Selective vs stepwise removal of deep carious lesions in primary molars: 24 months follow-up from a randomized controlled trial.

OBJECTIVES: For well-defined deep (> 2/3 dentin extension) carious lesions, selective (SE) or stepwise (SW) carious tissue removals have been recommended, while there is limited comparative evidence for both. We compared SE and SW over 24 months in a randomized controlled trial. METHODS: A two-arm superiority trial was conducted comparing SW/SE in primary molars without pulpal symptoms but well-defined deep lesions. Seventy-four children (1 molar/child) aged 3-9 years were recruited. In a first step, peripheral carious tissue was removed until hard dentin remained, while in proximity to the pulp, leathery dentin was left. An adhesive compomer restoration was placed and restorations re-examined after 6 months. In SW, re-entry and removal to firm dentin was conducted pulpo-proximally, followed by re-restoration. Molars were re-evaluated for a total of 24 months. Our primary outcome was success (absence of restorative/endodontic complications or pulp exposures). Secondary outcomes included total treatment and opportunity costs and restoration quality, assessed using modified USPHS criteria. RESULTS: After 24 months, 63 molars (31 SE, 32 SW) were re-assessed. Four failures occurred (2 exposures in SW; 2 pulpal complications in SE, 1 of them leading to extraction, p > 0.05). Restoration integrity was satisfying in both groups (USPHS A/B/C in 21/8/0 SE and 23/7/0 SW, p > 0.05). Treatment and opportunity costs were significantly higher in SW than SE (mean 171 ± 51 vs. 106 ± 90; p < 0.001). CONCLUSIONS: After 2 years, SE and SW showed similar efficacy for managing deep carious lesions in primary molars. The higher costs for SW should be considered during decision-making. CLINICAL SIGNIFICANCE: In primary molars with well-defined deep carious lesions SE was less costly and similarly efficacious like SW. From a cost and applicability perspective, SW may need to be indicated restrictively, e.g., for very deep (> 3/4 dentin extension) lesions only. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02232828.

Selective vs stepwise removal of deep carious lesions in primary molars: 12-Months results of a randomized controlled pilot trial.

OBJECTIVES: For deep carious lesions, selective or stepwise carious tissue removal (SE, SW) seem advantageous compared with non-selective removal. For primary molars, there is insufficient evidence comparing SE against SW. This randomized pilot trial compared SE and SW over 12 months. METHODS: A two-arm superiority trial was conducted comparing SE and SW in primary molars with deep lesions but without pulpal symptoms. We recruited 74 children (one molar/child) aged 3-9 years. In both groups, peripheral carious tissue removal was performed at T1 to hard dentin. In proximity to the pulp, leathery dentin was left followed by an adhesive compomer restoration. Blinded re-examination was performed after six months (T2). Molars allocated to SW were re-entered, removal to firm dentin carried out pulpo-proximally, and again restored. After another 6 months, all molars were re-examined (T3). Our primary outcome was success, defined as no restorative/endodontic complications (including pulp exposure) leading to reinterventions. Secondary outcomes included total treatment and opportunity costs. Patients', dentists' and parents' subjective assessments were recorded. This trial was registered (ClinicalTrials.gov/NCT02232828). RESULTS: After 12 months a total of 72 children (36 SE, 36 SW) were analyzed. Three failures occurred (2 exposures in SW, 1 pulpal complication leading to extraction in SE) (p > 0.05). The subjective evaluation by patients, parents or dentists did not differ significantly. Combined treatment and opportunity costs were significantly higher in SW (mean;SD: 186;61 Euro) than SE (100;59) (p < 0.001). CONCLUSIONS: The significantly increased costs for performing SW instead of SE in deep carious lesions in primary molars may not be justified. CLINICAL SIGNIFICANCE: For primary molars with deep lesions, but vital pulps, SE was less costly at similar efficacy compared with SW. Dentists' decision-making should consider this alongside further clinical aspects.

Sealing or infiltrating proximal carious lesions.

OBJECTIVES: Micro-invasive treatment (sealing, infiltration) seems more efficacious to arrest early (non-cavitated) proximal carious lesions than non-invasive treatment (NI). Uncertainty remains as to the efficacy of sealing versus infiltration and the robustness of the evidence. We aimed to review and synthesize this evidence using pairwise and network meta-analysis (NMA) and to perform trial sequential analysis (TSA). SOURCES: Searching three electronic databases (Medline, Embase, Cochrane Central) was complemented by hand searches and cross-referencing. STUDY SELECTION: Randomized controlled trials comparing micro-invasive strategies against each other, NI or placebo for managing proximal carious lesions were included. The primary outcome was radiographically assessed lesion progression. Pairwise and Bayesian network meta-analyses as well as TSA were used for synthesis. DATA: Thirteen split-mouth studies (486 participants, mean age 15 years) were included. Mean follow-up was 25 months (min/max 12/36 months). Firm evidence on the superior efficacy of sealing/infiltration over NI (OR; 95% CI: 0.25; 0.18-0.32) was reached. Firm evidence was also reached on the superior efficacy of sealing (OR; 95% CI: 0.29; 0.18-0.46, 7 studies) and infiltration (OR; 95% CI: 0.22; 0.15-0.33, 7 studies) over NI. One study compared infiltration versus sealing and found no significant difference (0.70; 0.34-1.47). Based on Bayesian NMA, infiltration was ranked first in 80% of the simulations (sealing 20%, NI 0%). The surface-under-the-cumulative-ranking (SUCRA) values were 0.90 for infiltration, 0.60 for sealing and 0.00 for NI. We did not detect significant inconsistency (p = 0.89, node-split). CONCLUSIONS: Sealing or infiltration are likely to be more efficacious for arresting early (non-cavitated) proximal lesions than NI. CLINICAL SIGNIFICANCE: Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing or infiltration should be guided by practical concerns beyond efficacy.

The impact of demographic, health-related and social factors on dental services utilization: Systematic review and meta-analysis.

OBJECTIVES: Regular and/or preventive dental services utilization is an indicator of healthcare access and associated with improved health outcomes. We assessed the proportion of individuals regularly/preventively utilizing dental services, and how this was affected by demographic, health-related and social factors. SOURCES: Three electronic databases (Medline, Embase, Central) were searched (2005-2017). STUDY SELECTION: We included observational studies investigating the association between preventive/regular dental service utilization and age, oral and general health, edentulism, family structure and health literacy. DATA: The proportion of individuals with regular/preventive utilization overall and in different sub-groups were extracted. Random-effects meta-analyses, with subgroup analyses by region, were performed. Meta-regression was used to assess whether and how associations changed with time and countries' human developmental status (HDI). 103 studies on 7,395,697 participants from 28 countries were included. The global mean (95% CI) proportion of individuals regularly/preventively utilizing dental services was 54% (50-59%). In countries with higher HDI, more individuals regularly/preventively utilized services (p < 0.001). Age did not have a significant impact on utilization in adults (OR = 1.00; 0.89-1.12). Utilization was significantly lower in younger than older children (OR = 0.52; 0.46-0.59), individuals with poorer general health (OR = 0.73; 0.65-0.80) and poorer oral health (OR = 0.64; 0.52-0.75), edentulous individuals (OR = 0.32; 0.23-0.41), and individuals with less supportive family structures (OR = 0.81; 0.73-0.89) or poor health literacy (OR = 0.41; 0.01-0.81). The observed differences within populations did not significantly change with time and were universally present. CONCLUSIONS: Regular/preventive utilization varied widely between and within countries. Understanding and tackling the reasons underlying this may help to consistently improve utilization. CLINICAL SIGNIFICANCE: Higher developmental status of countries is reflected in greater regular/preventive utilization of dental services. However, large demographic, health-related and social differences in utilization remain. These may contribute to dental health inequalities.

In vitro performance of the DIAGNOcam for detecting proximal carious lesions adjacent to composite restorations.

OBJECTIVES: To assess the accuracy of near-infrared-light transillumination (DIAGNO) compared to visual-tactile (VT) and radiographic (RA) evaluation of proximal carious lesions adjacent to composite restorations in vitro. METHODS: Two hundred extracted posterior permanent human teeth with occluso-proximal composite restorations were allocated to 50 groups of four posterior teeth, and mounted in a pilot-tested diagnostic model in a dummy head. The teeth were independently assessed by two examiners. Transverse microradiography and visual assessment served as reference tests to detect any lesions (prevalence 24%) and cavitated lesions (18%), respectively, adjacent to restorations. Sensitivity, specificity, positive and negative predictive values and the area under the receiver-operating-characteristics curve (AUC) were calculated. RESULTS: To detect any proximal carious lesions adjacent to composite, the mean sensitivity/specificity were 0.63/0.95 for DIAGNO, 0.70/0.88 for RA when lesions radiographically extending into enamel and dentin were considered, 0.26/0.98 for RA when only lesions extending into dentin were considered, and 0.31/0.96 for VT. For cavitated lesions adjacent to proximal composite restorations, these values were RA (enamel and dentin) 0.84/0.88, RA (dentin) 0.34/0.99, DIAGNO 0.69/0.94 and VT 0.40/0.97. AUC did not differ significantly between RA and DIAGNO, while VT showed significantly lower values (p < 0.05). CONCLUSION: Within the limitations of this study, DIAGNO seems useful for detecting proximal carious lesions adjacent to restorations. CLINICAL RELEVANCE: Near-infrared-light transillumination could be used as a radiation-free adjunct or alternative to RA for detecting carious lesions adjacent to composite restorations.

Global burden of molar incisor hypomineralization.

OBJECTIVES: We aimed to systematically review and meta-analyze the global, super-regional, regional and national prevalence of molar-incisor-hypomineralization (MIH) and to determine the numbers of prevalent and incident cases on different spatial scales. The review was registered (PROSPERO CRD42017063842). SOURCES: Five electronic databases (Medline, EMBASE, LILACS, Web of Science, Google Scholar) were searched systematically. STUDY SELECTION: Observational studies on the prevalence of MIH were included and the prevalence on different spatial scales (global, super-regional, regional, national) synthesized using random-effects meta-analyses. The prevalence was then regressed on a large set of methodological, socioeconomic and environmental variables to estimate the global burden (incident and prevalent cases) of MIH. DATA: Of 2239 identified studies, 99 studies on 113,144 participants from 43 countries were included. The meta-analysis yielded a mean (95% CI) prevalence of 13.1% (11.8-14.5%), with significant differences between super-regions, regions and countries. The number of prevalent cases in 2015 was estimated at 878 (791-971) million people, while the number of incident cases in 2016 was 17.5 (15.8-19.4) million. Of these, 27.4% (23.5-31.7%) (in mean, 240 million prevalent and 4.8 million incident cases, respectively) were or will be in need of therapy due to pain, hypersensitivity or posteruptive breakdown. Heavily populated countries contribute significantly to the burden of prevalent cases, while growing countries like India, but also Pakistan or Indonesia rank first with respect to the number of incident cases. CONCLUSIONS: MIH is highly prevalent across the globe. Certain (mainly low- and middle income) countries shoulder the majority of this burden. Clinical significance The consistently high prevalence and the large proportion of cases in need of care should be considered by both clinicians in their daily practice and healthcare planners and policy makers.

Inequality in Utilization of Dental Services: A Systematic Review and Meta-analysis.

BACKGROUND: Dental diseases are among the most prevalent conditions worldwide, with universal access to dental care being one key to tackling them. Systematic quantification of inequalities in dental service utilization is needed to identify where these are most pronounced, assess factors underlying the inequalities, and evaluate changes in inequalities with time. OBJECTIVES: To evaluate the presence and extent of inequalities in dental services utilization. SEARCH METHODS: We performed a systematic review and meta-analysis by searching 3 electronic databases (MEDLINE, Embase, Cochrane Central Database), covering the period from January 2005 to April 2017. SELECTION CRITERIA: We included observational studies investigating the association between regular dental service utilization and sex, ethnicity, place of living, educational or income or occupational position, or insurance coverage status. Two reviewers undertook independent screening of studies and made decisions by consensus. DATA COLLECTION AND ANALYSIS: Our primary outcome was the presence and extent of inequalities in dental service utilization, measured as relative estimates (usually odds ratios [ORs]) comparing different (high and low utilization) groups. We performed random effects meta-analysis and subgroup analyses by region, and we used meta-regression to assess whether and how associations changed with time. MAIN RESULTS: A total of 117 studies met the inclusion criteria. On the basis of 7 830 810 participants, dental services utilization was lower in male than female participants (OR = 0.85; 95% confidence interval [CI] = 0.74, 0.95; P < .001); ethnic minorities or immigrants than ethnic majorities or natives (OR = 0.71; 95% CI = 0.59, 0.82; P < .001); those living in rural than those living in urban places (OR = 0.87; 95% CI = 0.76, 0.97; P = .011); those with lower than higher educational position (OR = 0.61; 95% CI = 0.55, 0.68; P < .001) or income (OR = 0.66; 95% CI = 0.54, 0.79; P < .001); and among those without insurance coverage status than those with such status (OR = 0.58; 95% CI = 0.49, 0.68; P < .001). Occupational status (OR = 0.95; 95% CI = 0.81, 1.09; P = .356) had no significant impact on utilization. The observed inequalities did not significantly change over the assessed 12-year period and were universally present. AUTHORS' CONCLUSIONS: Inequalities in dental service utilization are both considerable and globally consistent. Public Health Implications. The observed inequalities in dental services utilization can be assumed to significantly cause or aggravate existing dental health inequalities. Policymakers should address the physical, socioeconomic, or psychological causes underlying the inequalities in utilization.

Cost-effectiveness of caries-preventive fluoride varnish applications in clinic settings among patients of low, moderate and high risk.

OBJECTIVES: The total body of evidence finds fluoride varnish effective to prevent caries. However, most trials were conducted in high-risk populations, with more recent trials on low-risk groups finding a lower efficacy. We aimed to assess the cost-effectiveness of fluoride varnish application in clinic setting in populations with different caries risk. METHODS: A mixed public-private-payer perspective in the context of German health care was performed using a lifetime Markov model. Effectiveness data were derived from an update of the most recent systematic Cochrane review and synthesized in three different risk groups according to control group caries increment via random-effects meta-analysis. Varnish was assumed to be applied twice yearly between age 6 and 18 years. Teeth with carious defects would be treated restoratively and could experience further follow-up treatments. Costs were deduced from German fee item catalogues. Monte Carlo microsimulations were used for to analyse lifetime treatment costs and caries increment (Euro/Decayed, Missing, Filled Teeth (DMFT)). RESULTS: In low-risk groups, fluoride varnish was nearly twice as costly and minimally more effective (293 Euro, 8.1 DMFT) than no varnish (163 Euro, 8.5 DMFT). The incremental cost-effectiveness ratio (ICER) was 343 Euro spent per avoided DMFT. The ICER was lower in medium-risk (ICER 93 Euro/DMFT) and high-risk groups (8 Euro/DMFT). CONCLUSIONS: Application of fluoride varnish in the clinic setting is unlikely to be cost-effective in low-risk populations. There is the need to either target high-risk groups or to provide fluoride varnish at lower costs, possibly in nonclinic settings.

Oral manifestations, dental management, and a rare homozygous mutation of the PRDM12 gene in a boy with hereditary sensory and autonomic neuropathy type VIII: a case report and review of the literature.

BACKGROUND: Hereditary sensory and autonomic neuropathy type VIII is a rare autosomal recessive inherited disorder. Chen et al. recently identified the causative gene and characterized biallelic mutations in the PR domain-containing protein 12 gene, which plays a role in the development of pain-sensing nerve cells. Our patient's family was included in Chen and colleagues' study. We performed a literature review of the PubMed library (January 1985 to December 2016) on hereditary sensory and autonomic neuropathy type I to VIII genetic disorders and their orofacial manifestations. This case report is the first to describe the oral manifestations, and their treatment, of the recently discovered hereditary sensory and autonomic neuropathy type VIII in the medical and dental literature. CASE PRESENTATION: We report on the oral manifestations and dental management of an 8-month-old white boy with hereditary sensory and autonomic neuropathy-VIII over a period of 16 years. Our patient was homozygous for a mutation of PR domain-containing protein 12 gene and was characterized by insensitivity to pain and thermal stimuli, self-mutilation behavior, reduced sweat and tear production, absence of corneal reflexes, and multiple skin and bone infections. Oral manifestations included premature loss of teeth, associated with dental traumata and self-mutilation, severe soft tissue injuries, dental caries and submucosal abscesses, hypomineralization of primary teeth, and mandibular osteomyelitis. CONCLUSIONS: The lack of scientific knowledge on hereditary sensory and autonomic neuropathy due to the rarity of the disease often results in a delay in diagnosis, which is of substantial importance for the prevention of many complications and symptoms. Interdisciplinary work of specialized medical and dental teams and development of a standardized treatment protocols are essential for the management of the disease. There are many knowledge gaps concerning the management of patients with hereditary sensory and autonomic neuropathy-VIII, therefore more research on an international basis is needed.

Industry sponsorship in trials on fluoride varnish or gels for caries prevention.

OBJECTIVES: Fluoride is effective for caries prevention, but trials on fluoride varnish or gels are often industry-sponsored. We assessed trial design and findings in sponsored and nonsponsored trials on fluoride varnish and fluoride gels for caries prevention. METHODS: Data on trials included in the most recent Cochrane Reviews on fluoride varnish and fluoride gels were extracted. Sample sizes/age/dentition, year/country of publication, follow-up, test and control, risk of bias and spin (claims of a beneficial effect that were not supported by reported data) were assessed. Studies were categorized as certainly, possibly and not sponsored, and statistically compared. Inverse-generic meta-analysis and multivariable weighted least-squares meta-regression were used to assess impact of sponsorship status on effect estimates. RESULTS: Based on 19 nonsponsored, 14 possibly sponsored and 11 certainly sponsored trials, sponsored studies were published significantly earlier, always had >1 test group, and had significantly lower risk of spin. Caries-preventive effects were higher in earlier trials, without indication for sponsorship bias in trials published until 1990 (there were no sponsored trials afterwards). If assessing the overall body of evidence and accounting for confounders, the caries-preventive effect was significantly associated with year of publication (ß: -0.06, 95% CI: -0.10/-0.02), but not sponsorship status. CONCLUSIONS: Industry-sponsorship bias had limited impact on the overall evidence.