[Child-friendly restorations of primary molars using the Hall technique]. / Kindvriendelijke restauraties van tijdelijke molaren met de Hall-techniek.

Minimally invasive dentistry is being used increasingly often, especially in paediatric dentistry. It involves replacing traditional 'drilling and filling' with treatment modalities that are tissue-saving and minimally burdensome to the patient. One of these techniques for treating carious dentine lesions is the Hall technique. A stainless-steel crown is cemented onto the primary molar without the use of anaesthesia or any form of preparation. The molar is 'sealed' under the crown and this stops the carious process in the cavity. Usually, the procedure requires 2 sessions. The Hall technique is well tolerated by children and provides the primary molar with a durable restoration. Together with this technique, the patient is also guided in an individual prevention process. The survival rates of Hall crowns are very high.

[Consensus recommendations on minimally invasive removal of carious tissue from dentine]. / Aanbevelingen van een consensus­bijeenkomst over weefselsparende manieren om carieus weefsel uit dentine te verwijderen.

The International Caries Consensus Collaboration (ICCC) presented recommendations on terminology, methods of carious tissue removal and managing cavitated carious lesions. It identified 'dental caries' as the disease that dentists should manage by controlling the activity of existing cavitated lesions by preserving as much hard tissue as possible, maintaining pulp sensibility and retaining functional teeth in the long-term. The ICCC recommended the level of hardness as the criterion for determining the clinical consequences of the process of demineralisation and defined new strategies for the selective removal of carious tissue. The starting point is to effectively remove the biofilm from cavitated carious lesions. Only when cavitated carious lesions are either non-cleansable or can no longer be sealed, are restorative interventions indicated, with due regard for the principles of a minimally invasive approach. Applying a restoration facilitates biofilm removal, guards the pulpodental complex and restores form, function and aesthetics.

Survival of multiple-surface ART restorations using a zinc-reinforced glass-ionomer restorative after 2 years: A randomized triple-blind clinical trial.

OBJECTIVE: To investigate the effectiveness of a new zinc-reinforced glass-ionomer in comparison to a common high-viscous glass-ionomer cement (HVGIC) used in multiple-surface ART-prepared cavities. The hypothesis tested was that the cumulative survival percentage of the new HVGIC is higher than that of the common HVGIC over 2 years. METHODS: A randomized triple-blind parallel group clinical trial was used. A total of 218 participants, average age 15.4 years (SD=0.2), with an occluso-proximal carious lesion in a permanent (pre-) molar were included. Restorations using test (ChemFil Rock) and control (Fuji IX GP) restoratives were placed according to the ART method by four calibrated operators. Restorations were evaluated after one week (baseline), and at 6-, 12-, 18- and 24 months from replicas and coloured photographs according to the ART restoration assessment criteria by two independent evaluators. Restoration survival curves were estimated using the Kaplan-Meier method and difference between dependent and independent variables tested with a Wald (chi-square) test. RESULTS: There was a statistically significant difference in cumulative survival percentages between the two types of restorations at 2 years (P=0.02). A higher percentage of multiple-surface restorations of Fuji IX GP (95.4%) than ChemFil Rock (85.3%) survived. Gender (P=0.64), operator (P=0.56) and cavity size (P=0.81) had no effect on the survival of the type of restoration observed. Type of tooth (P=0.004) and type of jaw (P=0.05) showed an effect. Severe wear was the major reason for restoration failure (ChemFil Rock=7; Fuji IX GP=1). SIGNIFICANCE: ChemFil Rock appears not to be a viable alternative to Fuji IX GP in restoring ART multiple-surface cavities in permanent posterior teeth.

Randomized clinical trial of class II restoration in permanent teeth comparing ART with composite resin after 12 months.

OBJECTIVE: This study evaluated the effectiveness of class II restorations, in permanent teeth, through the ART technique in comparison to composite resin. MATERIALS AND METHODS: Participants (154), aged 8 to 19 years, with good general health, with class II cavities in permanent teeth, and without pulp involvement and tooth pain were included in this parallel and randomized clinical trial. The Ethics Committee approval number was CAAE: 24012913.0.1001.5417. Seventy-seven restorations were made with each restorative material (Equia Fil-GC Corporation and Z350-3M). Evaluations occurred at 6 and 12 months by the criteria of ART and the USPHS modified. Data were analyzed by Mann-Whitney, chi-square, Fisher's exact, chi-square tests with linear trend and logistic regression by enter method (p < 0.050). The Kaplan-Meier test evaluated the survival rates of the restorations. The log-rank test compared the survival curves. RESULTS: Regardless of the evaluation criteria used, the success rates of ART restorations were 98.7% (6 months) and 95.8% (12 months) and for composite resins were 100% (6 months) and 98.7% (12 months), with no statistical difference of restoration groups (p > 0.050). Survival rates for restorations, regardless of the evaluation criteria used, are the same as the success rates, with the exception of ART restorations at 12 months of follow-up (94.8%). CONCLUSION: No differences in the success rates of class II restorations of ART compared to resin composite, in permanent teeth, were observed after 12 months. CLINIC SIGNIFICANT: HVGIC can safely be used to restore proximal cavities in permanent teeth up to 12 months.

Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: an updated systematic review and meta-analysis.

OBJECTIVE: The aim of the present study is to update the results of two previous meta-analyses, published in 2006 and 2012, on the survival percentages of atraumatic restorative treatment (ART) restorations and ART sealants. The current meta-analysis includes Chinese publications not investigated before. MATERIALS AND METHODS: Until February 2017, six databases were interrogated (two English, one Portuguese, one Spanish and two Chinese). Using six exclusion criteria, a group of six independent reviewers selected 43 publications from a total of 1958 potentially relevant studies retrieved. Confidence intervals and/or standard errors were calculated and the heterogeneity variance of the survival rates was estimated. RESULTS: The survival percentages and standard errors of single-surface and multiple-surface ART restorations in primary posterior teeth over the first 2 years were 94.3% (± 1.5) and 65.4% (± 3.9), respectively; for single-surface ART restorations in permanent posterior teeth over the first 3 years, they were 87.1% (± 3.2); and for multiple-surface ART restorations in permanent posterior teeth over the first 5 years, they were 77% (± 9.0). The mean annual dentine-carious-lesion-failure percentages in previously sealed pits and fissures using ART sealants in permanent posterior teeth over the first 3 and 5 years were 0.9 and 1.9%, respectively. CONCLUSIONS: ART single-surface restorations presented high survival percentages in both primary and permanent posterior teeth, whilst ART multiple-surface restorations presented lower survival percentages. ART sealants presented a high-caries-preventive effect. CLINICAL RELEVANCE: ART is an effective evidence-based option for treating and preventing carious lesions in primary and permanent posterior teeth.

Replacing amalgam with a high-viscosity glass-ionomer in restoring primary teeth: A cost-effectiveness study in Brasilia, Brazil.

OBJECTIVES: When planning primary oral health care services the cost implications of adopting new intervention practices are important, especially in resource-strapped countries. Although on a trajectory to be phased-out, amalgam remains the standard of care in many countries. METHODS: Adopting a government perspective, this study compared the costs of performing amalgam and ART/high-viscosity glass-ionomer cement (HVGIC) restorations and the consequences of failed restorations over 3 years in suburban Brasilia, Brazil. Cost data were collected prospectively; cost estimates were developed for the study sample and a projection of 1000 single- and 1000 multiple-surface restorations per group. Probabilistic sensitivity analysis was conducted in TreeAge Pro. RESULTS: Results were mixed. For single-surface restorations, ART/HVGIC will cost US$51 per failure prevented, while for multiple-surface restorations, ART/HVGIC was cost-effective with a savings of US$11 compared to amalgam. Probabilistic sensitivity analysis (Monte Carlo simulation) predicted amalgam would be cost-effective 49.2% of the time compared to HVGIC at 50.6% of the time at a willingness to pay threshold of US$237 per failure prevented. Personnel accounted for more than half the cost burden for both methods; instruments and supplies accounted for about one third. The per restoration cost to replace amalgam with HVGIC ranges from US$1 to a savings of US$0.84. CONCLUSION: Replacing amalgam with a high-viscosity glass-ionomer as part of the ART method comes at a minimal increase in cost for governments. Increasing the number of restorations seems to diminish the cost burden. CLINICAL SIGNIFICANCE: ART/HVGIC could be considered a viable alternative to amalgam in primary teeth.

Contemporary operative caries management: consensus recommendations on minimally invasive caries removal.

The International Caries Consensus Collaboration (ICCC) presented recommendations on terminology, on carious tissue removal and on managing cavitated carious lesions. It identified 'dental caries' as the name of the disease that dentists should manage, and the importance of controlling the activity of existing cavitated lesions to preserve hard tissues, maintain pulp sensibility and retain functional teeth in the long term. The ICCC recommended the level of hardness (soft, leathery, firm, and hard dentine) as the criterion for determining the clinical consequences of the disease and defined new strategies for carious tissue removal: 1) Selective removal of carious tissue - including selective removal to soft dentine and selective removal to firm dentine; 2) stepwise removal - including stage 1, selective removal to soft dentine, and stage 2, selective removal to firm dentine 6 to 12 months later; and 3) non-selective removal to hard dentine - formerly known as complete caries removal (a traditional approach no longer recommended). Adoption of these terms will facilitate improved understanding and communication among researchers, within dental educators and the wider clinical dentistry community. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious dentine lesions are either non-cleansable or can no longer be sealed, are restorative interventions indicated. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralised tissues close to the pulp do not need to be removed. The evidence and, therefore these recommendations, supports minimally invasive carious lesion management, delaying entry to, and slowing down, the destructive restorative cycle by preserving tooth tissue, maintaining pulp sensibility and retaining the functional tooth-restoration complex long-term.

Atraumatic restorative treatment and minimal intervention dentistry.

Too many people worldwide suffer from the consequences of untreated dentine carious lesions. This finding reflects the inability of the currently used traditional mode of treatments to manage such lesions. A change is needed. Dental training institutions should depart from the traditional 'drill and fill' treatments and embrace the holistic oral healthcare approach that is minimal intervention dentistry (MID) and includes within it minimally invasive operative skills. Dental caries is, after all, a preventable disease. The atraumatic restorative treatment (ART) concept is an example of MID. ART consists of a preventive (ART sealant) and a restorative (ART restoration) component. ART sealants using high-viscosity glass-ionomer (HVGIC) have a very high dentine carious lesion preventive effect. The survival rate of these sealants is not significantly different from that of sealants produced with resin. The survival rate of ART/HVGIC restorations matches those of amalgam and resin composite in single- and multiple-surface cavities in primary teeth and in single-surface cavities in permanent teeth. The principles of carious tissue removal within a cavity recommended by the International Caries Consensus Collaboration are in line with those of treating a cavity using ART. Owing to its good performance and the low levels of discomfort/pain and dental anxiety associated with it, ART and/or other evidence-based atraumatic care procedures should be the first treatment for a primary dentine carious lesion. Only if the use of ART is not indicated should other more invasive and less-atraumatic care procedures be used in both primary and permanent dentitions.

[How useful is restorative care in the primary dentition?] / Hoe zinvol is restauratieve behandeling van het tijdelijk gebit?

Too many children develop carious lesions and many such lesions progress into a dentine carious lesion. In 2010, the percentage of dentine carious lesions in the primary dentition of 6-year-old Dutch children that were restored was less than 50 per cent. Owing to research, the necessity to restore dentine carious lesions routinely has been called into question. Current understanding of cariologic principles point in the direction of a causal treatment that is based on cleaning accessible dentine carious cavities and those that can be made accessible, possibly supported by the application of silver diamine fluoride. The ultimate goal of a restoration in the primary dentition is to make it possible to remove biofilm from the tooth surface and to prevent infection of the pulp. If restoration in primary teeth is necessary, dental practitioners will, in order to prevent the development of dental anxiety, first have to consider whether it is feasible to place restorations in an atraumatic manner, for example by means of the ART method or the Hall technique.

Managing Carious Lesions: Consensus Recommendations on Terminology.

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided.Dental cariesis the name of the disease, and thecarious lesionis the consequence and manifestation of the disease-the signs or symptoms of the disease. The termdental caries managementshould be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereascarious lesion managementcontrols the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions' clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1)selective removal of carious tissue-includingselective removal to soft dentineandselective removal to firm dentine; 2)stepwise removal-including stage 1,selective removal to soft dentine, and stage 2,selective removal to firm dentine6 to 12 mo later; and 3)nonselective removal to hard dentine-formerly known ascomplete caries removal(technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

Managing Carious Lesions: Consensus Recommendations on Carious Tissue Removal.

The International Caries Consensus Collaboration undertook a consensus process and here presents clinical recommendations for carious tissue removal and managing cavitated carious lesions, including restoration, based on texture of demineralized dentine. Dentists should manage the disease dental caries and control activity of existing cavitated lesions to preserve hard tissues and retain teeth long-term. Entering the restorative cycle should be avoided as far as possible. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious lesions either are noncleansable or can no longer be sealed are restorative interventions indicated. When a restoration is indicated, the priorities are as follows: preserving healthy and remineralizable tissue, achieving a restorative seal, maintaining pulpal health, and maximizing restoration success. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissues close to the pulp do not need to be removed. In deeper lesions in teeth with sensible (vital) pulps, preserving pulpal health should be prioritized, while in shallow or moderately deep lesions, restoration longevity becomes more important. For teeth with shallow or moderately deep cavitated lesions, carious tissue removal is performed according toselective removal to firm dentine.In deep cavitated lesions in primary or permanent teeth,selective removal to soft dentineshould be performed, although in permanent teeth,stepwise removalis an option. The evidence and, therefore, these recommendations support less invasive carious lesion management, delaying entry to, and slowing down, the restorative cycle by preserving tooth tissue and retaining teeth long-term.

[Clinical aspects of Atraumatic Restorative Treatment]. / Klinische aspecten van de Atraumatic Restorative Treatment.

The objective of Atraumatic Restorative Treatment is to prevent carious lesion development and to stop its progression. This can be achieved, among other ways, by placing high-viscosity glass-ionomer cement sealants in pits and fissures in the enamel. A second area of utilisation is the treatment of dentine carious lesions. The weakened demineralised dentine can effectively be removed using hand instruments only. An accurately placed sealant-restoration prevents remaining cariogenic bacteria from reigniting the process of decay and allows the residual carious dentine to remineralise. To achieve good results using Atraumatic Restorative Treatment, an oral healthcare provider should complete a programme of instruction and have command of sufficient knowledge of cariology, the principles of treatment and the available restorative materials. High-viscosity glass-ionomer cement is the material of first choice for the prevention of enamel caries and the treatment of dentine carious lesions, but there is a constant search for improvements to this material and for a qualitatively better alternative.

Caries preventive measures in orthodontic practice: the development of a clinical practice guideline.

OBJECTIVES: White spot lesions (WSLs) are a side effect of orthodontic treatment, causing esthetic problems and a risk of deeper enamel and dentine lesions. Many strategies have been developed for preventing WSLs, but great variability exists in preventive measures between orthodontists. This study developed statements on which a clinical practice guideline (CPG) can be developed in order to help orthodontists select preventive measures based on the best available evidence. MATERIALS AND METHODS: A nominal group technique (RAND-e modified Delphi procedure) was used. A multidisciplinary expert panel rated 264 practice- and evidence-based statements related to the management of WSLs. To provide panel members with the same knowledge, a total of six articles obtained from a systematic review of the literature were read by the panel in preparation of three consensus rounds. According to the technique, a threshold of 75% of all ratings within any 3-point section of the 9-point scale regarding a specific statement was accepted as consensus. RESULTS: After the first and second consensus rounds, consensus was reached on 37.5 and 31.1% of statements, respectively. For the remaining 31.4% of statements, consensus was reached during a 4-h consensus meeting. CONCLUSIONS: Statements on the management of WSLs derived from a systematic literature review combined with expert opinion were formally integrated toward consensus through a nominal group technique. These statements formed the basis for developing a CPG on the management of WSLs before and during orthodontic treatment.

Caries experience in the primary dentition and presence of plaque in 7-year-old Chinese children: A 4-year time-lag study.

OBJECTIVES: The aim of the present study was to test the hypothesis that dental caries prevalence and caries experience in primary dentitions has increased over 4 years and to compare the presence of plaque on permanent teeth in child cohorts over 4 years. MATERIALS AND METHODS: A time-lag study design was used comprising two cohorts of children aged 7 years from the same five primary schools in Wuhan examined in 2007 and 2011. Two calibrated examiners visually assessed plaque accumulation according to the Greene and Vermillion Index and the dentitions according to the Atraumatic Restorative Treatment (ART) caries criteria. Analysis of variance (ANOVA), logistic regression, and Chi-square test were used to test for differences between dependent and independent variables. RESULTS: The 2007 sample consisted of 817 children and the 2011 sample consisted of 1010 children. The prevalence of dental caries (d3mft) was 68.2% in 2007 and 67.7% in 2011, while that of d2mft was 78.5% in 2007 and 71.4% in 2011 (P < 0.0006). The mean d3mft score was 2.8 in 2007 and 3.1 in 2011 (P = 0.046), while the mean d3mfs score was 4.9 in 2007 and 7.3 in 2011 (P < 0.0001). The d3-component of the d3mft index was 73% in 2007 and 69% in 2011, while the f-component was 22% in 2007 and 26% in 2011. The hypothesis was not accepted. The proportion of children with plaque code 3 (extensive coverage) was higher in 2011 (21.8%) than in age mates in 2007 (5.7%). CONCLUSIONS: There were no obvious signs that dental caries prevalence had been increased in primary dentitions of this child population between 2007 and 2011. But as the mean caries experience scores at the surface level were higher in 2011 than in 2007, monitoring caries prevalence remains essential, but should start at an earlier age than that covered by this study. Health and educational authorities should collaborate in setting up programs aimed at ensuring good oral health for school children.

Caries-preventive Effect of Supervised Toothbrushing and Sealants.

To investigate the effectiveness of 3 caries-preventive measures on high- and low-caries risk occlusal surfaces of first permanent molars over 3 y. This cluster-randomized controlled clinical trial covered 242 schoolchildren, 6 to 7 y old, from low socioeconomic areas. At baseline, caries risk was assessed at the tooth surface level, through a combination of ICDAS II (International Caries Detection and Assessment System) and fissure depth codes. High-caries risk occlusal surfaces were treated according to daily supervised toothbrushing (STB) at school and 2 sealants: composite resin (CR) and atraumatic restorative treatment-high-viscosity glass-ionomer cement (ART-GIC). Low-caries risk occlusal surfaces received STB or no intervention. Evaluations were performed after 0.5, 1, 2, and 3 y. A cavitated dentine carious lesion was considered a failure. Data were analyzed according to the proportional hazard rate regression model with frailty correction, Wald test, analysis of variance, and t test, according to the jackknife procedure for calculating standard errors. The cumulative survival rates of cavitated dentine carious lesion-free, high-caries risk occlusal surfaces were 95.6%, 91.4%, and 90.2% for STB, CR, and ART-GIC, respectively, over 3 y, which were not statistically significantly different. For low-caries risk occlusal surfaces, no statistically significant difference was observed between the cumulative survival rate of the STB group (94.8%) and the no-intervention group (92.1%) over 3 y. There was neither a difference among STB, CR, and ART-GIC on school premises in preventing cavitated dentine carious lesions in high-caries risk occlusal surfaces of first permanent molars nor a difference between STB and no intervention for low-caries risk occlusal surfaces of first permanent molars over 3 y.

[Atraumatic restorative treatment in relation to pain, discomfort and dental treatment anxiety]. / Atraumatic restorative treatment in relatie tot pijn, ongemak en angst voor tandheelkundige behandelingen.

Dental treatment anxiety usually develops during childhood due to a bad experience and the dental drill as well as the injection needle are the most common causes. The Atraumatic Restorative Treatment provides the opportunity to provoke little or no dental treatment anxiety because only hand instruments are used and local anaesthesia is seldom required. Several scientific studies have indicated that the Atraumatic Restorative Treatment causes less pain, discomfort and anxiety by comparison with conventional treatments. Therefore, the Atraumatic Restorative Treatment is considered to be promising for the treatment of carious lesions in anxious children and adults, and potentially also for patients suffering from dental treatment phobia. Furthermore, the Atraumatic Restorative Treatment may be indicated as the primary treatment method in children to prevent dental treatment anxiety and treatment under general anaesthesia. These conclusions must still be confirmed with responsible scientific research.

[The history and scientific development of atraumatic restorative treatment]. / De historie en wetenschappelijke ontwikkeling van de Atraumatic Restorative Treatment.

Atraumatic Restorative Treatment is a minimally invasive treatment modality which is intended to prevent carious lesions and to stop the progression of carious lesions. The treatment modality was developed to preserve carious teeth and was primarily aimed at communities having little or no electricity, piped water and oral healthcare and who have limited financial resources. In 1994, Atraumatic Restorative Treatment was recognised by the World Health Organization. Several systematic studies have demonstrated that Atraumatic Restorative Treatment using high-viscosity glass ionomer cement provides reliable results for one-surface restorations in deciduous molars and permanent (pre)molars. In developed as well as developing countries, more possibilities have been created with this low-cost treatment to improve the oral health of communities who have previously not had access to adequate care.

Validation of micro-CT against the section method regarding the assessment of marginal leakage of sealants.

BACKGROUND: The aim of this study was to validate the micro-CT and related software against the section method using the stereomicroscope for marginal leakage assessment along the sealant-enamel interface. METHODS: Pits and fissures of the occlusal surface of 10 teeth were sealed with a resin-fissure sealant material without acid etching, thermocycled for 5000 cycles, immersed in 50% silver nitrate for three hours and scanned using micro-CT. Teeth were embedded in epoxy resin and cut in three sections. The middle section was subjected to micro-CT and stereomicroscopy. Images were taken from the left and right sides of the sealant-enamel interface at both the left and the right site of the section. Two experienced evaluators assessed marginal leakage. RESULTS: Both assessment instruments observed no leakage in 37 out of the 40 images evaluated. Leakage at the sealant-enamel interface was observed in three stereomicroscopy images only. A fracture line in the sealant was seen on eight stereomicroscopy images and observed in only two micro-CT images. CONCLUSIONS: The quality of the micro-CT and related software used in the present study does not qualify it to replace the section method as the gold standard for marginal leakage assessment at the sealant-enamel interface of permanent teeth.