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.

儿童乳磨牙金属预成冠的修复治疗

乳牙龋病是儿童常见的口腔疾病之一.第三次全国口腔健康流行病学调查结果显示,中国儿童乳牙存在患龋率高、就诊率低下的现状.由于儿童乳牙解剖形态及组织结构特点、儿童饮食特点等原因,导致儿童乳牙龋具有区别于恒牙龋的特殊临床表现,且可对继承恒牙、儿童生长发育及心理等产生不良影响.目前,针对乳牙龋的治疗主要采用药物治疗和修复治疗,修复治疗是最重要的治疗方法,其中对于较大面积的乳磨牙龋损,临床上多选择金属预成冠的修复治疗.本文从金属预成冠的背景、适应证、临床操作步骤及相关研究等方面,就儿童乳磨牙的金属预成冠修复治疗进行阐述.     

A 2-year clinical evaluation of sealed noncavitated approximal posterior carious lesions in adolescents

The objective was to evaluate the clinical performance of a therapeutic sealant to arrest the progression of noncavitated approximal posterior carious lesions. The study population comprised 50 adolescents in whom bitewing radiographs had been taken for diagnosis of caries. Approximal noncavitated lesions in premolars and molars (4d–7m) were selected. One group (n=17) had a sealant placed after tooth separation on all enamel lesions. A second group (n=7) received sealant and fluoride varnish in a split-mouth design. A control group (n=26) received a standard fluoride varnish treatment without tooth separation. Follow-up radiographs were taken after 2 years and were analyzed together with the baseline radiographs in a blind study setting. About 93% of the sealed initial carious lesions showed no progression. The corresponding value for the fluoride varnish control group was 88%. In the split-mouth study, 92 and 88% of the surfaces with enamel caries showed no progression after sealant or fluoride varnish treatment, respectively. The difference between the two treatment procedures was not statistically significant. The incidence rate for the transition from enamel caries to dentin caries or fillings was 3.5–3.9 surfaces/100 years in the sealant groups and 5.9–6.1 surfaces/100 years in the fluoride varnish groups. The results show the potential of sealants to act as a noninvasive treatment of early approximal enamel lesions.     

Caries removal strategies for deep carious lesions in primary teeth: Systematic review

The study aimed to compare the efficacy of three caries removal techniques—complete caries removal (CCR), selective caries removal (SCR), and stepwise caries removal (SWR)—for deep carious lesions in vital temporary teeth by conducting a systematic review and meta‐analysis of randomized controlled trials (RCTs). Electronic databases (PubMed [MEDLINE], Cochrane Library, EMBASE) were searched for corresponding references up to 31 May 2019. Possible outcomes were pulp exposure, pulpo‐periodontal complications, or restorative failures . Three reviewers independently selected studies, extracted data, and assessed the risk of bias using RoB 2. Meta‐analyses for intention‐to‐treat and per‐protocol scenarios were performed using Revman5. Of 1374 potentially eligible articles, ten relevant references corresponding to eight studies were included. Pooled results showed decreased risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using USPHS criteria, after SCR compared with CCR only in intention‐to‐treat analysis. Risk of clinical or radiographic failure of pulpo‐periodontal complications was unchanged when compared with SCR and CCR or SWR. SCR and SWR may result in lower pulp exposure risk than CCR. RCTs with lower risk of bias, higher power, and longer follow‐up are required to choose between these three caries removal techniques for deep carious lesions in vital temporary teeth.     

The Caries Management System: an evidence‐based preventive strategy for dental practitioners. Application for children and adolescents

The application of the Caries Management System (CMS) for children and adolescents follows the rationale underlying the application of the CMS for adults. Briefly, the CMS is a 10‐step, risk‐based, non‐invasive strategy to arrest and remineralize early lesions and to enhance caries primary prevention. The method for assessing each patient’s diet, plaque distribution, and signs of caries as shown in bitewing radiograph images, follows the protocols for adults. Protocols presented here relating to caries risk assessment, lesion diagnosis and management, and patient recall are specific for children and adolescents. Fundamentally, non‐cavitated lesions in primary and especially permanent teeth are managed: (1) professionally by preservative non‐invasive means, including fluoride varnish and sealants; and (2) daily home toothbrushing using fluoride toothpaste where the aim is to arrest lesion progression so that restorations will not be necessary. Monitoring of lesions through the review of clinical signs and bitewing images is the means for assessing caries activity. For those who fail to respond to advice to reduce cariogenic exposures and continue to develop new lesions at a steady or increased rate, a more intensified programme is required; their higher risk status is confirmed and treatment follows the corresponding protocol.     

Effectiveness of Pit and Fissure Sealants for Preventing and Arresting Occlusal Caries in Primary Molars: A Systematic Review and Meta-Analysis

ObjectiveThe use of pit and fissure sealants have been well supported in permanent teeth, but no concrete evidence is available to support this procedure in primary molars. This review aims to systematically assess randomized controlled trials and summarize the evidence on the effectiveness of different sealants in prevention and arrest of the pit and fissure occlusal caries in primary molars of children.Materials and methodsFour electronic databases were searched from inception to March 2018. Seven studies were included in the qualitative and quantitative syntheses. Two reviewers independently selected studies, extracted data, assessed risk of bias using the revised Cochrane risk of bias tool, and evaluated the certainty in the evidence adopting the Grading of Recommendations Assessment Development and Evaluation approach. Odds ratio and retention rate of different sealants were recalculated and analyzed.ResultsThis review identified no significant difference in the overall caries incidence and progression when evaluated over 24 months between (1) resin-based sealant (RBS) and glass ionomer sealants (GIS) or resin-modified GIS; (2) conventional and newly developed RBS; (3) autopolymerized and light-polymerized RBS; (4) RBS with topical fluoride application and topical fluoride alone; and (5) RBS with topical fluoride application and resin infiltration with topical fluoride application. The pooled estimates of the mean retention rates of RBS and GIS on primary molars over an 18-months period were 85.94% and 23.18%, respectively. The certainty in the evidence of each outcome was determined as low or very low mainly because of high risk of overall bias and imprecision.ConclusionThere are currently insufficient well-controlled randomized controlled clinical trials to determine whether sealants are beneficial in preventing or arresting noncavitated occlusal caries in the primary molars.     

Prevalence of noncavitated and cavitated carious lesions in 5-year-old head start schoolchildren in Alachua County, Florida

PURPOSE: The diagnosis of early carious lesions is essential for nonsurgical management of dental caries. This report describes the prevalence of early noncavitated and cavitated carious lesions in the primary dentition of 5-year-old Head Start schoolchildren in Alachua, Fla. METHODS: As part of the Fluoride Varnish Study conducted at the University of Florida, modified caries diagnostic criteria-which differentiated caries lesion activity and severity-were developed for the primary teeth. Dental examinations were conducted on 221 children ages 5 years by 2 calibrated examiners. RESULTS: Overall, 86% of the children had experienced noncavitated or cavitated caries lesions in the primary dentition. Prevalence of cavitated dentinal lesions was 48%, and prevalence of active noncavitated enamel lesions was 71%. The mean number of active noncavitated enamel lesions (mean +/- SEM: 2.91 +/- 0.21) was slightly higher than the mean number of cavitated dentinal lesions (2.52 +/- 0.31). The mean number of restored surfaces was 1.24 (+/- 0.42), and only 8% of the children had 1 or more restored surfaces. Noncavitated lesions were most common on occlusal surfaces, especially in mandibular second molars. African-American children had a higher prevalence of noncavitated lesions (81%) than whites (69%) or others (33%; P<.0001). Prevalence of cavitated lesions was 49% for African Americans, 46% for whites, and 48% for others. CONCLUSIONS: This study shows that noncavitated enamel and cavitated dentinal lesions are common in this study population's primary dentition. There is a need for preventive measures and treatment of decay in these children living in low-income families.     

A study investigating the formation of artificial sub-surface enamel caries-like lesions in deciduous and permanent teeth in the presence and absence of fluoride

OBJECTIVES: Clinical and in situ studies have shown that caries formation and progression is faster in primary than in permanent teeth. Ambient levels of fluoride are also known to influence the processes of carious lesion formation. The aims were, firstly to investigate the incidence of artificial sub-surface caries lesion formation in the enamel of deciduous and permanent teeth in vitro. Secondly, to compare quantitatively the mineral content and distribution of these lesions and assess the possible influence of fluoride upon the lesion parameters. METHODS: Twenty primary molars and 20 permanent premolars were randomly assigned to one of four experimental groups. Samples in each experimental group were immersed in a 0.05M lactic acid gel (6% w/v hydroxyethyl cellulose, pH 4.5) either in the absence or presence of fluoride for 7 days. Subsequently, lesion parameters of mineral loss (vol x % microm) and lesion depth (microm) were assessed by transverse microradiography and image analysis. RESULTS: No significant differences existed between the lesion parameters of permanent and primary teeth (P=0.20). Irrespective of tooth type, lesion parameters were significantly reduced in samples demineralised in the presence of fluoride (P< or =0.002). CONCLUSIONS: Fluoride significantly reduces the severity of sub-surface caries lesions formed in vitro and in contrary to previous studies, there were no significant differences in lesions parameters between permanent and primary teeth.     

Systematic reviews of selected dental caries diagnostic and management methods.

A systematic review of the English-language literature was conducted to address three related questions concerning the diagnosis and management of dental caries: a) the performance (sensitivity, specificity) of currently available diagnostic methods for carious lesions, b) the efficacy of approaches to the management of noncavitated or initial carious lesions, and c) the efficacy of preventive methods among individuals who have experienced or are expected to experience elevated incidence of carious lesions. From 1,328 caries diagnostic and 1,435 caries management reports originally identified, thirty-nine diagnostic studies and twenty-seven management studies were included in the final evidence tables. Point estimates or reasonable range estimates for the diagnostic validity of methods for the diagnosis of carious lesions could not be established from the literature reviewed. There are insufficient numbers of reports of diagnostic performance involving primary teeth, anterior teeth, and root surfaces. For posterior occlusal and proximal surfaces, quality issues and the variation among studies precludes establishing such estimates. The apparent differences in sensitivity among methods are generally smaller than the variation reported within methods. The literature on the management of noncavitated carious lesions consisted of five studies describing seven experimental interventions. Because these interventions varied extensively in terms of management methods tested as well as other study characteristics, no conclusions about the efficacy of these methods were possible. The literature on the management of individuals at elevated risk of carious lesions consisted of twenty-two studies describing twenty-nine experimental interventions. The strength of the evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk subjects was fair, and the evidence for all other methods was incomplete. Because the evidence for efficacy for some methods, including chlorhexidine, sucrose-free gum, and combined chlorhexidine-fluoride methods, is suggestive but not conclusive, these interventions represent fruitful areas for further research.     

Caries prevalence in children with cleft lip and palate--a systematic review of case-control studies

AIM: To conduct a systematic review of literature in order to examine the evidence of an increased prevalence of dental caries in children with cleft lip and palate (CLP). METHODS: A search of the PubMed database was conducted through May 2006. Sex- and age-matched case-control studies with noncavitated and manifest caries lesions as endpoint were targeted (n = 6). The studies were assessed independently by two reviewers and scored A-C according to predetermined criteria for methodology and performance. RESULTS: Significantly more caries in CLP children were reported in two of the four studies in the permanent dentition and in three out of four publications dealing with primary teeth. None of the articles were, however, assessed with the highest grade 'A' and the level of evidence was therefore based on three papers graded 'B'. There was a tendency towards higher caries scores in preschool children, but as conflicting results were revealed, the evidence that children with CLP exhibit more caries than noncleft controls was inconclusive. CONCLUSION: This systematic review of literature was unable to find firm evidence for the assumption that CLP children have an increased prevalence of dental caries.     

Effectiveness of methods used by dental professionals for the primary prevention of dental caries.

This paper summarizes and rates the evidence for the effectiveness of methods available to dental professionals for their use in the primary prevention of dental caries. It reviews operator-applied therapeutic agents or materials and patient counseling. Evidence of effectiveness is extracted from published systematic reviews. A search for articles since publication of these reviews was done to provide updates, and a systematic review of the caries-inhibiting effects of fluoride varnish in primary teeth is provided. Good evidence is available for the effectiveness of fluoride gel and varnish, chlorhexidine gel, and sealant when used to prevent caries in permanent teeth of children and adolescents. The evidence for effectiveness of fluoride varnish use in primary teeth, chlorhexidine varnish, and patient counseling is judged to be insufficient. Use of fluoride, chlorhexidine and sealant according to tested protocols and for the populations in which evidence of effect is available can be recommended. However, they may need to be used selectively. Estimates for the number of patients or tooth surfaces needed to treat to prevent a carious event suggest that the effects of these professional treatments are low in patients who are at reduced risk for dental caries. The literature on use of these preventive methods in individuals other than school-aged children needs expansion.     

Direct materials for restoring caries lesions: Systematic review and meta-analysis—a report of the American Dental Association Council on Scientific Affairs

BackgroundThe goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth.Type of Studies ReviewedThe authors included parallel and split-mouth randomized controlled trials comparing the effectiveness of direct restorative materials commercially available in the United States placed in vital, nonendodontically treated primary and permanent teeth. Pairs of reviewers independently conducted study selection, data extraction, and assessments of risk of bias and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The authors conducted pair-wise meta-analyses to summarize the evidence and calculated measures of association and their 95% CIs.ResultsThirty-eight randomized controlled trials were eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass ionomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials.Conclusions and Practical ImplicationsOwing to a relatively low event rate across various outcomes indicating restoration failure, there was limited evidence to support important differences between direct restorative materials used in practice.     

Dental caries status of young children in a suburban community of Mexico City

One hundred and thirty-four children, 6 to 7 yr of age from a public school in Tepepan, Mexico were examined for the prevalence and severity of dental caries. Average deft score was 6.08 and defs was 12.15. Average DMFT and DMFS scores were .57 and .99 respectively. It was observed that 66% of primary teeth with carious lesions required one surface restoration and 11% three or more surface restorations. In the permanent dentition 99% of the affected teeth required one surface restoration. A comparison of the results with those of the Mexico City public school children survey (1980) showed that the Tepepan children had a similar caries level in primary teeth and a lower caries level in permanent teeth. Although the Tepepan group showed fewer carious lesions, their caries index and unmet restorative index are still high, especially for primary dentition, so an intensive educational, preventive and restorative program is required.     

The atraumatic restorative treatment (ART) approach for the management of dental caries.

There is worldwide interest in and increasing usage of the conservative atraumatic restorative treatment technique or approach for the restoration of primary and permanent teeth. However, most published data on the clinical performance of the newer, high-strength esthetic conventional glass-ionomer restorative cements marketed for the procedure have been derived from short-term studies. There have been very few reports comparing different types of restorative materials and methods of cavity preparation. In primary teeth, after 1 year, success rates have been approximately 80% to 95% for Class I and Class V single-surface restorations, 55% to 75% for Class II multisurface restorations, and 35% to 55% for Class III and Class IV restorations. In permanent teeth, after 2 to 3 years, success rates have been approximately 90% for Class I and Class V single-surface restorations, but little data have been reported for other restoration classes. Failures usually result from restoration losses, fractures, and wear. Further improvements in the design of hand instruments and in the mechanical properties of the newer glass-ionomer cements are required. Currently, use of the atraumatic restorative treatment approach should be restricted to restoration of single-surface caries lesions, especially in permanent teeth, and to sealing of occlusal fissures in selected teeth.     

Comparison of the caries-preventive effect of a glass ionomer sealant and fluoride varnish on newly erupted first permanent molars of children with and without dental caries experience

Abstract

Purpose: This longitudinal clinic study evaluated the effect of a glass ionomer sealant (GIS) and a fluoride varnish (FV) in the prevention of dental decay on newly erupted permanent molars of children with and without caries experience. Materials and methods: Eighty children, aged 6–8 years, with all four newly erupted first permanent molars, were divided into two groups. Group 1 consisted of 53 children without caries experience and group 2 consisted of 27 children with dental caries experience. Permanent molars of the right side were sealed with GIS and the fluoride varnish was applied on the other two permanent first molars. Evaluation of GIS retention and the effectiveness of both materials in the prevention of dental caries were performed after 6, 12 and 18 months. Results: After 18 months, of the 299 teeth, 271 (91%) showed no caries lesions and 28 presented caries lesions (9%). Teeth sealed with GIS had more carious lesions (15) than teeth with fluoride varnish (13). Most of the teeth (70%) that presented carious lesions were in group 2. Of the 138 sealed teeth, only one showed GIS to be totally present, 95 were partially present and 42 teeth were absent. Conclusion: The caries-preventive effect was very similar between both treatments. The presence of dental caries prevailed in the children with caries experience.     

A combined approach to preventing dental caries in schoolchildren: caries reductions after 3 years

A combination of preventive methods have been used to reduce dental caries in children residing in a fluoridated area of Southeastern Michigan. These children had very low restorative treatment levels. The methods used include dental health education, prophylaxis, pit and fissure sealants, topical application of fluoride and restorative care. Prophylaxis, sealant and fluoride procedures were repeated every 6 months. Sealant was applied to all caries-free posterior teeth in the mouth. Three-year results show reduction of occlusal caries increments of nearly 73% for both 1st and 6th school grades. Although at baseline examination there was no statistically significant difference between the two groups in mean DMF teeth and surface scores, the difference in mean increments at the end of 3 years was statistically significant (P less than 0.01). Percent reductions in caries increment for permanent first molars in 1st graders were 65.6 for DMF teeth and 66.7 for DMF surfaces. Corresponding figures for permanent teeth among 6th graders were 71% and 58.3%.     

Present and future approaches for the control of caries

This article summarizes current and potential future approaches for the management of caries. Current surveys suggest that traditional "drill, fill, and bill" dentistry is still widely practiced in the United States in spite of considerable evidence that supports a minimally invasive treatment approach. Because there is a wide variability in treatment decisions on when and how to prevent new lesions, on how to arrest the progression of existing lesions, and on when and how to place initial and replacement restorations, the findings from some studies differ significantly from the results of other studies. While fluoride treatments are known to prevent a percentage of new lesions, they do not have the ability to prevent all caries lesions. Modern management of caries entails treating patients according to risk and monitoring early lesions in tooth surfaces that are not cavitated. Although we know that the dmfs score for children is a powerful predictor of caries increment in permanent teeth of these children a few years later, this score is rarely used in private practice as a measure of risk or as a measure of treatment success. Although these modern methods for caries management offer great promise for controlling the disease, they may take decades to apply in a standardized way so that the variability in treatment is reduced. However, during the next two decades, an alternative approach to caries prevention such as replacement therapy and a caries vaccine may become available as a more consistent method of controlling this disease.     

Diagnostic levels in dental public health planning

This concept paper discusses the rationale for using different diagnostic criteria for dental caries in public health programs. The author contends that epidemiological data or needs assessment surveys should collect data to provide information on the epidemiology of different stages of the caries process in order to enable planners to design tailored programs to prevent dental caries. In a rapidly progressing caries environment, conventional approaches to delivering preventive measures may not work. The author also contends that dental public health programs should expand their vision to influence how dentists are detecting, diagnosing and managing dental caries. Dentists' restorative decisions have significant impact on the oral health status of a nation. Henceforth, detecting the early or noncavitated caries level and preventing these lesions from progressing to the cavitated stage (or being restored) could have a significant impact on the oral health status around the world. There is a need for more research on the best methods to detect, prevent and treat early carious lesions.     

Paediatric Dentistry Discussion Paper and Case Report Management of small carious lesions in primary teeth: Caries removal versus fluoride application and periodic ‘observation’ until exfoliation

Differences in treatment rationale exist between dental practitioners with respect to the management of small carious lesions in primary teeth. Some do not consider it necessary to use a conventional restorative approach, preferring to apply topical fluoride and/or ‘monitor’ the lesion(s). This paper advocates the alternative approach which entails complete caries removal by mechanical means, the rationale being to eliminate the pool of cariogenic microorganisms and thereby protect sound teeth from succumbing to carious attack. A case is presented to illustrate the extent to which caries can progress and also involve other teeth if small cavitated lesions are simply treated by ‘spot’ application of fluoride. Clinical treatment of caries must be based on scientific knowledge of the microorganisms involved and an understanding of its transmissible and infectious nature.     

Silver Diamine Fluoride: Extending the spectrum of Preventive Dentistry,a literature review

Dental caries continues to be a severe oral health problem despite a decrease in its prevalence over the past few decades. The contemporary philosophy of caries management has shifted from the traditional approach to a newer medical one, that frequently includes utilization of fluoridated and antimicrobial agents. Among these different agents, Silver Diamine Fluoride (SDF)¹ has gained significant recognition. Dr Nishino and Dr Yamaga in Japan, pioneered its application to arrest caries. It is an alkaline, colourless solution composed of diamine-silver and fluoride ions having silver's antibacterial and fluoride's remineralising property. It has been used successfully to arrest and prevent caries in deciduous and permanent teeth, prevent recurrence of secondary caries and treat dentinal hypersensitivity. No adverse systemic effects due to SDF have been noted although black discolouration following its application has raised concerns. When used wisely it is an effective, sustainable and inexpensive option for children with high caries risk, for individuals who cannot endure conventional modalities of restorative treatment and those with special health-care needs. The current review is an insight into the clinical significance and application of SDF based on published literature.