Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document.

PURPOSE: The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage deep carious lesions in primary teeth. METHODS: Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified. RESULTS: There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions. Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs) using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual failure rates. CONCLUSION: The management of deep carious lesions in primary teeth can be challenging and must consider the patient's compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing carious primary teeth as a mainstream rather than a compromise option.

Minimal Intervention Dentistry (MID) mainstream or unconventional option? Study exploring the impact of COVID-19 on paediatric dentists' views and practices of MID for managing carious primary teeth in children across the United Kingdom and European Union.

PURPOSE: To explore the techniques used to manage carious primary teeth during the COVID-19 pandemic by paediatric dentists and dentists with a special interest in paediatric dentistry (DwSI) who are members of the British Society of Paediatric Dentistry (BSPD) and the European Academy of Paediatric Dentistry (EAPD), and their views on the use of minimal intervention dentistry (MID) in children prior to, during and post the COVID era. METHODS: A total of 212 paediatric dentists and DwSI completed an online questionnaire. Six MID techniques were explored: fissure sealants, resin infiltration, Hall Technique (HT), 38% silver diamine fluoride (SDF), atraumatic restorative treatment (ART), stepwise removal and selective caries removal. RESULTS: The majority were specialists (26%) followed by clinical academics (23.1%) working mainly in university teaching hospitals (46.2%). Routine dental treatment for children with carious primary teeth was provided by the majority (92.5%) during the pandemic. HT (96%) and 38% SDF (65.7%) were the most commonly used techniques among the BSPD members whereas conventional restoration of non-selective caries removal and pulp therapy remained the most widely used technique among the EAPD members (66.2%). Most of the MID techniques were used as a treatment option (48.1%) rather than a choice (43.4%), with most of these choices having been affected by the patient's behaviour (82.5%). More than one thirds (39.2%) of the participants were reluctant to adopt MID after the pandemic. Several barriers such as lack of teaching and confidence as well as perceived lack of evidence were identified. CONCLUSION: A range of MID techniques is practiced broadly by a sample of paediatric dentists and DwSI across the United Kingdom (U.K) and European Union (E.U). The majority of clinicians are willing to continue using these techniques going forward after COVID restrictions are lifted. The pandemic served as an opportunity for many dentists to become familiar with various MID practices, such as SDF, which has been already established some time ago.

Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review.

PURPOSE: This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research. METHOD: An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area. RESULTS: Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has significantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7-88%, respectively, over 3 years follow-up). CONCLUSION: Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.

Trends in CBCT current practice within three UK paediatric dental departments.

INTRODUCTION: Cone beam computed tomography (CBCT) is used across all dental specialties and has a number of advantages compared to 2D images. The SEDENTEXCT guidelines provide a number of indications for the use, however there are currently no specific guidelines for paediatric dentistry. The aim of this study was to assess current practice of CBCT imaging within paediatric dental departments in England, audit compliance of CBCT justifications against the standards set by SEDENTEXCT and assess whether the use of CBCT affected the treatment plan for each individual patient. METHODS: From the retrospective analysis of CBCT examinations taken over a 4-year period across three dental hospitals in the north of England, the following data were collected: age at the time of exposure, clinical indication, region of interest (ROI) and diagnostic findings. Clinical notes were also used to identify whether the CBCT had an effect on the final treatment plan. RESULTS: A total of 335 CBCT examinations were performed, mean age: 11 years. The number of CBCTs increased each year with a twofold increase in the first 2 years. The main clinical indication in 46% of CBCT examinations was the assessment of localised developing dentition, 68% were in the upper anterior sextant and 61% of CBCT exams were in the mixed dentition age group. The investigations were justified in 100% of the cases. CONCLUSION: The quantity of CBCT examination in paediatric dental patients is increasing to assist treatment planning but more often to enable improved surgical planning.

Dental RECUR Randomized Trial to Prevent Caries Recurrence in Children.

The purpose of this study was to determine the efficacy of a dental nurse-delivered intervention-the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI)-in reducing the recurrence of dental caries in children who have a primary tooth extracted. It was based on a 2-arm multicenter randomized controlled trial with blinded outcome assessment. Participants were 5- to 7-y-old children (n = 241) scheduled to have primary teeth extracted in 12 UK centers. Test intervention parents (n = 119) received DR-BNI led by trained dental nurses. DR-BNI is a 30-min structured conversation informed by motivational interviewing with a forward focus to prevent future caries. Preventive goals are agreed, and a review appointment is made with child's general dental practitioner, who is advised to treat the child as being at high caries risk. The control intervention (n = 122) was a parent-nurse conversation about child's future tooth eruption, with advice given to visit a general dental practitioner as usual. At baseline, the DR-BNI group's mean dmft was 6.8, and the control group's was 6.3. A median of 5 teeth were extracted, mainly under general anesthesia. Final dental assessments were conducted by a single examiner visiting 189 schools 2 y after intervention; 193 (80%) of 241 children were examined. In the control group, 62% developed new caries in teeth that were caries-free or unerupted at baseline, as compared with 44% in the test group, a significant reduction (P = 0.021). The odds of new caries experience occurring were reduced by 51% in the DR-BNI group as compared with control. There was a 29% decrease in the relative risk of new caries experience in the DR-BNI group as compared with control. This single low-cost, low-intensity intervention was successful in significantly reducing the risk of recurrence of dental caries in children. This trial has implications for changing pediatric dental practice internationally. Training in and implementation of a motivational interviewing-informed brief intervention provides opportunities for dental nurses to facilitate behavior change improving the oral health of children at high caries risk (ISRCTN 24958829).

The use of Hall technique preformed metal crowns by specialist paediatric dentists in the UK.

Background Hall technique preformed metal crowns (HTPMCs) have been increasing in use recently, but little is currently known about their use by specialists.Aim To investigate the views and usage of HTPMCs by UK specialist paediatric dentists.Design This was a prospective questionnaire-based study, distributed online to all specialists on the British Society of Paediatric Dentistry email list between July and September 2014.Results Ninety-four questionnaires were completed. The majority of respondents, 65% (61) worked in teaching hospitals, followed by community dental services, 37% (35). Ninety-six percent (89) reported that they used HTPMCs in their practice. Fifty-eight percent (54) used HTPMCs as a treatment option for restoring symptomless carious primary molars, and 15% (14) only when unable to provide conventional restoration. Twenty-three percent (21) used HTPMCs as the treatment of choice. Only 4% (4) of respondents never used them. Sixty percent (53) had been using HTPMCs for over five years. Seventy-six percent (68) would consider placing HTPMCs under inhalation sedation, and 26% (23) under general anaesthesia. Over 90% (85) believed that HTPMCs are suitable for undergraduate teaching, general practice, postgraduate training and specialist practice.Conclusion HTPMCs are widely used among specialist paediatric dentists in the UK.

Are diet diaries of value in recording dietary intake of sugars? A retrospective analysis of completion rates and information quality.

Objectives Current guidance recommends that dental practitioners should routinely give dietary advice to patients, with diet diaries as a tool to help diet assessment. We explored patients' compliance with diet-diaries usage in a paediatric clinic within a teaching hospital setting, where remuneration is not an issue. Objectives were to investigate associated factors affecting diet diaries return rate and the information obtained from returned diaries.Methods A retrospective study of 200 randomly selected clinical records of children aged 5-11 years who had received diet analysis and advice as part of a preventive dental care programme at a dental teaching hospital between 2010 and 2013. Clinical records, with a preventive care pro forma, were included in the study. Data on social and family history, DMFT-dmft, oral hygiene practices, dental attendance and dietary habits were obtained and compared with information given in completed diet-diaries. A deductive content analysis of returned diet-diaries was undertaken using a pre-developed coding scheme.Results Of 174 complete records included in this study, diet diaries were returned in 60 (34.5%) of them. Diet diaries were more likely to be returned by those children who reported that they regularly brushed their teeth (P <0.05), and those who came from smaller families (P <0.05). Content analysis of diet diaries enabled the identification of harmful types of foods and drinks in 100% of diaries. General dietary issues, frequency and between-meals intake of sugars were also all captured in the majority of diaries (95.0%, N = 56). Information on sugar amount (53.0%, N = 32), prolonged-contact with teeth (57.0%, N = 34) and near bedtime intakes (17.0%, N = 28) was reported in fewer diaries.Conclusions The return rate of diet-diaries in this setting was low, and associated with patients' demographic and oral health characteristics. Returned diet-diaries showed a varied range of missing important dietary information, such as sugar amount, which appears to compromise their validity as a diet assessment tool. Development of a more reliable and acceptable dietary assessment tool for use in the dental setting is needed.

The use of diet diaries in general dental practice in England.

OBJECTIVES: Diet diaries are recommended as a tool to support behaviour change in dental patients at high risk of dental diseases. However, little is known about their use in dental practice. This study aimed to investigate whether and how general dental practitioners (GDPs) use diet diaries and identify factors which influence their use. METHODS: A postal questionnaire was sent to a stratified random sample of general dental practitioners. The questionnaire asked about demographic and professional characteristics of the GDPs and their practices regarding diet advice, collection of dietary information, diet diaries usage (e.g. frequency, considerations and barriers), and interpretation of diet diaries. Descriptive, bivariate and multivariate analyses were conducted. RESULTS: From 972 eligible GDP participants, 250 (26%) responses were received. Whilst almost all of these GDPs reported giving diet advice to patients routinely, and 40% reported also referring to dental care professionals in the practice to deliver dietary advice, only 28% (70) reported that they are involved in using diet diaries. GDPs appeared to target patients for dietary advice: GDPs reported they personally gave diet advice to an estimated 63% of their patients, and referred patients to DCPs for diet advice for 11% of their (GDPs') patients. GDPs used diet diaries more often for child than adult patients. Diet diaries usage was lower among younger dentists and in practices with higher percentages of NHS patients (p⟨0.05). Perceived insufficient remuneration for time involved in using diet diaries was the main reason given for their lack of use. CONCLUSION: Although recommended as best practice, most English GDPs do not frequently use diet diaries to collect diet information in dental practice, mainly due to perceived financial and time constraints. Development of a more efficient tool to assess the dietary habits of dental patients is needed.

A multicentre, multicycle audit of the prescribing practices of three paediatric dental departments in the North of England.

BACKGROUND: Odontogenic infections are frequently treated with antimicrobials. The inappropriate use of these medications has led to bacterial resistance and the development of species which are resistant to the antimicrobials currently available. This has serious implications for global public health. AIM: A multicycle clinical audit was carried out to compare the prescribing practices of three paediatric dental departments in the North of England. RESULTS: Results revealed deficiencies in prescribing practices in all three centres. Following education and the provision of an aide-memoire in subsequent cycles, improvements were seen in appropriateness of prescribing, increasing from 28% in the first cycle, to 71% in the third cycle.

Technical outcome of root canal treatment on permanent teeth in children: a retrospective study.

AIM: The aim was to assess the technical quality of root canal treatment conducted in paediatric patients. No specific data is available assessing endodontic treatment quality in children. General adult populations report satisfactory technical quality between 12.8 and 55.7 %, with higher rates by endodontists (77.4-91.0 %). METHODS: Radiographs of 100 chronological cases, conducted by staff (categorised as; junior staff, middle grades or consultants) in a UK teaching hospital, were evaluated retrospectively. Technical outcomes were compared to the European Society of Endodontology quality guideline consensus. A satisfactory root filling was defined as having: root filling material <2 mm from the radiographical apex; no canal space seen beyond the end of the obturation and an obturation of homogeneous density with no voids. In addition where MTA was used a plug of ≥3 mm was required. Any variation was considered unsatisfactory treatment. RESULTS: 61 % [95 % CI 51-70 %] of cases were deemed satisfactory. Of the remaining obturations 20.5 % were short of the apex, 28.2 % had extruded material and 56.4 % contained voids. Patients with co-operation issues, particularly anxiety, had lower technical outcomes (p = 0.001) and the use of thermoplastic obturation greatly reduced the chance of void inclusion (p = 0.004; OR 0.20 [95 % CI 0.06-0.65]). Although 'staff grade' did not show a statistically significant difference, a trend between experience and quality was suspected. CONCLUSION: Overall technical quality of treatment was comparable to the higher rates found in the general adult population. Additionally thermal obturation may be superior to cold lateral condensation in improving obturation quality, and anxiety negatively impacts on treatment provision.

Undergraduates' perceptions of the value of practical inhalation sedation experience in a UK dental school.

AIM: This was to establish the level and reported value of paediatric IHS experience from the perspective of final year undergraduates and to evaluate whether those students with more experience expressed feeling better-prepared for future practice and more likely to undertake further postgraduate education in IHS. METHODS: All final year students were invited to complete an anonymous questionnaire designed to elicit undergraduate perceptions of IHS using visual analogue scales and free-text questions. RESULTS: A response rate of 77 % was achieved. Results revealed that only 21 % of participants reported acting as operator sedationist in ten or more IHS cases. Thus, the majority of undergraduates' did not meet the recommended quantity of practical IHS experiences, as outlined by the British Dental Sedation Teachers Group. In general, students felt on the value of IHS in the management of anxious children and expressed a desire to undertake further postgraduate education in conscious sedation. However, those students with more experience of practical IHS expressed feeling better able to describe the IHS experience with patients and parents, and were more satisfied with the quality of teaching. Furthermore free-text comments revealed that, regardless of experience, students wished to gain more experience of the practical administration of IHS. CONCLUSION: There is a need to increase the provision of IHS training within an undergraduate curriculum, in addition to improving the accessibility of postgraduate sedation courses.

Undergraduates' self-reported clinical experience, confidence and perspectives of hospital and outreach paediatric dentistry: a three-year multi-centre evaluation.

A variety of educational approaches exist within U.K. dental schools, and institutions are constantly striving to improve the quality of their graduates. This study aimed to evaluate the self-reported confidence in, and clinical exposure to, paediatric dentistry at three U.K. dental schools (Liverpool, Manchester and Sheffield) over a three year period. Seventy-five percent of final year BDS undergraduates at the three dental schools completed an anonymous questionnaire capturing student self-reported clinical experience in seven core paediatric dentistry treatment skills, both in hospital and outreach settings. Visual analogue scales were used to record self-assessed confidence levels in aspects of paediatric dentistry and students were also asked to provide a written reflection of both their hospital and outreach placements. The results revealed that despite the variety of educational approaches taken, undergraduates reported very similar levels of clinical experience and confidence. Significant interschool differences in student experience were found with respect to the management of carious primary molars, believed to be a result of individual schools favouring different treatment regimes. Although outreach placements were seen as essential for gaining adequate student experience, the need to improve the consistency of teaching between hospital and outreach centres was highlighted. The study also emphasises the need to take care when using clinical targets in undergraduate teaching and identifies the potential benefits of undergraduate training in inhalation sedation. Finally, despite changes to the paediatric programmes with respect to dental trauma management, students remained lacking in confidence suggesting the need for further development.

Working length determination in general dental practice: a randomised controlled trial.

OBJECTIVE: To evaluate the ability of apex locators as a tool in determining working length in comparison to traditional working length radiographs in general dental practice. DESIGN: Randomised controlled clinical trial. SETTING: General dental practices in the North West of England.Subjects Adults requiring root canal treatment of at least one tooth with minimal or moderate difficulty. INTERVENTION: Root canal treatment was carried out with the working length determined by apex locator in the treatment group (AL), and periapical radiograph in the control group (PA). OUTCOME MEASURE: The acceptability of the master cone gutta percha measured from a radiograph before obturation was used as the primary outcome. RESULTS: Twenty-one of 23 fillings in the AL group were judged as acceptable, compared to 17 of 23 fillings in the PA group. This difference was not statistically significant. CONCLUSION: In general dental practice, no significant difference was found in working length determined using apex locator combined with a master cone GP radiograph or using the conventional method. There is a need for larger trials to investigate these methods further.

Undergraduate experience and self-assessed confidence in paediatric dentistry: comparison of three UK dental schools.

Previous studies have suggested that dental students may not receive sufficient clinical experience in core paediatric dentistry skills. This study aimed to compare dental undergraduates' self-reported experience and confidence in paediatric dentistry within three UK dental schools (Liverpool, Manchester and Sheffield). In April/May 2009, 147 final year dental students completed an anonymous questionnaire which captured their experience of seven core clinical skills in both hospital and outreach settings. A visual analogue scale was also employed to record perceived levels of confidence for six generic activities including: examination, diagnosis and treatment planning; patient selection for treatment under general anaesthesia; operative dentistry; preventive dentistry; management of dento-alveolar trauma, and provision of routine care for children on qualification. The key finding was that Liverpool, Manchester and Sheffield dental students received comparable clinical experiences in paediatric dentistry, which appeared to satisfy the requirements of the General Dental Council's The first five years. One hundred percent had carried out fissure sealants and restorations, and 87-98% had experience of extractions. Outreach placements were crucial in ensuring students had sufficient opportunity to undertake core skills, notably extractions and pulp therapies. All students reported a lack of confidence in dental trauma management which warrants greater emphasis in the undergraduate curriculum.

Initial management of paediatric dento-alveolar trauma in the permanent dentition: a multi-centre evaluation.

OBJECTIVE: To investigate the time lapse prior to provision of emergency dental care and appropriateness of earliest treatment provided for children with dental trauma. DESIGN: A multi-regional prospective and cross-sectional survey. SETTING: Paediatric dental departments of Liverpool, Manchester and Sheffield. SUBJECTS: One hundred and fifty referred or emergency paediatric patients with trauma to the permanent incisors. RESULTS: One hundred and fifty subjects were recruited. Mean age of the subjects was 11.1 years (SD = 2.6; range = 6.2-16.6); 100 were male and 50 were female. The mean time interval from injury until initial presentation to a health care professional was 22.6 hours (SD = 76.1; range = 0-672). Thirty-six percent of children (n = 54) first presented to a general dental practitioner whilst 30% (n = 45) presented to accident and emergency medical staff. Following initial assessment, a further mean time lapse of 8.1 hours (SD = 43.7; range = 0-504) was incurred in 25% of cases prior to dental referral. In 39% of subjects (n = 58/150), treatment was considered inappropriate. The most frequent example of inadequate management was failure to protect exposed dentine, which was found for 71% (n = 24/34) of complicated crown fractures and 40% (n = 25/62) of uncomplicated crown fractures. CONCLUSION: This study identified marked delays in the management of some paediatric dental trauma to permanent incisor teeth which, in itself, could be suboptimal. Greater educational and clinical support would seem to be warranted in this area of service provision.

Case report: Rutherfurd syndrome associated with Marfan syndrome.

BACKGROUND: Rutherfurd syndrome is a rare genetic disorder that is primarily characterised by the classical triad of gingival fibromatosis, delayed tooth eruption and corneal dystrophy. Associated features of the condition include abnormally shaped teeth, mental retardation and aggressive behaviour. CASE REPORT: His Consultant Clinical Geneticist referred a 2-year-old boy to the Dept. of Paediatric Dentistry at Manchester Dental Hospital. The child and his father had a diagnosis of Rutherfurd Syndrome; a rare autosomal-dominant condition featuring corneal dystrophy, gingival hypertrophy, abnormally shaped teeth and delayed eruption. The only erupted teeth were 52, 71 and 81. The patient also suffers from features of Marfan syndrome, a condition he has inherited from his mother. CLINICAL MANAGEMENT: Preventive advice was provided and the patient was placed on regular review. By the age of 4 years, 52, 61, 72, 71 and 81 were the only teeth present clinically. Maxillary and mandibular dentures were provided, which he refused to wear. FOLLOW-UP: At age 8 years, 31 and 41 were erupted lingual to the primary incisors. No other permanent teeth had erupted. Radiographs revealed failure of eruption of multiple primary and permanent teeth. The second premolars had formed above the unerupted mandibular primary second molars. The patient continued to refuse any intervention. Treatment options discussed included overdentures and /or removal of primary teeth and exposure of permanent teeth. CONCLUSION: This case has presented a rare syndrome with two important dental features, namely gingival hyperplasia and failure of eruption. The case has a long term follow up of 6 years and has a first time association to Marfan syndrome. It also highlights the importance of family history and how it can affect the attitude of the child towards dental treatment.

The use of objective digital matching to achieve an esthetic composite restoration.

OBJECTIVE: To investigate the ability to match composite restorations to teeth using digital imaging and CIE L*a*b* color differences. METHODS: Ten extracted human central incisors were used. Eleven discs of composite of differing shades were produced and mounted on white cardboard to create a customized shade guide (CSG). The CSG was photographed next to each of the ten teeth in a phantom head using a digital SLR camera. The images were analyzed, and color differences (deltaE) between the teeth and the shade discs were calculated using CIE L*a*b* values. Three cavities were then drilled into the labial surface of each tooth. Composite shades with the lowest three deltaE values were then used to restore the cavities. Ten observers evaluated the teeth under a standard D65 light source and recorded the best match. RESULTS: The majority of the observers selected the lowest deltaE in six out of the 10 teeth, and in a further two out of 10 teeth the second lowest deltaE was chosen. CONCLUSION: The lowest deltaE selected by objective color matching was agreed as the best match by observers. The high correlation between digital and visual color matching confirms the ability of digital camera and image analysis software to detect color differences.