Correlation between Matrix Metalloproteinase Presence and Caries Surface Appearance.

INTRODUCTION: Cariogenic bacterial acids dissolve the inorganic elements in dentine, leaving the dentine matrix exposed. Host-derived matrix metalloproteinases (MMPs) play an essential role in caries progression as they are significant regulators of extracellular matrix turnover and can degrade exposed collagen. This paper investigates the expression of MMP2 and MMP9 across various stages of caries in primary human teeth and relate this with a diagnosis recorded by the International Caries Detection and Assessment System (ICDAS). METHODS: Twenty-four sections (150 µm in thickness) from extracted teeth, clinically diagnosed using ICDAS, were immunohistochemically treated with monoclonal anti-MMP2 and anti-MMP9 antibodies. Positive staining was visualised by immunofluorescence using a VectorFluor Duet Double Labeling Kit. Images from triplicate samples for each ICDAS score were analysed using ImageJ software. Collagen degradation in caries lesions was detected using a hydroxyproline assay. RESULTS: MMPs were weakly detected in caries with ICDAS 1-2 scores, and an insignificant increase was detected in ICDAS 3. However, a significant increase in MMP expression was seen in caries with an ICDAS score of 4-6. There was a strong positive correlation between the ICDAS score and MMP2 (r [6] = 0.86, p = 0.002) and between ICDAS and MMP9 (r [6] = 0.82, p = 0.004). Data were analysed using two-way ANOVA followed by Tukey multiple comparison test (*p < 0.05). CONCLUSION: The use of ICDAS to assess the severity of caries lesions and how this correlates with the presence of MMP in these lesions validates the modern approach to caries management with a minimally invasive concept.

Should we splint traumatised primary teeth?

DESIGN: Systematic review. REVIEW QUESTION: Does splinting of traumatised primary teeth improve clinical outcomes? CASE SELECTION: Clinical studies published after 2003 reporting trauma (luxation, root fracture or alveolar fracture) to primary teeth, with a minimum follow-up of 6 months, were eligible for inclusion. Case reports were excluded, but case series were included. Studies reporting the outcome of splinting following avulsion injuries were excluded, as current guidance does not recommend re-implantation of teeth for these injuries. DATA ANALYSIS: Two researchers independently assessed the risk of bias in the included studies, with a third researcher resolving any disagreements. The same two independent researchers conducted a quality assessment of the included studies. RESULTS: Three retrospective studies met the inclusion criteria. Only one of these studies had a control group. High success rates were reported for the management of teeth with root fractures. A benefit for splinting teeth with lateral luxation was not identified. No alveolar fractures were included. CONCLUSIONS: This review suggests that the outcome of the management of root fractures in primary teeth may benefit from flexible splinting. However, the evidence base is low.

What are the health impacts of nicotine and tobacco products on young people?

DESIGN: Narrative review. REVIEW QUESTION: What are the implications of new nicotine and tobacco products on adolescent health? PRODUCTS: E-cigarettes and oral nicotine products such as pouches, lozenges, tablets, gum, and gummies. RESULTS: These products can be addictive and can cause respiratory, cardiovascular and oral potential health problems. They also have effects on brain development. Products are attractive to adolescents, with more than 1:10 American adolescents uses them. CONCLUSIONS: The use of nicotine and tobacco products by adolescents puts their health at risk and may, in some instances, lead to nicotine addiction. Those providing healthcare for adolescents have an opportunity to provide advice and signpost people to resources to help them stop using such products. There is also a need for legislation to restrict the sale of e-cigarettes and tobacco products.

What is the influence of oral health literacy on the parents' choice of fluoride toothpaste?

DESIGN: Investigator blind randomised controlled trial. INTERVENTION: One hundred and forty-five parents or carers of children up to four years of age were recruited from families attending a clinic for premature children in Brazil. The aim was to assess the influence of Oral Health Literacy (OHL/OHL-AQ) on the effective and safe use of fluoride toothpaste. The participants were stratified into adequate (12-17) and marginal/inadequate OHL (0-11) and randomly allocated into one of four intervention groups as follows, based on how information was provided: 1. written, 2. oral, 3. written & photograph, 4. oral & photograph. Socioeconomic status was also recorded. Prior to the intervention, the participant's ability to apply the correct amount of toothpaste (1000 p.p.m F-) was assessed. DATA ANALYSIS: Data were analysed using the t-test and one-way ANOVA. The chi-squared test was used to evaluate associations between participants' ability to select the correct toothpaste, sociodemographic characteristics, oral health habits and OHL. RESULTS: The majority of the sample were female (89%), with the whole sample's mean age being 31.9 ± 8.3 years. The OHL-AQ score ranged from 2-16 (mean: 11.3 ± 3.0). Before or after the intervention, having a higher level of OHL was associated with a tendency to deliver the more correct amount of toothpaste onto the brush. The interventions did lead to an improvement in the volume of toothpaste used across all groups. Only schooling was associated with the correct choice of toothpaste. CONCLUSIONS: Parents or guardians with higher OHL used less, and consequently more ideal amounts of, fluoride toothpaste for children compared to those with a lower level of OHL. This was the case both before and after the educational interventions. The allocation to intervention group did not predict the amount of toothpaste used. Finally, only schooling predicted the choice of correct fluoride toothpaste.

Melatonin for pre-medication in children: a systematic review.

BACKGROUND: Melatonin's effectiveness as an anxiolytic medication has been confirmed in adults; however, its efficacy in a paediatric population is unclear. A number of small studies have assessed its use in children as a pre-operative anxiolytic, with conflicting results. METHODS: We undertook a systematic review of pre-operative melatonin use in children. Four databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Web of Science), and ' ClinicalTrials.gov ' were searched for ongoing and completed clinical trials of relevance. Citation tracking reference lists and relevant articles were also accessed. The review was unrestricted by comparator or outcomes. Eleven studies were judged eligible for inclusion. There were high levels of heterogeneity in melatonin administration (in terms of dose and timing). Variable outcomes were reported and included: anxiety; anaesthetic success; analgesia; sedation; post-operative recovery; and safety. Outcomes were not always assessed with the same measures. RESULTS: Evidence to support melatonin's anxiolytic properties in this setting is conflicting. Melatonin was associated with reduced sedative effects, post-operative excitement and improved emergence behaviour, compared to comparator drugs. One study reported the benefit of melatonin use on sleep disturbance at two weeks post-surgery. No adverse safety events were identified to be significantly associated with melatonin, affirming its excellent safety profile. CONCLUSION: Despite potential advantages, including improved emergence behaviour, based on current evidence we cannot confirm whether melatonin is non-inferior to current "usual care" pre-medications. Further consideration of melatonin as an anxiolytic pre-medication in paediatric surgery is needed.

Effect of Demineralizing Agents on Organic and Inorganic Components of Dentine.

There is a requirement to ensure that in vitro studies that use demineralized human dentine models are reliable and clinically relevant. The literature reports several strategies for these studies with a lack of consensus on the mode of action of the different demineralizing acids on human dentine. This in vitro study aims to characterize the effect of clinically relevant acids on human dentine, using standardized substrates and complementary analytical techniques. The study focuses on an analysis of the mineral content and the integrity of the collagen following partial demineralization. Samples of human dentine were exposed to a range of acids commonly encountered in the oral cavity. Characterization of the mineral content used Vickers micro-hardness, energy-dispersive spectroscopy, and X-ray fluorescence. Characterization of the collagen integrity was undertaken by means of scanning electron microscopy and hydroxyproline assay. The following conclusions were reached: (i) each demineralizing agent tested had a unique effect on the mineral levels; (ii) chelating agents, strong acids, and weak acids affect the mineral and organic phases of dentine in significantly different ways with no correlation between them; and (iii) the demineralizing agents caused some degree of collagen denaturation, citric acid causing the most damage. Overall, there is no clear link between the type of demineralizing agent and the effect on the organic and inorganic dentine. The choice of demineralizing agent should be aligned to the experiment objectives so that the selected dentine (caries or erosion) model is fit for the purpose.

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

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

The legal position of delivering dental care in a time of COVID-19.

Aim To provide an international perspective on COVID-19 (SARS-CoV-2) safety measures and discuss the medico-legal perspective of providing dental care during the COVID-19 pandemic.Data sources This paper is a narrative review. The authors are drawn from academic dentistry and academic law.COVID-19 safety measures in dental clinics Dental care professionals are considered to be at high risk of exposure and subsequent transmission of COVID-19. Therefore, it is of great importance that dental professions put in place measures to prevent cross infection from the virus. These measures include screening patients and spacing of appointments to allow fallow time. Within the clinic, there is a requirement for adequate ventilation (perhaps aided by air cleaners and disinfection air fogging devices) together with cleaning and use of alcohol gels to ensure hands are clean. With regards to dental treatment, the measures expected are also itemised, such as the use of virucidal antiseptic mouthwash, use of personal protective equipment, rubber dam and moving to non-aerosol generating procedures wherever possible.COVID-19 safety measures and the law The point is made that the need for the implementation of these precautions is not only necessary for cross-infection prevention but also for the avoidance of legal issues. The paper discusses the liability of a dentist, both criminal and civil, should a person contract COVID-19 as a result of attending for dental treatment. Although opinion varies across legal jurisdictions, the general consensus is that a practitioner would only be liable if they had been negligent. This is not just the case when guidelines are available, whether legally enforced or not, as the practitioner is required to deliver care in an up-to-date and evidence-based manner. There is a need to document persuasions taken to protect the practitioner from litigation.Conclusion Dentists should follow the scientific evidence to reduce as much as possible the risk of them contracting or spreading COVID-19. In addition, to avoid criminal or civil legal consequences, all procedures to avoid cross infection should be documented, as in not doing so, the practitioner will not be able to prove they were carried out.

What is the best caries removal strategy for primary molars?

Aim This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the efficacy of different caries removal techniques: complete caries removal (CCR), selective caries removal (SCR) and stepwise caries removal (SWR) for deep carious lesions in vital primary teeth.Data sources The design of this review followed the PRISMA guidance ( http://www.prisma-statement.org/ ). Relevant studies were identified using electronic databases (PubMed [Medline], Cochrane Library, EMBASE) and finally reference lists were screened. The US National Institutes of Health Trials Register (NIHTR; http://clinicaltrials.gov ) and World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP; http://apps.who.int/trialsearch ) were used to help assess publication bias, as it was not possible to test funnel plot asymmetry. Duplicates were located and eliminated using EndNote X7 programme.Study selection To be included, studies had to be published RCTs comparing SCR or SWR with CCR as caries removal strategies for deep carious lesions in vital primary teeth. The outcomes were pulp exposure, pulpo-periodontal complications (clinical and radiological failures) and/or restorative failures. RCTs applying these caries removal techniques were excluded if one of the other trial arms did not involve caries removal (that is, Hall Technique, therapeutic sealing of cavity lesions). Initially, 1,374 potentially eligible articles were identified, out of which 15 (English or French language only) were selected for full-text screening, which included ten relevant references corresponding to eight studies.Data extraction and synthesis Two authors independently extracted data using a piloted data extraction sheet, with a third reviewer resolving any disagreements. The authors performed conventional intention-to-treat and per-protocol meta-analyses, and calculated odds ratios (ORs) as effect estimates in the random-effects model, using Revman5.Results The eight included RCTs were conducted between 1977 and 2018. They include 669 patients and 824 teeth, with follow-up ranging from four weeks to 24 months. Collective results showed reduced risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using United States Public Health Service (USPHS) criteria, after SCR was compared with CCR only in intention-to-treat analysis. However, when comparing the risk of clinical or radiographic failure of pulpo-periodontal complications, no difference was found between SCR, CCR or SWR.Conclusion The conclusions of the paper are that there is a significant decrease in pulp exposure risk with SCR and SWR in comparison with CCR. However, there is a need for further studies with less risk of bias powered to report on the long-term outcomes of pulpo-periodontal health and restoration longevity.

Do panoramic radiographs offer improved diagnostic accuracy over clinical examination and other radiographic techniques in children?

Aim The aim of this study was to establish the diagnostic efficacy of panoramic radiographs in six clinical situations for paediatric patients: caries, acute dental infections, dental trauma, dental anomalies, developmental disorders and pathological conditions.Data sources The authors searched the following databases: Medline, Embase, the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects and the Cochrane Health Technology Assessment database. Forward citation searches of included studies were carried out. There were no language restrictions. The dates were restricted to include studies published between 1990-2018.Study selection Inclusion criteria: children under the age of 18 for whom the diagnostic accuracy of panoramic radiography was compared to either clinical or an alternative radiographic examination for the six included indications. Exclusion criteria: panoramic radiographs taken for orthodontic indications outwith those stated in the aim. Studies of all designs were included. Screening of titles, abstracts and full texts were completed independently and in duplicate by two authors. Disagreement was resolved by discussion including a third author. A total of 3,420 abstracts were screened, from which 175 full texts were reviewed. Sixteen studies across the six indications were included in the review.Data extraction and synthesis Data extraction was performed independently and in duplicate by two authors, with a third resolving disagreement. A standardised form was used which was initially piloted on ten papers. A narrative synthesis was carried out due to heterogeneity of the included studies precluding data synthesis.Results Assessment of bias was completed using the QUADAS 2 tool. Of 16 included studies, the majority were of high or unclear risk of bias for domains including: patient selection, conduct or interpretation of the index test, reference standard, and patient timing and flow. Regarding detection of caries, one study was included which demonstrated clinical examination detected more carious surfaces than panoramic radiographs (6.0%, 95% CI 4.1-7.8%), but that bitewing radiography combined with panoramic radiography led to a higher diagnosis of approximal lesions than clinical examination alone by 4.3% (p <0.0001). Concerning acute dental infection, one study was included that did not present diagnostic accuracy data. Three studies related to dental trauma were included, all of which examined condylar fractures. Only one study reported diagnostic accuracy data: 70% diagnostic accuracy with panoramic radiography compared to 92% utilising CT scans. Four studies included examined diagnosis of a spectrum of dental anomalies. The only study to provide data on diagnostic accuracy reported a sensitivity of 50% for correct identification of supernumerary teeth on panoramic radiographs, with a specificity of 97.2%. Five included studies pertained to developmental disorders. One study gave data on diagnostic accuracy of panoramic radiographs. This showed sensitivity of 68.2% for identification of abnormalities in familial adenomatous polyposis. Two studies included were related to pathological conditions - one reported that panoramic radiographs gave 75% sensitivity to identify abnormal condylar morphology in patients with TMJ synovitis, with a specificity of 66.7%.Conclusions The study concluded that more research is required concerning the diagnostic accuracy of panoramic radiographs for oral conditions in order to produce clinical guidance based on high-quality evidence.

The COVID-19 pandemic: implications for dental education.

Aim This narrative review aims to report on the impacts of COVID-19 on the provision of dental education in the 67 dental schools in the United States (US). Having set the scene and current challenges, it aims to suggest some strategies to overcome the issues facing dental schools going forward.Background In the US the Occupational Safety and Health Administration classified dentists in the very high risk category because of the potential for exposure to the virus as a result of aerosol generating procedures (AGP). In the last 20 years there have been two previous outbreaks of coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome) which resulted in no long-term changes in the provision of dental education. The recent paper from Wuhan, China described action in the height of the infection but no sustainable actions to deliver dental education going forward.Challenges The challenges identified include: protecting the health of students, faculty and staff; ensuring the continuity and quality of dental education; ensuring confidence in health and safety measures; and keeping up with guidance. There is some variation across the US but most schools have suspended clinical teaching and implemented stay at home policies. Others have implemented social distancing in laboratories including clinical skills. The final challenge is ensuring that students have the teaching, experience and are assessed to ensure the competency of the graduating student.Solutions Technology in teaching and learning offers many opportunities. For didactic teaching distance learning has been implemented. There are 'off the shelf' programmes for teaching and assessment. The development of bespoke content is time consuming and one solution is for schools to share material. Although still requiring social distancing, manikins and haptics offer some opportunities for skills training. The need for excellent information sharing with faculty and students is emphasised.Conclusion Schools should re-evaluate their policies and curricula and incorporate appropriate methods of distance learning permanently into their teaching. Students should have outreach and multi-professional support in order to allow them to assist in the community during public health crises. Finally, gaps have been identified in US dental schools preparedness for pandemics.

Fluoride varnish and dental caries in preschoolers: a systematic review and meta-analysis.

Aim This systematic review aimed to assess the effectiveness of fluoride varnish in preschool children for reducing the incidence of caries into dentine.Data sources Data came from published and grey literature. Databases searched were: CDSR, Medline, EMBASE, Web of Science, SCOPUS, LILACS and BBO. Hand-searching was done of nine dental journals and two medical journals. Backward citation searches were carried out on the reference lists of identified trials and relevant systematic reviews. Trials registers (Current Controlled Trials, ClinicalTrials.gov, EU Clinical Trials Register, Australia New Zealand Clinical Trials Registry, and Registro Brasileiro de Ensaios Clínicos) were searched for ongoing trials. Grey literature was searched via a number of resources including International Association for Dental Research (2001-2018) and European Organisation for Caries Research (1998-2018) conference abstracts and Open Grey, EThOS, the New York Academy of Medicine (GreyLit Report) and Banco de Teses CAPES.Study selection Inclusion criteria were; the use of fluoride varnish (different regimes and doses were included), randomised controlled trials, preschool age (under 71 months) and over 12 months follow up. Outcomes were caries into dentine and hospitalisations due to caries. A combination of free text and controlled terms were used based on the study question. A total of 2441 studies were identified at initial search, 20 were included for narrative and quantitative analysis after full text reviews of 79 studies.Data extraction and synthesis Data was extracted independently by two reviewers with a third resolving any disagreement. Data was combined by subgroup to compare different interventions and controls, with a global random effects meta-analysis performed on 16 studies to provide a relative risk (RR) of dentinal caries at the individual level. At the individual level meta-analysis was by RR, at the tooth and surface level this was prevented fraction (PF) and weighted mean difference (WMD).Results Only one study was determined at low risk of bias, with four unclear and 14 at high risk based on the Cochrane risk of bias tool. Studies were from 13 different countries. Children at baseline were from 0-100% caries free, with a dmft of 0-6.57 and aged 6 months - 5 years. There were no studies reporting hospitalisation due to caries. The combined RR for the outcome of dentine caries for an individual was 0.88 (95% CI 0.81-0.95) based on 16 studies with considerable heterogeneity (I2 = 75.7%). Tooth level results gave a PF of 31.13% (95% CI 21.08, 41.18) and a WMD of -0.30 (95% CI-0.69, 0.09) for fluoride varnish. At surface level the PF was 24.15% (95% CI 12.91-35.38) and WMD of -0.77 (95%CI; -1.23, -0.31).Conclusions The conclusions of the paper were that there is modest and uncertain evidence for fluoride varnish reducing the risk of developing dentine caries in pre-school children.

Should we root treat children's first permanent molars?

Study selection Medline via PubMed and Embase were searched on 6 November 2019 and all studies up to this date were included, including case reports and case series. This was noted as being due to the limited number of studies available in this research area. The outcome measured was clinical success, which was defined as the tooth being present and an assumption that it was sound and asymptomatic at the end of the study. Studies that did not include a minimum of six months' follow-up were excluded, as were editorial letters, in vitro studies and studies not reported in English.Data extraction and synthesis One reviewer searched databases for appropriate studies, then a second reviewer assisted in assessing studies by title and abstract. For each eligible article the operator, sample size, and a full dental diagnosis were recorded. Treatment method, follow-up and treatment success were also assessed.Results The systematic review included eleven studies. The GRADE approach was used to assess quality of evidence. Three studies were of high quality, six of low quality, and two of very low quality. Cochrane and Robins-I risk tools were used to assess bias. All randomised controlled trials were assessed to be of high risk of bias, due to the blinding process not being stated. Six non-randomised controlled trials were assessed to be of critical risk of bias, as the measurement of treatment outcomes was not stated. There was a high risk of bias determined overall.The review reported a 90.5% (range 70-100%) success rate over a mean follow-up period of 28.4 months (range 6-73.6 months) for coronal pulpotomies, which is in line with the results from adult studies. For partial pulpotomies the review reported a 91.3% (range 78.5-100%) success rate over a mean follow-up period of 34.4 months (range 12-140 months), which is slightly lower than reported in adult studies.Only one study on conventional pulpectomies was included in the review that reported a success rate of 36% for a small sample of patients (n = 10).No studies on apexification of molar teeth were included in the review. Therefore, further evidence is required to assess the success of this therapy.One case report showed success with regenerative endodontics for a single molar. Therefore, significant further evidence will be required to assess this approach.Conclusion The systematic review ascertained that partial and coronal pulpotomies had successful treatment outcomes for treating compromised first permanent molar teeth.

School dental screening programmes for oral health: Cochrane systematic review.

Objective To evaluate the effectiveness of school dental screening in improving oral health status and the use of dental services. This review is an update of the original review published in 2017. As you would expect of a Cochrane review, the methodology was of high quality.Study selection Inclusion criteria: randomised controlled trails (RCTs) that evaluated school dental screening compared with no intervention or with another type of screening. The outcome of six of the trials presented dental attendance as the main outcome, while one trail (Nelson 2019) measured the main outcome as receipt of dental care. The studies had an average follow-up period of three to four months, with none reporting on the long term. A total of 3,093 records were identified in the initial search. Twenty-seven full-text copies were requested, and 17 reports and one ongoing study were excluded. Seven studies met the inclusion criteria (reported in nine articles).Results The systematic review included seven trials (four from the UK, two from India and one from the USA) involving 20,192 children aged 4-15 years. Based on the Cochrane risk of bias tool, two trials were determined to be at low risk of bias, two trials were high risk of bias and three trials were assessed to be at unclear risk of bias. Due to the inconsistency in evidence, the review was unable to draw conclusions between traditional screening versus no screening. The comparison between criteria-based screening versus no screening was evaluated, showing a pooled effect estimate of RR 1.07 (95% CI 0.99 to 1.16), which suggested a possible benefit for screening. Criteria-based screening was compared to traditional screening (RR 1.01, 95% CI 0.94 to 1.08), with no evidence of a difference in effectiveness. No trials reported on the potential adverse effects of school dental screening programmes.Conclusion The systematic review found there was very low certainty of evidence to support the role of school screening programmes in improving dental attendance. There was a low certainty of evidence to conclude that criteria-based screening, personalised referral letters or screening supplemented with motivation improve dental attendance.

Effectiveness, Costs and Patient Acceptance of a Conventional and a Biological Treatment Approach for Carious Primary Teeth in Children.

BACKGROUND: Over the last years, conventional restorations for the treatment of active carious lesions (CL) in primary teeth have been challenged and a more biological approach has been suggested. This approach involves less invasive techniques that alter the environment of the CL isolating it from the cariogenic biofilm and substrate. AIM: To investigate the cost-effectiveness and patient acceptance of 2 treatment approaches for the treatment of deep CLs in primary teeth in children. METHODS: This was a retrospective/prospective cohort study carried out in 2 UK specialist hospital settings. Data on cost-effectiveness was extracted retrospectively from clinical dental records of 246 patients aged 4-9 years. A prospective study design was used to explore patient acceptance of the 2 treatment approaches. One hundred and ten patients aged 4-9 years and their carers completed 2 questionnaires on treatment acceptance. RESULTS: In total, 836 primary teeth that had received treatment with either approach were included. More than 2 thirds (75.7%) of the restorations in the conventional approach were of non-selective removal to hard dentine followed by pulpotomy (24.3%). In the biological approach, most of the restorations were stainless steel crowns placed with the Hall Technique (95%) followed by selective removal to firm dentine (5%). The majority of the primary teeth remained asymptomatic after a follow-up period of up to 77 months; 95.3% in the conventional and 95.8% in the biological arm. When the treatment costs were analysed, a statistically significant difference was found between the mean costs of the 2 approaches with a mean difference of GBP 45.20 (Pound Sterling; p < 0.001), in favour of the biological approach. The majority of the children and carers were happy with the conventional or biological restorations. CONCLUSION: Although both approaches had similar successful outcomes, the biological approach consisting mainly of Hall Technique was associated with reduced treatment costs. Both approaches were accepted favourably by the children and carers.

In vivo validity of proximal caries detection in primary teeth, with histological validation.

BACKGROUND: Detection and diagnosis of proximal caries in primary molars are challenging. AIM: The aim of this in vivo study was to assess the validity and reproducibility of four methods of proximal caries detection in primary molar teeth. DESIGN: Eighty-two children (5-10 years) were recruited. Initially, 1030 proximal surfaces were examined using meticulous visual examination (ICDAS) (VE1), bitewing radiographs (RE), and a laser fluorescence pen device (LF1). Temporary tooth separation (TTS) was achieved for 447 surfaces, and these were re-examined visually (VE2) and using the LF pen (LF2). Three hundred and fifty-six teeth (542 surfaces) were subsequently extracted and provided histological validation. RESULTS: At D1 (enamel and dentine caries) diagnostic threshold, the sensitivity of VE1, RE, VE2, LF1, and LF2 examination was 0.52, 0.14, 0.75, 0.58, and 0.60 and the specificity values were 0.89, 0.97, 0.88, 0.85, and 0.77, respectively. At D3 (dentine caries) threshold, the sensitivity values were 0.42, 0.71, 0.49, 0.63, and 0.65, respectively, whereas specificity was 0.93 for VE1 and VE2, and 0.98, 0.87, and 0.88 for RE, LF1, and LF2 examinations, respectively. ROC analysis showed radiographic examination to be superior at D3 . CONCLUSION: Meticulous caries diagnosis (ICDAS) should be supported by radiographs for detection of dentinal proximal caries in primary molars.

Outcomes of the conventional and biological treatment approaches for the management of caries in the primary dentition.

BACKGROUND: In the last few years, conventional restorations including complete removal of carious tissue (CT) with or without pulp therapy for the treatment of carious lesions (CL) in primary teeth have been challenged and a more biological approach has been suggested. This approach involves the use of less invasive techniques which alter the environment of the CL isolating it from the cariogenic biofilm and substrate. Two of these treatment approaches that are becoming increasingly widely accepted and used in paediatric dentistry are the Hall Technique and indirect pulp capping (IPC). AIM: To investigate the outcome of the conventional versus the biological approaches for the treatment of deep CL in the primary teeth in children, delivered in a specialist paediatric dentistry training environment. DESIGN: This was a retrospective cohort study of 246 children aged 4-9 years, treated with either approach, conventional and biological, in two UK specialist hospital settings. Data were extracted from clinical dental records and post-operative radiographs of patients treated during the period 2006-2012. The outcome of the treatment in this study was categorised into three main categories: clinical, radiographic, and final outcome. Clinical and final outcomes were further described as success, minor, and major failure. RESULTS: In total, 836 primary teeth were included. In the conventional approach, 324 teeth had complete CT removal and 104 teeth had a pulpotomy. In the biological approach, 388 teeth had Hall Technique preformed metal crowns (PMC) placed and 20 teeth received indirect pulp capping. PMC were the restoration of choice for most of the cases where a pulpotomy had been carried out, and resin composite was most frequently used restorative material for the complete CT removal group. The majority of the primary teeth treated with either approach remained asymptomatic after a follow-up period of up to 77 months, 95.3% in the conventional and 95.8% in the biological. No significant association was found between the final outcome and the approach used for treatment, age of the patient, gender and number of carious surfaces or tooth type. CONCLUSION: Both the conventional and biological treatment approaches had similar final outcomes and were equally successful for management of CL in the primary dentition.

The impact of dental caries and its treatment by conventional or biological approaches on the oral health-related quality of life of children and carers.

BACKGROUND: The effect of untreated dental caries and the approaches taken to its treatment have not been extensively elucidated in children. AIM: To investigate the impact of untreated dental caries on children aged 4-9 years and whether its treatment with either a conventional or a biological approach influenced the oral health-related quality of life (OHRQoL) of the children and their carers. DESIGN: Children (n = 110) and their carers attending two specialist centres for treatment of carious primary teeth completed the Early Childhood Oral Health Impact Scale and the Self-reported Scale of Oral Health Outcomes for 5-year-old Children at baseline prior to dental treatment and at 3-6 months following completion of dental care. Dental treatment was provided using either a conventional or a biological approach. RESULTS: Dental caries showed a negative impact on the child and family's OHRQoL (P = 0.001). Children reported difficulty eating (55.5%), sleeping (40%), and avoiding smiling because of how the teeth looked (27.3%). More than half of the parents reported their child had toothache. Parents perceived difficulty eating (40.9%), being irritable (38.2%), and difficulty drinking (30.9%) as being impacts of caries on their child's OHRQoL. In addition, approximately half the parents reported feeling a sense of guilt because of their child's dental disease. Following dental treatment, participants reported significant improvement in their overall health status (P = 0.001). Children's age, gender, or the treatment approach were not statistically significantly associated with changes in OHRQoL of the child or carer. Children and parents who initially reported greater impacts of untreated dental caries demonstrated greater improvements in their overall oral health status (P < 0.0001). CONCLUSION: Dental caries was associated with negative impacts on children and parents' quality of life. Treatment of caries improved the quality of life of children and families significantly, irrespective of whether the treatment was provided by a conventional or a biological approach.

Development and evaluation of CARIES-QC: a caries-specific measure of quality of life for children.

BACKGROUND: Existing paediatric oral health-related quality of life (OHRQoL) measures are generic instruments designed to evaluate a range of oral conditions. It has been found that disease-specific measures may be more adept at detecting subtle changes which occur following treatment of the condition in question. Furthermore, existing self-report OHRQoL measures have not involved children at all stages of development of the measure. The aim of this study was to develop a caries-specific measure of quality of life for children. METHODS: The first stage of the study involved a qualitative enquiry with children, aged 5-16 years, to inform the development of the measure. Children generated the potential items, contributed to item reduction and questionnaire design and participated in the testing of face and content validity. The resulting measure was evaluated in a cross-sectional validation study. Ethical approval was granted for the study. RESULTS: The qualitative study found that children discussed a number of caries-related impacts which affected their daily lives. These were incorporated into a draft measure which was further refined following testing of face and content validity. This resulted in the production of the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC), comprising 16 items and one global question. Two hundred participants with a mean (range) age of 8.1 (5-16) years took part in the further evaluation of CARIES-QC. Four items, which did not fit the Rasch model, were removed from further analysis. The remaining 12 items demonstrated good internal consistency (alpha = 0.9) and the total score showed significant correlations with the number of decayed teeth, presence of pain, pulpal involvement, the Child Perceptions Questionnaire (16-item short form) and the global score (p < 0.01, Spearman's rho). CONCLUSION: In conclusion, children's input allowed the development of a valid and reliable child-centred caries-specific quality of life measure. CARIES-QC can now be used to evaluate which interventions for dental caries are most effective in reducing impacts from the child's perspective.

How to Minimize Repeat Dental General Anaesthetics.

This article aims to provide general dental practitioners (GDPs) with the knowledge to improve their referrals primarily for children who they feel require a dental general anaesthetic. It discusses the impact of a general anaesthetic (GA) on a child and the financial impacts of dental general anaesthetics (DGAs). The risks of DGAs are well recognized and the ways in which the dental team in primary, secondary care and service commissioners can reduce the risk of repeat DGAs are discussed. Clinical relevance: Dentists should be aware of the risks involved in GA and the importance of reducing repeat DGAs.