resin infiltration, flossing orientation (control). All participants received the active treatment, in which they were allocated and they also received the placebo treatment corresponding to the other groups. Costs of materials used in the treatment were registered. In the end of treatment session, the Wong-Baker faces scale was applied to evaluate participants' reported discomfort. Children were examined after 1 month to evaluation of the oral hygiene and the presence of the biofilm on the treated surfaces. After 6, 12 and 24 months, visual and tactile examinations were performed to verify the lesions progression. Radiography was taken at 12- and 24-month follow-ups. To evaluate the efficacy of non-operative treatments, two outcomes were considered: (I) any clinical progression and (II) progression to cavity into dentine

The radiographic progression was used as a secondary outcome and to evaluate with clinical standard of lesions progression. Regression analyses were used to verify if the treatment influenced on these outcomes after 12 and 24 months (per-protocol analyses - multilevel Poisson and survival analysis). Cost-efficacy ratios were calculated for the treatments. To compare the cost-efficacy of implementing the use of DFP versus other options tested, the incremental cost-efficacy ratio was used. Poisson regression analyses were used to verify the association between discomfort and explanatory variables. The parents' satisfaction about the treatments were explored descriptively. A total of 316 approximal surfaces were included. The majority of them were classified as ICDAS (International Caries Detection and Assessment System) score 2 associated with absence of radiographic image. The dropout in the study was 15% and 24% at 12-month and 24-month follow-up, respectively. There was no association between treatment groups and lesions progression at 12 and 24 months, both for the per-protocol analysis and by survival analysis. The rate of clinical lesions progression to cavity into dentine was 2.5% at 12 months and 5.6% at 24 months. Lesions without initial radiographic image did not progress into the middle of the dentine or more. Baseline clinical condition of caries lesions was associated with lesions progression in all analyses. The caries risk was also associated to caries progression in 24-month analyses and in the survival analyses