Which caries removal method to select?

DATA SOURCES: Searches were carried out using PubMed/MEDLINE and Web of Science databases between January 2008 and January 2023. Only articles in English language were included. Boolean operators were used to search: "permanent teeth" OR "permanent tooth" OR "permanent dentition" AND "deep caries" OR "stepwise" AND "partial caries removal OR "stepwise caries removal" OR "pulp vitality" OR "healing rate". STUDY SELECTION: Inclusion criteria were randomised controlled trials, which compared the total removal of carious tissue with either a selective or stepwise removal in permanent teeth with deep carious lesions. Criteria also required a follow up of at least 6 months and publications in English. Exclusion criteria were articles in other languages, articles not comparing different types of total or selective caries removal and articles published before January 2008. DATA EXTRACTION AND SYNTHESIS: Data extraction followed PRISMA guidelines. Two reviewers independently screened articles, analysing titles and abstracts using Rayyan's Intelligent Systematic Review Platform. They also collected data and risk of bias assessed using the Cochrane Risk of Bias Tool for Randomised Trials, dividing articles into high risk of bias, few concerns and low risk of bias. A third researcher resolved conflict or doubt in case of divided opinions. RESULTS: In total, 105 articles were identified, and 10 duplicates removed. 95 articles were reviewed by title and abstract and 75 of these did not meet the inclusion criteria. 20 articles were then read, excluding a further 15 due to comparing only partial removal or non-selective caries removal or absence of numerical data. This left 5 articles which met eligibility criteria. These were randomised controlled trials between 2010 and 2021. Follow up ranged from 1 month to 5 years. The inclusion and exclusion criteria in all studies had similar clinical parameters. 3 studies performed management only on permanent molars, whilst the rest also included management on permanent incisors/canines/premolars and molars. Management of caries was divided into non-selective caries removal vs partial caries removal (either selective or stepwise). All but 2 studies included specific information about the materials used. Liners were calcium hydroxide or Dycal, provisional restorations were glass ionomer cements or Ketax Molar and definitive restorations were Herculite Tetric N-Ceram resin, Ivolclar Vivadent or amalgam. Clinical success or failure was measured using pulp vitality, absence of periapical lesions, radiographic analysis and lack of symptoms. Clinical follow up was evaluated by external examiners, although 2 studies did not specify this clearly. There were a variety of tools used for statistical analysis in each study. CONCLUSIONS: When comparing non-selective caries removal with either selective or stepwise, 3 studies proposed statistically significant differences in terms of longevity, marginal integrity and success rate of restorations. 1 study stated inexistence of statistically relevant divergences between procedures. Non-selective caries removal is not highly recommended for deep carious lesions and may be considered invasive and risks pulpal exposure. Both selective and stepwise removal are considered conservative approaches. Selective removal is considered the best management option in the short term (with 1.5 years follow up), predominantly related to a lower risk of pulpal exposure. At 5 years, however, the results of selective were similar to those of non-selective, accepting the null hypothesis. There were also no differences in success rates for materials used for definitive restorations.

Oral prehabilitation for patients with head and neck cancer: getting it right - the Restorative Dentistry-UK consensus on a multidisciplinary approach to oral and dental assessment and planning prior to cancer treatment.

Historically, oral and dental issues for head and neck cancer patients were often not considered until after cancer treatment was complete. As a result, outcomes for oral rehabilitation were sometimes suboptimal. Inconsistencies in service delivery models and qualification, training and experience of staff delivering dental care often compounded this problem, making research and audit almost impossible. Collaborative working by consultants in restorative dentistry from all over the UK as part of a Restorative Dentistry-UK (RD UK) subgroup, renamed more recently as the RD-UK Head and Neck Cancer Clinical Excellence Network (CEN), has re-emphasised the importance of specialist restorative dentistry intervention at the outset of the head and neck cancer pathway to optimise outcomes of patient care. The CEN has driven several initiatives, reflecting Getting It Right First Time (GIRFT) principles aimed at reducing unwarranted variation. This improved consistency in approach and optimised collaborative working of the team now presents a better environment for multicentre audit and research. Ultimately, this should result in a continued improvement in patient and carer experience.

Do resin-based sealers increase post-operative pain following root-canal treatment?

Design Systematic review. Case selection This systematic review had a focused and structured research question in term of PICO (Population, Intervention, Comparison and Outcomes). Patients included within the study were those with undergoing primary root canal treatment on a permanent tooth. The intervention was obturation with gutta percha and a resin-based sealer in comparison to obturation with gutta percha and another sealer type. The primary outcome being measured was post-operative pain incidence and/or intensity. An additional, secondary outcome, aimed to assess analgesic intake following treatment.Data analysis Data analysis was carried out by two independent reviewers using a specifically designed template which gave a concise summary of the study included within the review. The form allowed the following details to be recorded: whether a single operator completed treatment; pulpal status; irrigants used; sealer placement technique and type; obturation technique and quality; evaluation time; and outcome measures. An assessment was carried out of each study to ascertain the risk of bias which was categorised as low risk, having some areas of concerns or high risk.Six studies were included within the quantitative analysis which involved analysis of post-operative pain experiences at specified intervals. Qualitative data analysis was completed using a digital software package which allowed comparable results to be combined.Results The results from this systematic review demonstrated no significant difference in post-operative pain incidence between endodontic treatment using resin or non-resin sealers. While seven of the studies had high risk of overall bias, four were deemed low risk, and the majority of studies confirmed that there was no significant difference in the intensity of pain between the two groups. This review also confirmed that analgesic intake is not increased in patients where resin-based sealers are used when compared to non-resin sealers.Conclusion There is no significant difference in post-operative pain when resin-based root canal sealers are used when compared to other root canal sealers. For both resin and non-resin sealers, analgesics use, pain incidence post-operatively and intensity of pain reduce after 24 hours.

Do adjunctive antimicrobials improve the outcome of non-surgical peri-implantitis treatment?

Design This study was a single-centre, single-blind, controlled parallel group randomised control trial.Case selection Participants included those referred to The Hague Clinic for Periodontology in the Netherlands. The selection criteria included patients diagnosed with peri-implantitis, defined as marginal bone loss of >2 mm in addition to bleeding or suppuration on probing and a probing depth of >5 mm. The study was carried out over seven years and involved a control group (full mouth non-surgical peri-implantitis treatment) and a test group (non-surgical peri-implantitis treatment combined with systemic antimicrobials). Data analysis Sixty patients were recruited (30 allocated to each group) and 57 completed follow-up and were analysed according to the intention to treat principle. The patients were reviewed monthly and clinical data according to the parameters being measured were recorded. Microbiological analysis was also carried out. The power calculation was based upon the primary outcome measure of interest: bleeding on probing (BoP).Results The primary outcome parameter being measured was change in full mouth BoP and this study concluded that there were no significant differences in bleeding scores between the control and intervention at three months post-treatment. Secondary outcome parameters being measured included full mouth peri-implant and periodontal plaque scores (PS, %), clinical attachment levels, suppuration scores (SS, %), mean probing depths, mean peri-implant bone levels, change in detection frequency of periodontal pathogen species over the study duration, adverse event occurrence and need for additional surgical treatment. No significant differences were noted between the two groups for any clinical parameter.Conclusions Antimicrobial therapy does not lead to improved patient outcomes in terms of reducing microbial load and reducing pocket depth. Based on this study, there is inadequate evidence to support the use of adjunctive antimicrobials for the non-surgical treatment of peri-implantitis.

What are the main factors associated with root caries?

Data sources Medline, EMBASE, PubMed and Scopus databases were used as the data sources for the systematic review. Articles published between 1 January 1990 to 31 October 2018 were included with no language restrictions. A manual search of the references lists of the selected studies and review articles was conducted.Study selection Two independent researchers identified observational studies that investigated at least one risk factor of root caries in the study population. Studies were only included if they demonstrated statistical analysis of data on root caries, had a sample size of >100 and were in vivo. A third researcher was consulted to achieve consensus if there was disagreement. Methodological quality was evaluated via the modified Newcastle-Ottawa Scale for cross-sectional studies.Data extraction and synthesis Data was extracted and pooled into descriptive summary tables with study characteristics and results. Data on the presence and extent of root caries was recorded in addition to information on the relationship between the studied factors and root caries found in the unadjusted and adjusted data. Due to heterogeneity of key aspects among the included studies, meta-analysis was not conducted. Data were grouped under six categories - sociodemographic, general health behaviour, general health condition, fluoride exposure, oral health behaviour and oral health condition - and qualitatively analysed.Results Following screening of 984 articles, 62 were included in methodological quality assessment. Twenty-five were classified as moderate quality, 37 as low quality and 18 excluded. Of the 44 included articles which were qualitatively analysed, a higher association of dental caries was found in tobacco users and those with low socioeconomic status, gingival recession, poor oral hygiene and in older age groups.Conclusions Based on the present evidence, there are a number of factors associated with root caries. More high-quality observational analytical studies are needed in this field in future studies.

What is the most effective endodontic medicament for pulpotomies in immature permanent teeth?

Data sources MEDLINE (via PubMed), EMBASE, the Cochrane library (CENTRAL) and the clinicaltrials.gov database were used as the data sources for the systematic review. Date restrictions were from database inception to October 2018 and only articles published in English were included. Hand searching of reference lists was carried out. Missing data was sought from authors if required for analysis.Study selection Two independent researchers identified randomised controlled trials assessing the outcomes of pulpotomy procedures on vital permanent teeth with immature apices. Studies were only included if they reported clinical and radiographic success rates. After full text assessment, any disagreement between reviewers was resolved via discussion.Data extraction and synthesis Data extraction was carried out using a table which was custom designed for this study. Accuracy of data was checked by a third reviewer. Strict criteria for healing were used for clinical and radiographic outcomes. Success rates were calculated for each intervention. Statistical testing on the data was completed using a fixed- or random-effect model depending on heterogeneity identified, using the i2 test. Results were presented as relative risks with 95% confidence intervals. Two independent reviewers assessed the quality of studies using the Cochrane risk of bias assessment tool.Results Following screening of 1364 articles, five studies were included for qualitative analysis and two for quantitative analysis. All included studies were assessed as having a high risk of bias, which was attributed to the nature of the intervention and challenges in blinding the researcher. Four out of the five included studies were assessed as having a low risk of bias for detection, because of blinding of the investigator assessing the outcome. The remaining study had an unclear risk of bias for this parameter. No significant difference was detected between mineral trioxide aggregate (MTA) and calcium hydroxide (CH) at 6 months or 12 months post-treatment. MTA was also compared to platelet-rich fibrin (PRF), calcium-enriched mixture (CEM) and triple antibiotic paste (TAP) in individual studies with no statistically significant differences identified between groups. Significant clinical and radiographic differences were observed in favour of MTA and TAP compared to abscess remedy (AR), although this was noted as weak evidence.Conclusions Based on the present evidence, there were similar success rates when using MTA, CH, CEM, RPF and TAP as medicaments for pulpotomies in the treatment of immature permanent teeth. More high-quality RCTs are needed in this field in future studies.

Impact of frequency of denture cleaning on microbial and clinical parameters - a bench to chairside approach.

Objective: Robust scientific and clinical evidence of how to appropriately manage denture plaque is lacking. This two-part study (i) developed an in vitro model of denture plaque removal, and (ii) assessed effectiveness of these approaches in a randomised clinical trial. Method: (i) a complex denture plaque model was developed using the dominant microbial genera from a recent microbiome analyses. Biofilms formed on polymethylmethacrylate were brushed daily with a wet toothbrush, then either treated daily for 5 days or only on Days 1 and 5 with Polident® denture cleanser tablets (3 min soaking). Quantitative and qualitative microbiological assessments were performed. (ii), an examiner-blind, randomised, crossover study of complete maxillary denture wearers was performed (n = 19). Either once-daily for 7 days or on Day 7 only, participants soaked dentures for 15 min using Corega® denture cleansing tables, then brushed. Denture plaque microbiological assessment used sterilized filter paper discs. Results: The in vitro model showed daily cleaning with denture cleanser plus brushing significantly reduced microbial numbers compared to intermittent denture cleaning with daily brushing (p < 0.001). The clinical component of the study showed a statistically significant reduction in denture plaque microbial numbers in favour of daily versus weekly treatment (aerobic bacteria p = 0.0144). Both in vitro and in vivo studies showed that denture plaque biofilm composition were affected by different treatment arms. Conclusions: This study demonstrated that daily denture cleansing regimens are superior to intermittent denture cleansing, and that cleansing regimens can induce denture plaque compositional changes. Clinicaltrials.gov registration: NCT02780661.

Indications for Cuspal Coverage.

Cuspal-coverage restorations are important to preserve the integrity of a weakened tooth against the forces of occlusion. This article discusses the clinical indications for both direct and indirect cuspal-coverage restorations and the evidence supporting their use. Factors that modify a tooth's ability to dissipate normal occlusal forces and the effect cuspal-coverage restorations have on force distribution are examined. Clinical criteria, choice of restorative material and methods for tooth preparation are also discussed. CPD/Clinical Relevance: Re-enforcement of weakened teeth with cuspal-coverage restorations provides a minimally invasive alternative to conventional crowns.

Radiotherapy associated with higher rates of dental implant loss.

DATA SOURCES: Cochrane Oral Health Group's Trials Register, CENTRAL, Medline via PubMed and EMBASE; no restrictions on language, published before February 1st 2013. STUDY SELECTION: Observational studies reporting outcomes from irradiated and non-irradiated patients were eligible for inclusion as were randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing irradiated patients submitted to different implant-based treatment protocols. DATA EXTRACTION AND SYNTHESIS: Screening of titles, abstracts and full texts was by two reviewers, with disagreements resolved through discussion, consensus, or failing this by consultation with a third reviewer. Data extraction was in duplicate and attempts were made to contact authors for missing data. Risk of bias was assessed using adapted versions of the Cochrane Collaboration's tool (for RCTs and CCTs) and the Newcastle-Ottawa scale for observational studies. RESULTS: Fifteen trials with 10,150 implants were included with 1,689 (14.3%) placed in irradiated mouths. There were 13 case series and two RCTs. three of the studies were on hyperbaric oxygen (HBO) therapy. Neither of the RCTs was rated as low risk of bias. Mean survival rates ranged from 46.3% to 98% with pooled estimates showing that implant failure was statistically significantly higher in irradiated patients compared to patients who had not undergone radiotherapy (an increase of 174%) with a risk ratio of 2.74 (95% confidence interval {CI}: 1.86, 4.05; p<0.00001). In maxillary sites, the risk ratio was 5.96 (95% CI:2.71, 13.12;p<0.00001) with the risk of loss increasing to 496%. Hyperbaric oxygen therapy did not reduce the risk of implant failure showing a risk ratio of 1.28 (95% CI:0.19, 8.82). CONCLUSIONS: Irradiation of the head was linked to increased failure rate of implants compared to failure rates in patients who had not undergone radiotherapy. The failure rate was higher in the maxilla and HBO therapy did not improve implant survival.