Cost-effectiveness of selective caries removal versus stepwise excavation for deep caries lesions.

A multicenter, randomized controlled clinical trial evaluated the effectiveness of two treatments for deep caries lesions in permanent molars - selective caries removal (SCR) to soft dentin with restoration in a single visit, and stepwise excavation (SW) - regarding pulp vitality for a 5-year follow-up period. The present study aimed to determine the cost-effectiveness of these treatments. Treatments were conducted in two Brazilian cities (Brasília and Porto Alegre). At baseline, 299 permanent molars (233 patients) were treated and 229 teeth (174 patients) were evaluated after 5 years. The discounted cash flow method was adopted. The total cost of each treatment was calculated, and the failure cost (endodontic treatment + restoration) was added to the final cost, according to the 5-year failure rates of each therapy (20% for SCR and 44% for SW). A public health service unit composed of three dentists in 4-hour work shifts was used to calculate the monetary value of the treatments, assuming a total of 528 treatments/month. Considering the 229 teeth evaluated after 5 years (115 SCR and 114 SW), SCR provided savings of 43% (amalgam) and 41% (resin composite) per treatment, compared to SW. The SCR technique provides benefits for public finances (direct economy) and for public health services (increase in the number of treatments performed). Considering that maximizing profit and reducing costs are powerful motivating factors for adopting a certain treatment, this study provides data to better support the decision-making process, regarding the management of deep caries lesions in permanent molars.

Chapter 6: Diagnostic Considerations regarding Coronal Caries.

This chapter considers the main principles guiding diagnosis of the disease dental caries in clinical practice by means of clinical examination and radiographs as adjunct method. Dental professionals have been trained to diagnose caries disease by assessing clinical symptoms and signs of caries lesions complemented by radiographic examination as an adjunct method. Clinical examination is the foundation of the diagnosis and should be performed after removal of dental biofilm of tooth surfaces, air-drying, and under good illumination. Clinical diagnostic methods categorize caries lesions according to their severity and in some methods according to their activity. Caries lesion activity has been determined by surface reflection and texture. The detection of thick or heavy biofilm on tooth surfaces is an additional diagnostic clinical tool to estimate caries lesion activity. Patients with no caries experience, that is, without clinical and/or radiographic signs of caries lesions in the dentition, are considered caries inactive. Other caries-inactive patients may present inactive caries lesions/restorations in their dentition. In contrast, patients are considered caries active when presenting any active caries lesion at clinical level and/or any progressing lesion as demonstrated by at least two bitewing radiographs taken at different points in time. The main concern about caries-active patients is that caries lesions are likely to progress unless effective measures are implemented to interfere with its progression. Prescribed according to individual needs, bitewing radiographs provide additional information for clinical examination in the detection of approximal enamel and outer third dentine lesions that can be inactivated by nonoperative treatment.

Cost-effectiveness of selective caries removal versus stepwise excavation for deep caries lesions

Abstract A multicenter, randomized controlled clinical trial evaluated the effectiveness of two treatments for deep caries lesions in permanent molars - selective caries removal (SCR) to soft dentin with restoration in a single visit, and stepwise excavation (SW) - regarding pulp vitality for a 5-year follow-up period. The present study aimed to determine the cost-effectiveness of these treatments. Treatments were conducted in two Brazilian cities (Brasília and Porto Alegre). At baseline, 299 permanent molars (233 patients) were treated and 229 teeth (174 patients) were evaluated after 5 years. The discounted cash flow method was adopted. The total cost of each treatment was calculated, and the failure cost (endodontic treatment + restoration) was added to the final cost, according to the 5-year failure rates of each therapy (20% for SCR and 44% for SW). A public health service unit composed of three dentists in 4-hour work shifts was used to calculate the monetary value of the treatments, assuming a total of 528 treatments/month. Considering the 229 teeth evaluated after 5 years (115 SCR and 114 SW), SCR provided savings of 43% (amalgam) and 41% (resin composite) per treatment, compared to SW. The SCR technique provides benefits for public finances (direct economy) and for public health services (increase in the number of treatments performed). Considering that maximizing profit and reducing costs are powerful motivating factors for adopting a certain treatment, this study provides data to better support the decision-making process, regarding the management of deep caries lesions in permanent molars.

Restorations after selective caries removal: 5-Year randomized trial.

OBJECTIVE: To compare the survival of restorations placed in deep caries lesions after selective caries removal to soft dentin (SCRSD) over a 5-year period. A secondary aim was to investigate whether the material (amalgam or resin composite) affected the survival of restorations. METHODS: This study used data derived from a multicenter randomized controlled clinical trial (Clinical trials registration NCT00887952). Inclusion criteria were: patients with permanent molars presenting occlusal or proximal deep caries lesions (≥1/2 of the dentin thickness on radiographic examination), positive response to a cold test, absence of spontaneous pain, negative sensitivity to percussion, and absence of periapical lesions. The teeth were randomized into SCRSD and restoration in a single visit or stepwise excavation (SW). Each of these groups was divided according to the filling material: amalgam (AM) or resin composite (RC). Survival analyses were performed to estimate therapy success rates over 5 years (adjusted Weibull regression model). RESULTS: 172 restorations were evaluated, 95 from SCRSD group and 77 from SW group, being 61 AMG and 111 RC. The 5-year survival analysis showed similar success rates for SW (76 %) and SCRSD (79 %) as well as for AM and RC (p > 0.05). CONCLUSION: This study showed that, after a 5-year follow-up period, the presence of decayed tissue beneath restorations in deep caries lesions did not seem to affect restoration survival. Amalgam and resin composite restorations had similar survival rates, irrespective of the caries removal technique used - SCRSD or SW. CLINICAL SIGNIFICANCE: Selective caries removal to soft dentin can be used in the management of deep caries to avoid pulp exposure and preserve tooth structure without affecting restoration longevity.

Diagnosing non-cavitated lesions in epidemiological studies: practical and scientific considerations.

Over the last decade, there has been growing interest in diagnosing non-cavitated lesions in epidemiological studies involving large numbers of preschool children, schoolchildren and young adults. In this context, assessment of lesions characteristics indicating whether or not there is ongoing mineral loss is also considered relevant. The reasoning sustained by these studies is that diagnosis of the caries process limited to the cavitated level is no longer in accordance with current state-of-the-art knowledge in cariology. This paper highlights one topic of the lecture entitled "Caries Process: Evolving Evidence and Understanding," presented at the 18th Congress of the Brazilian Association for Oral Health Promotion (Associação Brasileira de Odontologia de Promoção de Saúde - ABOPREV) in April 2013. In the framework of epidemiological studies, the interest in diagnosing active and inactive non-cavitated lesions was elucidated. However, relevant questions associated with the diagnosis of non-cavitated lesions that might raise concerns among researchers and health administrators were not addressed. The present paper aims to bring these questions into discussion. The contribution of this discussion in terms of developing the understanding of caries decline is analyzed by using data from a caries trends study of Brazilian preschool children residing in the Federal District of Brazil as an example. The inclusion of active and inactive non-cavitated lesions in the diagnosis of the caries process allowed us to demonstrate that, in Brazilian 1- to 5-year-old children, caries prevalence decreased significantly from 1996 to 2006, simultaneously with a reduction in the rate of caries progression.

Diagnosing non-cavitated lesions in epidemiological studies: practical and scientific considerations

Over the last decade, there has been growing interest in diagnosing non-cavitated lesions in epidemiological studies involving large numbers of preschool children, schoolchildren and young adults. In this context, assessment of lesions characteristics indicating whether or not there is ongoing mineral loss is also considered relevant. The reasoning sustained by these studies is that diagnosis of the caries process limited to the cavitated level is no longer in accordance with current state-of-the-art knowledge in cariology. This paper highlights one topic of the lecture entitled "Caries Process: Evolving Evidence and Understanding," presented at the 18th Congress of the Brazilian Association for Oral Health Promotion (Associação Brasileira de Odontologia de Promoção de Saúde - ABOPREV) in April 2013. In the framework of epidemiological studies, the interest in diagnosing active and inactive non-cavitated lesions was elucidated. However, relevant questions associated with the diagnosis of non-cavitated lesions that might raise concerns among researchers and health administrators were not addressed. The present paper aims to bring these questions into discussion. The contribution of this discussion in terms of developing the understanding of caries decline is analyzed by using data from a caries trends study of Brazilian preschool children residing in the Federal District of Brazil as an example. The inclusion of active and inactive non-cavitated lesions in the diagnosis of the caries process allowed us to demonstrate that, in Brazilian 1- to 5-year-old children, caries prevalence decreased significantly from 1996 to 2006, simultaneously with a reduction in the rate of caries progression.

Craniofacial and dental features in kabuki syndrome patients.

Objective : To describe oral manifestations in Brazilian individuals with Kabuki syndrome, a multiple congenital anomaly/mental retardation syndrome. Study Design : A total of 16 Kabuki syndrome individuals, aged between 8 to 24 years and of both sexes, were referred by the Department of Clinical Genetics for oral treatment and follow-up to the Oral Care Center for Inherited Diseases, University Hospital of Brasília, Brasília, Brazil. Each individual underwent complete physical examination, as well as intraoral and radiographic examinations. Results : Craniofacial and dental alterations were observed in all Kabuki syndrome patients examined. In addition, atypical shape of the molars' crowns, occlusal convergence of the premolars' crowns, and root dilaceration were also observed. Enamel diffuse opacities were observed in permanent dentition (n  =  10). Conclusion : A great clinical heterogeneity was observed in Kabuki syndrome individuals in line with previous studies in the literature. Further clinical and molecular studies are necessary in order to better understand the presence of dental anomalies in this syndrome.

Pycnodysostosis with craniosynostosis: case report of the craniofacial and oral features.

Pycnodysostosis (OMIM 265800) is an uncommon hereditary disorder characterized by osteosclerosis of the skeleton, short stature, and bone fragility. The syndrome was first described by Maroteaux and Lamy (1962). Facial dysmorphology, hypoplasia of the mandible,dysplasia of the skull, bones with delayed closure of the cranial sutures, clavicular dysplasia, acroosteolysis or partial aplasia of the terminal phalanges, and abnormal tooth eruption have also been reported (Gelb et al., 1995). An autosomal recessive mode of inheritance has been also suggested and the locus of the disease was initially mapped to human chromosome 1q21 by genetic linkage (Bernard et al., 1980). Since then, several mutations on unrelated patients and consanguineous families have been identified in the cathepsin K gene (CTSK), affecting osteoclast function.Only two previous reports have demonstrated the presence of craniosynostosis in patients with pycnodysostosis(Fleming et al., 2007; Osimani et al., 2010). The purpose of this case report is to describe the craniofacial and dental features of a 12-year-old boy with pycnodysostosisand an uncommon association with craniosynosotosis.

Novel cathepsin C mutation in a Brazilian family with Papillon-Lefèvre syndrome: case report and mutation update.

PURPOSE: Papilion-Lefèvre syndrome (PLS) is a rare autosomal recessive disorder that involves palmoplantar keratosis (PK) and severe aggressive periodontitis. Cathepsin C (CTSC) gene mutations are etiologic for PLS, with more than 60 different mutations reported in different ethnic groups worldwide. The purpose of this study was to report a novel cathepsin C mutation in a Brazilian patient. METHODS: A 4-year-old boy presented with aggressive periodontitis, recession, missing teeth, and hyperkeratosis of the palms of hands and soles. Peripheral blood samples were obtained from family members for genomic DNA isolation. The coding region and exon/intron boundaries of the CTSC gene were amplified and sequenced. RESULTS: The patient had a PLS phenotype, which included PK and early-onset severe periodontitis. Sequence analysis showed a novel CTSC mutation (c.267-268del) present in the homozygous state. CONCLUSION: This report described a novel mutation in a family with Brazilian Papillon-Lefèvre syndrome and presented a review of all cathepsin C (65) mutations reported to date.

Partial caries removal in deep lesions: 19-30 months follow-up study / Remoção Parcial de Dentina Cariada em Lesões Profundas: estudo de 19-30 meses de acompanhamento

O objetivo deste ensaio clínico controlado randomizado multicêntrico foi avaliar a efetividade da remoção parcial de dentina cariada seguida de restauração em única sessão (RPDC) em lesões de cárie profundas no Brasil (Porto Alegre e Brasília) após dois anos de acompanhamento. Critérios de inclusão: pacientes com ≥ seis anos de idade apresentando molares permanentes com lesões profundas primárias, ausência de alteração periapical, sensibilidade pulpar, ausência de dor espontânea e sensibilidade à percussão negativa. Os indivíduos foram randomicamente atribuídos ao grupo teste - RPDC, ou grupo controle - tratamento expectante (TE). O TE consistiu na remoção parcial de dentina cariada, capeamento pulpar indireto com cimento de hidróxido de cálcio, restauração provisória com cimento de óxido de zinco e eugenol, reabertura da cavidade após 60 dias, remoção da dentina cariada remanescente amolecida e restauração. Cada grupo foi dividido de acordo com o material restaurador: amálgama ou resina. Avaliações clínicas e radiográficas foram realizadas anualmente. Os desfechos considerados foram sensibilidade pulpar ao teste frio e ausência de alteração periapical. Foram executados 299 tratamentos, 153 RPDC e 146 TE. Não houve diferença entre os grupos em relação às características basais. Após dois anos de acompanhamento, foram avaliadas 181 restaurações e a taxa de sobrevivência dos tratamentos RPDC e TE foram 95,45% e 80,85%, respectivamente (p=0,001). Razões dos insucessos: pulpites, osteíte, hiperemia, necroses, extração e fratura da restauração. Nenhuma variável foi significativamente associada ao desfecho. A partir destes resultados, é possível concluir que a RPDC é um tratamento mais efetivo que o TE.

The aim of this multicenter randomized controlled clinical trial was to evaluate the effectiveness of partial caries removal followed by restoration in a single session (PDR) for deep caries lesions in Brazil (Porto Alegre and Brasilia) after 2-year follow-up. Inclusion criteria: patients with ≥ six years old presenting permanent molars with primary deep lesion, absence of periapical alterations, pulp sensitivity, absence of spontaneous pain and negative percussion test. The subjects were randomly assigned to test group - PDR, or control group - stepwise excavation (SW). SW consisted of partial removal of carious dentine, indirect pulp capping with calcium hydroxide cement, temporary filling, cavity re-opening after 60 days, removal of the remaining soft carious dentine and filling. Each group was divided according to the filling material: amalgam or resin. Clinical and radiographic evaluations were performed in annual basis. The outcomes were considered as pulp sensibility to cold test and absence of periapical alterations. There were performed 299 treatments, 153 PDR and 146 SW. There were no differences between the groups regarding baseline characteristics. After 2 years of follow-up, 204 restorations were evaluated and the therapy survival rates of PDR and SW were 95.45% and 80.85%, respectively (p=0.001). Reasons for failure: pulpitis, osteitis, hyperemia, necrosis, extraction and restoration fracture.. None variable was significantly associated with the outcome. From these results, it is possible to conclude that the PDR is a more successful treatment than SW.

Seqüelas dentomaxilofaciais em crianças submetida a tratamento multimodal para rabdomiossarcoma / Dentomaxillofacial sequelae in a Child Reated for Rhabdomyosarcoma

O rabdomiosarcoma é o sarcoma de tecidos moles mais comum em crianças e adolescentes. A multimodalidade terapêutica para tumores de cabeça e pescoço, embora eficaz, pode resultar em uma variedade de complicações orais, com efeito significativo sobre o crescimento esquelético maxilomandibular e sobre o desenvolvimento dentário.Neste relato de caso, discutem-se as principais anormalidades tardias encontradas em um sobrevivente pediátrico que teve o tumor, o qual foi irradiado em estádio precoce do desenvolvimento dental. As anormalidades dentomaxilofaciais encontradas incluíram defeitos de esmalte, encurtamento radicular, microdontia, agenesia dentária, mobilidade dentária, micrognatia e assimetria facial. As morbidades cosméticas e funcionais encontradas exigem acompanhamento em longo prazo para melhorar a qualidade de vida da criança após o tratamento da lesão.

Rhabdomyosarcoma is the most common soft tissue sarcoma in children and adolescents. Multi-modality therapy for tumors in the head and neck region may result in a variety of oral complications, with a significant effect on maxillofacial skeletal growth and dental development. This article reports on major oral abnormalities in one long-term survivor of paediatric head and neck rhabdomyosarcoma who had irradiation at an early stage of their teeth’s development. Dentomaxillofacial abnormalities found included enamel defects, disturbance in the root development, microdontia, tooth agenesis, severe dental mobility, micrognatia and facial asymmetry. In addiction, the cosmetic and functional morbidity require follow-up over time to improve patients’ quality of life in survivors of oncologic treatment.

Alterações dentárias em criança celíaca / Dental alteratins in celiac children: a review of literature and case report

A doença celíaca (DC) é uma intolerância permanente ao glúten, caracterizada por atrofia das vilosidades da mucosa intestinal, que ocorre em indivíduos geneticamente susceptíveis. No Brasil, a prevalência de doença celíaca é de 1:681 em pacientes adultos. As manifestações clínicas mais comuns são diarréia crônica, esteatorréia, má absorção de nutrientes e, conseqüentemente, atraso do desenvolvimento pôndero-estatural. Defeitos de desenvolvimento de esmalte têm sido relatados em pacientes com doença celíaca. Essas alterações podem variar desde opacidades de esmalte a severas hipoplasias. O presente relato de caso revelou presença de opacidades difusas em dentes decíduos e permanentes, assim como cronologia de erupção alterada em uma criança com diagnóstico de DC

Saúde bucal de pré-escolares de instituiçöes públicas no Distrito Federal

A prevalência de gengivite e cárie dentária e a influência de algumas variáveis na condição da saúde bucal foram verificadas em 594 crianças de 5 anos de idade, de ambos os sexos, de pré-escolas públicas em diferentes regiões do Distrito Federal, onde a água de abastecimento é fluoretada. Os exames clínicos foram realizados por único examinador e a reprodutibilidade foi feita em 10 por cento da amostra. A frequência de gengivite foi avaliada pelo índice de sangramento gengival (ISG) em todos os dentes e à de cárie dentária pelos índices ceod e ceos, considerando dois níveis de exame: nível 1, quando o componente "cariado" representava apenas lesões cavitadas de acordo com recomendações da Organização Mundial da Saúde (OMS), e nível 2, quando o componente "cariado" representava lesões cavitadas e não cavitadas. A atividade de cárie dentária foi descrita em seus diferentes estágios. A correlação das variáveis com a saúde bucal das crianças foi verificada pela aplicação aos pais de um questionário contendo informações sobre condição sócio-econômica, visita das crianças ao dentista, última visita dos pais ao dentista, freqüência e forma de escovação dentária, frequência de ingestão de guloseimas das crianças, conhecimento dos pais sobre prevenção da cárie dentária e opinião e fundamento da opinião dos pais sobre a condição dentária dos filhos

Traumatic dental injuries in Brazilian pre-school children / Lesões dentárias traumáticas em pré-escolares brasileiros

The purpose of this investigation was to estimate the prevalence of traumatic dental injuries in a sample of Brazilian pre-school children with limited access to dental care. The sample included 1,853 one-to-fiveyear-old children attending public nursery schools in the Federal District of Brazil. Dental injuries were clinically assessed as follows: 1) uncomplicated crown fracture, 2) complicated fracture, 3) crown discoloration, 4) intrusive luxation, 5) extrusive luxation, 6) exarticulation or extration after trauma and 7) subluxation. The results showed that 10 percent (<2 years), 12 percent (3-4 years) and 20 percent (5 years) of the children had suffered at least one type of injury clinically identified at the time of the examination. Boys and girls were similarly affected. Dental injuries were almost entirely restricted to the maxillary central incisors (88 percent). Single tooth injury was predominant in all age groups. In the youngest group the most common types of injuries were crown fracture (69 percent) and crown discoloration (18 percent). However, from the age of three, crown discolaration showed percentages ranging from 41 percent to 47 percent. Prematurely lost tooth accounted for 11 percent of the injuries in 5-year-old children. The observed increase of dental injuries with age indicates accumulated treatment needs due to the children's limited access to dental care

Fusäo de dente extranumerário com incisivo central permanente / Fusion of extranumerary tooth with a permanent central incisor

Os autores relatam a conduta clínica tomada diante de um caso de fusäo de dente extranumerário com incisivo central superior permanente, com separaçäo entre ambos e conservaçäo da vitalidade do incisivo central

Periodontite prépuberal generalizada / Generalized prepuberal periodontitis

É relatado um caso de periodontite pré-puberal generalizada em um menino de cinco anos de idade. Em relaçäo a todos os dentes decíduos remanescentes, foi encontrada retraçäo gengival sem inflamaçäo e reabsorçäo acentuada de osso alveolar. Näo foram relatados problemas respiratórios ou infecçöes frequentes. Exames laboratoriais revelaram valores normais para sangue e urina e os testes genéticos confirmaram o diagnóstico