The Core Curriculum in Cariology: Fiction or Reality? Challenges about Implementation.

INTRODUCTION: The Core Curriculum in Cariology (CCC) was developed by ORCA and ADEE in 2010. This article summarizes challenges for the implementation of the CCC at university/country level identified at the "Education Platform" of the ORCA 2022 conference in Cagliari, Sardinia. METHODS: Participants from universities from 3 European (Italy, Poland, and UK), 2 Asian (India and Russia), and 3 American countries (Brazil, Colombia, and USA) led the presentations, discussion, and generation of statements. Presentations were transcribed and summarized through qualitative content analysis. Key themes were identified, transformed into key topics, and sent to the panel for agreement. RESULTS: Regardless of the wide variety of dental schools per country, from few (Poland n = 10) to many (India n = 318, Brazil n = 563) or from country/continent itself, frequent challenges to CCC implementation were highlighted. These included lack of agreement on a basic CCC as standard (96%), insufficient support or reimbursement for caries prevention and management (90%), separation between cariology and restorative dentistry (68%), focus on restorative/surgical management with prevention and nonoperative management being disconnected (73%). The group agreed that the integration of cariology and restorative dentistry remains essential to enhancing evidence-based decision-making, resulting in a shift of emphasis from cure to care. CONCLUSION: There is variation in the level of implementation of the CCC. A frequent challenge is the disconnect between cariology and restorative dentistry. The CCC should be disseminated and promoted as a uniform blueprint/framework to facilitate the implementation of a common cariology curriculum among universities within each country, as well as internationally.

Factors Associated with Reevaluation of the Stepwise Excavation Procedure: An 8-Year Retrospective Study.

Although the stepwise excavation procedure (SWP) has been shown to be an effective caries treatment technique, studies reporting its application outside of controlled clinical trials are limited. We performed a retrospective study from patient record data to assess the proportion of patients who had an SWP reevaluated within 18 months at The University of Iowa College of Dentistry (UICOD) between 2004 and 2012, and evaluated the association between different variables and this outcome. A total of 1,985 SWPs were performed in 1,326 patients, with 518 patients having had reevaluation within 18 months. Bivariate analysis and logistic regression modeling revealed strong associations between explanatory variables such as provider type, tooth type, patient age, number of recalls and the calendar year in which the SWP was done and reevaluation status. There was also evidence of association with dental insurance status. Other characteristics such as gender, distance traveled to the UICOD, number of surfaces treated and tooth arch did not show any significant association. In general, patients were more likely to have reevaluation when seen by faculty members or residents, the procedure was performed in molars/pre-molars, they were older, they had more recalls and were seen earlier in the study period. These results suggest that decisions to use SWP should consider patient demographics and treatment characteristics such as provider level, tooth type, patient age and number of recalls. The impact of treatment year may reflect program heterogeneity or temporal changes in external societal factors.

Conservative treatment planning in veneer replacement.

This clinical report describes a conservative treatment in veneer replacement where diastemas, malalignment, and midline shift were the main modifying factors. When replacement veneers are indicated, the definitive results can only be accurately predicted after an esthetic reanalysis of the existing restorations.

Repair versus replacement of defective direct restorations: A cross-sectional study among US dentists.

BACKGROUND: Repair increases the longevity of restorations and is well-accepted by patients. In this study, the authors assessed the acceptance of dental restoration repair by dentists and determined the main variables of repair versus replacement of defective restorations. METHODS: A 15-item questionnaire was developed and distributed electronically to the American Dental Association Clinical Evaluators panel members (n = 785) during a 2-week period in 2019. Descriptive, bivariate, and multivariable analyses were conducted. RESULTS: Of the 387 respondents, 83.7% stated that they repair defective restorations, and 16% stated that they always replace them. Reasons to forego a restoration repair among dentists who perform repairs included defect size and carious lesion extension (42%) and negative personal experience or lack of success (37.9%). However, the latter was considerably higher for dentists who do not perform repairs (60.7%). The most commonly cited patient-related reason and tooth condition to repair restorations were limited patient finances (67%) and noncarious marginal defects (86%), respectively. Neither sex nor age group was significantly associated with the practice of restoration repair (P = .925 and P = .369, respectively). However, sole proprietors were more likely to perform repairs than those in an employee, associate, or contractor practice setting (P = .008). The most significant reason to forego restoration was negative experience or lack of success (P = .002). CONCLUSIONS: Restoration repair is considered a treatment option for managing defective restorations. Negative personal experience or lack of success and practice setting influenced the dentists' decision to repair or replace a defective restoration. PRACTICAL IMPLICATIONS: Understanding dentists' clinical challenges and practice environment is necessary when advocating for this approach.

Knowledge, attitudes, and behaviors of federal service and civilian dentists concerning minimal intervention dentistry.

BACKGROUND: Although minimal intervention dentistry (MID) is on the increase, little is known about the patterns of knowledge, attitudes, and behaviors of dentists in the United States. METHODS: Federal service and civilian dentists who were active members of the American Dental Association (N = 1,500) received a pretested questionnaire about their knowledge, attitudes, and behaviors concerning MID. Descriptive statistics and bivariate analyses were conducted to assess dentist personal and practice characteristics associated with the knowledge, attitudes, and behaviors. RESULTS: Federal service dentists reported more knowledge of MID than civilian dentists (Cochrane Mantel Haenszel Ridit Scores), p < 0.0043, with similar attitudes toward fluoride (p = 0.11), and decisions regarding monitoring or restoring enamel caries (p = 0.22). Federal service dentists remineralized noncavitated carious lesions more (p < 0.0001) and had lower composite scores, indicating more MID tendency (Wilcoxon p < 0.0001). CONCLUSION: Federal service dentists reported more knowledge and clinical practices regarding minimal intervention dentistry compared to civilian dentists.

A conservative treatment for amelogenesis imperfecta with direct resin composite restorations: a case report.

Rehabilitation of a patient with amelogenesis imperfecta (AI) from both the functional and esthetic standpoints represents a challenge. The complexity of the condition requires an interdisciplinary approach for optimal treatment outcomes. A number of treatment options have been proposed. Recently, the use of bonded restorations has gained popularity because of the many benefits associated with these materials; excellent esthetics, conservative approach, and improved wear make their use advantageous. This article describes a direct approach with resin composite restorations for the transitional treatment of an adolescent with hypoplastic AI who had not completed skeletal growth. Protection against further wear, sensitivity, and plaque accumulation while significantly enhancing the patient's esthetic appearance made this case a success. Furthermore, this article describes the use of a "Clear matrix" technique, which considerably helped simplify the placement of the bonded restorations.

Caries Management Decision-Making: Diagnosis and Synthesis.

The purposes of this article are to (1) offer a critical thinking skill set in decision-making and synthesis for caries diagnosis, and risk-adjusted and personalized management based on emulating the intended activity of the expert, (2) offer patient/case scenarios for application of the critical thinking skill set, (3) compare and contrast the results of applying an algorithm and expert thought process approach to patient analyses, (4) offer characteristics of the person making decisions and synthesizing information, and (5) for patients with complex health and social histories, include perspectives from other health care team members.

Management of initial carious lesions: Iowa survey.

BACKGROUND: The authors explore Iowa dentists' agreement with the International Caries Classification and Management System (ICCMS) in the nonsurgical management of initial carious lesions in patients at low, moderate, and high caries risk and identify factors related to their agreement. METHODS: Electronic surveys were mailed to 916 actively practicing dentists who are alumni of the College of Dentistry at The University of Iowa. Questions included clinical scenarios that used text, clinical photographs, and radiographic images of initial carious lesions. Dentists were asked what type of treatment they would recommend. Treatment options included no treatment, nonsurgical treatment, or surgical treatment. Logistic regression analyses were used to assess associations among agreement with ICCMS, characteristics of the dentist's practice, and patients' caries risk level. RESULTS: A total of 138 Iowa dentists responded to the survey. Agreement with ICCMS regarding nonsurgical management of initial carious lesions for patients at low, moderate, and high risk levels were 73%, 59%, and 51% respectively. Compared with their counterparts, dentists who agreed with the recommendations for nonsurgical treatment were more likely to dry the teeth during caries detection (95% confidence interval [CI], 1.02 to 12.67, P = .0468), use magnification (95% CI, 1.16 to 7.17, P = .0225) for caries detection, have graduated less than 20 years ago (P = .0024), practice in public health settings (P = .0089), and perform a caries risk assessment (95% CI, 1.10 to 4.29, P = .0262). CONCLUSIONS: Dentists who dry teeth, use magnification for caries detection, graduated in the past 20 years, practice in a public health setting, and perform a caries risk assessment were significantly more likely to make decisions that were consistent with the guidelines of the ICCMS. PRACTICAL IMPLICATIONS: Knowledge of evidence-based options personalized for a patient's risk status is essential for applying the best management of initial caries lesions.

The inhibitory effect of MI paste, fluoride and a combination of both on the progression of artificial caries-like lesions in enamel.

This in-vitro study evaluated the inhibition of demineralization in enamel sections produced by MI paste, fluoride and a combination of both, compared to artificial saliva and NaF 5000 ppm in a caries progression pH-cycling model. Twenty-one teeth were demineralized to create subsurface enamel lesions (approximately 200 microns in depth). The teeth were sectioned and characterized using polarized-light-microscopy (PLM). A single section from each lesion was assigned to a treatment group: Artificial saliva, NaF 5000 ppm (Prevident, Colgate), MI paste (Recaldent, GC America Inc), NaF 1100 ppm (Crest, Procter & Gamble) and NaF 1100 ppm plus MI paste. The sections were covered with varnish except for an exposed window on the external surface of the lesion and placed in a six-day pH-cycling model with two daily treatment applications of two minutes each. The sections were characterized by PLM, and the lesion areas were measured using a digital image analysis system. Based on a paired-sample t-test, significant differences (p < .05) in percentage of change in lesion size were found between the high fluoride group and all the other groups. No significant difference was found between the artificial saliva and MI paste group, neither was there any significant difference between the NaF 1100 ppm, the combined application group or the MI paste group alone. In conclusion, the higher concentration of NaF (5000 ppm) reduced lesion progression to the greatest extent. The MI paste group did not show any effect on the inhibition of lesion progression. Further studies on the preventive effect and longer treatment applications are recommended.

Retrospective analysis of factors associated with the success of stepwise excavation procedure in deep carious lesions.

BACKGROUND: Recent scientific evidence regarding the stepwise excavation procedure (SWP) has not addressed the consideration of patient factors when selecting SWP as treatment for deep carious lesions (DCLs). This study assessed patient factors predicting a successful SWP defined as a tooth restored with SWP and did not result in root canal treatment or a dental extraction. METHODS: SWPs completed in 626 patients without symptomatic irreversible pulpitis at the University of Iowa College of Dentistry from January 2004 through December 2012 were evaluated. Patient demographic and tooth-specific characteristics were assessed in their relationship with the main outcome. RESULTS: SWPs had a 75% success rate when evaluated within 36 months of the initial treatment. Findings showed that patients who had successful SWP treatment of DCLs were somewhat younger than patients whose SWP treatment was not successful (mean age, 37.4 years and 40.5 years, respectively; odds ratio, 0.981; 95% confidence interval, 0.967 to 0.994; P = .0058). Patients who returned to their second appointment within 5 to 9 months were more likely to have a successful SWP treatment than those returning sooner than 5 months (odds ratio, 0.338; 95% confidence interval, 0.210 to 0.545; p < .0001). CONCLUSION: Treatment of deep carious lesions with SWP is effective for pulp preservation and patient age may influence the outcome. PRACTICAL IMPLICATIONS: Although a somewhat younger mean patient age was associated with successful treatment of DCLs, SWP can be successful regardless of patient age and clinicians should consider SWP in treating DCLs.

Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association.

BACKGROUND: An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults. TYPES OF STUDIES REVIEWED: The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions. RESULTS: The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

Management of high caries risk and high caries activity patients: rampant caries control program (RCCP).

The purpose of this article is to describe the Rampant Caries Control Program established in the operative dentistry third-year clinic at the University of Iowa College of Dentistry. This program represents a new approach to the management of high caries risk and high caries activity patients who come to the school. The patients are referred initially to the third-year operative clinic only for disease control (phase I) to help them decrease the caries risk and activity. The disease control phase has three important components: 1) caries risk assessment evaluation and reevaluation throughout their treatment, in which individual risk factors are identified and recommendations are made; 2) caries removal and placement of transitional restorations using fluoride release restorative materials (glass ionomers); and 3) chemotherapeutic agents and preventive treatment in which a therapeutic regimen for prevention and nonsurgical treatment is established according to each patient's individual risk factors. About 50 percent of patients have dropped from the program, 36 percent currently are under disease control treatment, and 14 percent have finished the disease control phase of the program. After the disease is controlled through modification of risk factors and activity, the patients can be referred for reevaluation prior to beginning the rehabilitation phase.

Exploring How U.S. Dental Schools Teach Removal of Carious Tissues During Cavity Preparations.

Approaches for managing carious tissues during cavity preparations vary considerably among clinicians, which may reflect inconsistencies in the teaching of this subject by dental schools. The aims of this study were to investigate practices related to the preclinical and clinical teaching of caries removal at U.S. dental schools and the relationship between that teaching and requirements for U.S. dental licensure examinations. The electronic survey included questions about terminology, methods, instruments and materials, treatment planning, criteria for clinical exams, faculty calibration sessions, and licensure exams. The faculty members at U.S. dental schools responsible for teaching cariology were invited to participate; 54 of the 65 schools had identified a contact person at the time of the survey in October 2015. Of those 54 invited to participate, 43 completed the survey (response rate of 79.6%). Most of the respondents indicated that depth of carious lesions was a clinical determinant of the amount of carious dentin being removed in cavity preparations. Caries removal was used as a criterion in restorative clinical examinations by 95% of responding schools. Marked differences were observed regarding the criteria used for assessment and removal of carious tissues, management of deep carious lesions, and definition of "caries remaining at cavity preparations," which is considered a critical error on licensure exams. Faculty calibration sessions on caries removal were reported to occur in 65% of these schools and at different time frames. Overall, the study found a wide range of teaching practices related to caries removal. Best evidence in caries management needs to be aligned with teaching and the criteria used to calibrate faculty members and examiners.

Development of a Core Curriculum Framework in Cariology for U.S. Dental Schools.

Maintenance of health and preservation of tooth structure through risk-based prevention and patient-centered, evidence-based disease management, reassessed at regular intervals over time, are the cornerstones of present-day caries management. Yet management of caries based on risk assessment that goes beyond restorative care has not had a strong place in curriculum development and competency assessment in U.S. dental schools. The aim of this study was to develop a competency-based core cariology curriculum framework for use in U.S. dental schools. The Section on Cariology of the American Dental Education Association (ADEA) organized a one-day consensus workshop, followed by a meeting program, to adapt the European Core Cariology Curriculum to the needs of U.S. dental education. Participants in the workshop were 73 faculty members from 35 U.S., three Canadian, and four international dental schools. Representatives from all 65 U.S. dental schools were then invited to review and provide feedback on a draft document. A recommended competency statement on caries management was also developed: "Upon graduation, a dentist must be competent in evidence-based detection, diagnosis, risk assessment, prevention, and nonsurgical and surgical management of dental caries, both at the individual and community levels, and be able to reassess the outcomes of interventions over time." This competency statement supports a curriculum framework built around five domains: 1) knowledge base; 2) risk assessment, diagnosis, and synthesis; 3) treatment decision making: preventive strategies and nonsurgical management; 4) treatment decision making: surgical therapy; and 5) evidence-based cariology in clinical and public health practice. Each domain includes objectives and learning outcomes.

Surface coating and leakage of dentin-bonded resin composite restorations.

OBJECTIVES: To compare the marginal leakage of dentin-bonded resin composite restorations in tooth sections coated with nail varnish and similarly restored sections coated with cyanoacrylate cement. METHODS: MO and DO cavities were prepared with the gingival floor below the CEJ in 11 non-carious extracted human molars. Each cavity was restored with a dentin adhesive and resin composite. Sectioning yielded four specimens per tooth (N=44). One specimen from each restoration was coated with varnish. The other specimen was coated with cyanoacrylate cement. The coatings were applied to all surfaces except that a 1mm window on either side of the interproximal gingival margin was left uncoated. Specimens were thermocycled and stained with silver nitrate. Silver penetration into the gingival margin of each section was measured with a measuring microscope. The predominant leakage path for each coating type was determined by scanning electron microscopy. RESULTS: There was no significant difference between the leakage of the varnish-coated and cyanoacrylate-coated specimens. No marginal gaps were observed either by optical or by electron microscopy. However, the both optical and electron microscopy revealed leakage in nearly all specimens. This leakage was confined to either the dentin/hybrid layer interface or the adhesive resin/hybrid layer interface. CONCLUSIONS: The results suggest that these coating materials are not confounding factors in laboratory investigations of marginal leakage along dentin-bonded interfaces of resin composite restorations. Although marginal gaps were undetectable even at high magnification, leakage was observed along the gingival margin of almost all of these Class II resin composite restorations.

Relationship between nanoleakage and microtensile bond strength at the resin-dentin interface.

To evaluate the correlation between microtensile dentin bond strength (microTBS) and silver ion penetration, two total-etch 3-step and one self-etch 2-step system were investigated. OptiBond FL adhesive was applied to flat occlusal dentin on six non-carious human molars, and a resin composite "crown" was formed in 2 mm increments. After 24-hour water storage, the teeth were sectioned with a low-speed diamond saw to obtain four-square sticks (approximately 2 mm X 2 mm) per tooth. Cylindrical tensile test specimens were formed with an 0.5 mm2 cross-sectional area. Nail varnish was applied to the dentin within 0.5-1.0 mm of the interface before immersing in 50% silver nitrate for 15 minutes. Following silver fixation, tensile testing was performed in a Zwick UTM at 1 mm/minute using a passive gripping fixture to obtain 72-hour microTBS [23.9 MPa]. The percentage area of silver penetration was measured on debonded specimens using light microscopy and Image-Pro Plus Software [89%]. The procedures were repeated using Scotchbond Multi-Purpose Plus [microTBS = 27.8 MPa; nanoleakage = 67%] and Clearfil SE bond [microTBS = 36 MPa; nanoleakage = 55%]. No significant correlation between microtensile bond strength and nanoleakage was found for all systems. A weak-to-moderate negative relationship was found between microTBS and nanoleakage for OptiBond FL (Spearman r = -0.3844). No correlation was found for the remaining adhesive systems. The correlation between these two common laboratory measurements appears to be adhesive-system dependent.

Concepts in critical thinking applied to caries risk assessment in dental education.

Much progress has been made in the science of caries risk assessment and ways to analyze caries risk, yet dental education has seen little movement toward the development of frameworks to guide learning and assess critical thinking in caries risk assessment. In the absence of previous proactive implementation of a learning framework that takes the knowledge of caries risk and critically applies it to the patient with the succinctness demanded in the clinical setting, the purpose of this study was to develop a model learning framework that combines the science of caries risk assessment with principles of critical thinking from the education literature. This article also describes the implementation of that model at one dental school and presents some preliminary assessment data.