微创牙科学:文献回顾与最新进展

微创牙科学是指采用生物学方法而不是传统的牙体手术处理龋病,以最大限度地减少对牙体结构的破坏。这种新的龋病处理方法,将过去强调的视龋损为“洞”而反复充填的理念,转变为视龋损为口腔生态失衡而促使生物膜产生生物学变化。微创牙科学的目的在于阻止龋病进程,然后修复缺失的牙体结构和功能,最大限度地发挥牙体的愈合潜能。微创牙科学的处理方法可概括为3个步骤:(1)判定患者的患龋风险;(2)再矿化,即防止龋损形成并逆转未形成“洞”的浅龋;(3)修复,即控制龋活性,使愈合潜能最大化并修复龋损。龋病并非仅仅是牙体脱矿,而是一个因生物膜与牙界面生态和化学平衡失衡而致的反复的脱矿过程(生态菌斑学说)。饮食和生活方式(尤其是碳水化合物的摄入频次)、饮水、吸烟是导致生物膜生态和致病性的重要因素。椅旁评价菌斑和唾液的方法的问世,使得龋病危险评估和监测患者的顺从性成为可能。唾液的再矿化特性,可以通过使用能够释放Ca2 、P5 、F1-的再矿化剂(CPP-ACPandCPP-ACFP)而予强化。使用某些化学制剂(氟、氯已定和木糖醇),可改变菌斑的致病性。采用微创治疗方案,可修复早期龋损,增进患者的理解力和顺从性。本文从3个方面,详细论述了微创牙科学的概念、理论基础和操作方法。     

Minimally invasive operative care. II. Contemporary techniques and materials: an overview

SUMMARY: Restorative dentistry has experienced a shift from the mainly reparative dentistry of the 20th century towards a minimal intervention approach. Contemporary operative treatment incorporates the MI philosophy in cavity design. Currently available techniques to pursue minimally invasive restorative treatments are highlighted. Characteristics of adhesive materials that facilitate minimally invasive operative care are discussed. CONCLUSION: When operative intervention is the designated treatment for initial caries, currently available operative techniques and contemporary materials warrant a minimally invasive approach. Minimal intervention applied to the operative field keeps the options open for long-term preservation of the restored tooth.     

Involvement of dental hygienists in pedodontics. A recommendation

The proportion of dental hygienists in oral health care for children is not consistent with the potential of the profession. Developments in cariology point in a direction that fits the profile of the dental hygienist. Stimulation of a re-allocation of jobs in paediatric dentistry in relation to dental hygienists is therefore desirable. Moreover, tackling the causes of oral diseases should be an objective to a greater degree than has been the case in the past. For caries treatment this would mean giving priority to a plaque-related treatment. That amounts to: a non-invasive approach to non-cavitated caries lesions in permanent and temporary dentition and a non-restorative approach to cavitated caries lesions in temporary dentition.     

Caries,bitewings, and treatment decisions

BACKGROUND: The most common adjunct to the visual and tactile clinical examination for dental caries is the bitewing radiograph. The aim of this study was to report on treatment planning decisions made by Victorian dentists when given a range of predetermined radiographic scenarios. METHODS: A postal survey was conducted to obtain data from 550 dentists selected systematically (every fourth dentist) from the register of the Dental Board of Victoria (1996). RESULTS: The survey response rate was 64 per cent. Fifty per cent of responding dentists selected an operative intervention for radiographic lesions confined to enamel. CONCLUSIONS: A review of current dental literature does not support this approach because a large proportion of proximal tooth surfaces that have associated radiolucencies confined to enamel are not cavitated. This study supports the need for continuing education programmes on the management of dental caries; such programmes should follow an evidence-based model.     

Prevalence of non-cavitated and cavitated carious lesions in a random sample of 7-9-year-old schoolchildren in Montreal, Quebec

This report describes the prevalence of non-cavitated and cavitated carious lesions in 911 randomly selected children in grades one through three on the Island of Montreal, Quebec, Canada. The criteria for diagnosis were developed for a longitudinal epidemiological study of restorative treatment decisions by dentists practising under a provincial dental insurance program for children. The intra- and inter-examiner reliability correlation coefficients of the two examiners were excellent (Kappa > or = 0.80). The most frequent carious lesion found in the examined children were non-cavitated carious lesions (incipient) within 1.5 of the gingival line on smooth tooth surfaces, and stained or non-cavitated carious lesions on pits and fissures. Out of 911 children in the study, 19.6% had sealants. Children whose parents completed a university education had a significantly lower prevalence of non-cavitated and cavitated carious lesions and fillings, and a significantly higher mean number of sealants than children whose parents had only primary school education. Education status of the parents was a significant risk marker of children with high caries experience and these children had a significantly higher mean number of non-cavitated carious lesions. This study has found that non-cavitated carious lesions are significantly more prevalent than cavitated carious lesions in children.     

The implications of the new paradigm of dental caries

The caries process is the ubiquitous, natural metabolism in the biofilm that causes numerous fluctuations in pH. The interaction of this biofilm with the dental tissues may result in a caries lesion. However, lesion formation and progression can be controlled, particularly by disturbing plaque regularly with a fluoride containing toothpaste. This paradigm implies that everyone with teeth is at risk to lesion development. Treatment of caries is principally non-operative, involving plaque control, fluoride and a sensible diet. Operative dentistry repairs un-cleansable cavities and is part of plaque control. A diagnosis is a mental resting place on the way to a treatment decision. The relevant diagnostic features with respect to caries are lesion activity (active lesions require active management) and un-cleansable cavities. When teaching undergraduates, it is important that they are credited for the non-operative treatment of caries as well as for operative dentistry. This is equally important in dental practice where an appropriate skills mix of the dental team is required to deliver dental health cost-effectively. Training more dentists may be an expensive mistake as far as disease control is concerned. It is ironic that dentists make most money from operative care and specialist treatment when disease control could be delivered relatively cheaply. The key to dental health is regular and effective plaque control with a fluoride containing toothpaste, from cradle to grave.     

The attitudes of parents toward the oral health of children and their reflection on the non-cavitated caries lesions

ObjectiveTo determine the extent of non-cavitated caries lesions in preschool children, and compare its relationship with socioeconomic status, oral and dental health practices, knowledge of caries prevention, and nutrition.Materials and methodsNinety-seven parents of 36–72 month-old children completed a questionnaire on the socioeconomic status of the family, parent's knowledge of caries prevention, the children's oral health practices, and nutrition. In the children, the cavitated dental caries were assessed according to World Health Organization (WHO) criteria and non-cavitated caries lesions on occlusal and smooth surfaces were evaluated by Universal Visual Scoring System (UniViSS). Statistical analysis was conducted using the SPSS software program. The relationships between variables were assessed using the chi-square test and logistic (ordinal) regression analysis.ResultsStatistically significant results were obtained relating to the parents' age, number of children, the time of first oral hygiene, frequency of tooth brushing, knowledge of caries prevention, drinks most often consumed by the children, and number of non-cavitated lesions. According to the regression model, the significant variables were caries activity (yes), drinks most often consumed by the children (milk–juice; juice–buttermilk), the frequency of tooth brushing (once a day, twice a day), observed changes in a child's teeth (change in color and breaks in teeth), the number of cavitated caries lesions and decayed, missing and filled teeth (dmft).ConclusionsThe primary factors contributing to non-cavitated caries lesions include the time of first oral hygiene and frequency of tooth brushing. The early diagnosis of non-cavitated caries is essential for preventive measures.     

Comparison of three methods for detection of carious lesions in proximal surfaces versus direct visual examination after tooth separation

The present study aimed to compare clinical, fiber-optic transillumination and bite-wing radiographic assessment of carious lesion depth in contacting proximal surfaces with the results obtained by direct visual inspection after tooth separation of the respective surfaces. It is suggested that when a carious lesion is diagnosed as non-cavitated by clinical examination or restricted to enamel by FOTI or radiographic examinations in a population of children with low caries prevalence, dentists should adopt a preventive approach.     

Attitudes and expectations of treating deep caries: a PEARL Network survey

A survey was conducted within a practice-based dental research network to determine dentists' treatment methods for deep caries lesions and whether the dentists' intended treatment approaches were influenced by their expectations for pulpal exposure. The survey further examined how general dentistry practices have adopted scientific evidence of caries classification, excavation, and capping techniques. Dentists were queried regarding liner use, hypersensitivity considerations, point of endodontic therapy, and anticipated vitality outcomes from Class I resin-based composite restorations over three to five years. Of the 93 practitioner-investigators who were in the network at the time of the survey, 85 (92%) completed it. Of those who responded, 62% said that they would remove all caries when presented with a case in which one would expect pulpal exposure, while 18% would partially remove caries and 21% would initiate endodontic treatment; 17% reported that they would utilize an antimicrobial agent before a liner or bonding agent during restoration. The outcomes projected for tooth vitality over the next three to five years were equivalent regardless of the caries removal approach or the use of a liner/bonding agent. When beginning the preparation, the method of treatment did not change if a pulpal exposure was anticipated, other than a threefold increase in immediate endodontic treatment. When dentists were given a direct pulp cap scenario, the projected use of a liner/bonding agent changed little while the vitality projections decreased. Overall survey findings indicate that approximately 20% of network dentists favor partial caries removal techniques and that deep caries treatment outcome studies are warranted, given the various treatments employed.     

Clinical diagnosis of dental caries: a North American perspective.

This paper summarizes current trends in the clinical diagnosis of occlusal caries in response to the RTI/UNC review and reflects the dilemma felt by many dentists who understand the difficulty in accurately assessing the extent and activity of pit and fissure caries in many of their patients. They are unsure if they should be aggressive in instrumenting suspicious lesions and provide small restorations, some of which may not be indicated. Alternatively, should they wait until signs are more clear-cut and provide larger restorations? Discussed here is the advantage of practicing dentists who obtain immediate false-positive feedback when they instrument a tooth with no clinical caries and false-negative feedback when a recall patient exhibits progression of an equivocal lesion. They should be encouraged to use this feedback as part of their diagnostic procedure and explain to their patients the difficulty of providing an accurate and precise diagnosis with existing tests.     

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.     

The role of remineralizing agents in dentistry: a review

Minimal intervention is a key phrase in today's dental practice. Minimal intervention dentistry (MID) focuses on the least invasive treatment options possible in order to minimize tissue loss and patient discomfort. Concentrating mainly on prevention and early intervention of caries, MID's first basic principle is the remineralization of early carious lesions, advocating a biological or therapeutic approach rather than the traditional surgical approach for early surface lesions. One of the key elements of a biological approach is the usage and application of remineralizing agents to tooth structure (enamel and dentin lesions). These agents are part of a new era of dentistry aimed at controlling the demineralization/ remineralization cycle, depending upon the microenvironment around the tooth. This article details the various agents that enhance and/or promote remineralization and discusses their clinical implications.     

Conservative treatment of the Class I lesion: a new paradigm for dentistry

BACKGROUND: A shift is occurring in dentistry that involves a change from reliance on gross mechanical instrumentation of dental caries to early diagnosis and treatment of the bacterial infection that causes caries. TYPES OF STUDIES REVIEWED: The author explores the topic of minimally invasive dentistry, and cites several studies that offer scientific evidence of the effectiveness of this approach. The author also examines the role of third-party payers, who are reluctant to provide reimbursement for sealants or treatment of incipient caries. CONCLUSIONS: As dentists embrace a new paradigm in the treatment of the Class I lesion, they are beginning to acknowledge their role as clinical cariologists with the means to accurately assess the extent and threat of existing disease, determine the appropriate clinical response, provide minimally invasive treatment and unambiguously describe services rendered. CLINICAL IMPLICATIONS: As evidence-based protocols become more widely accepted, dentistry will have the necessary tools to interact with third parties, which also are struggling to cope with and adapt to an emerging standard of care.     

Decision making of Hebrew University and Tel Aviv University Dental Schools graduates in every day dentistry--is there a difference?

This study was designed to evaluate decision-making among Jerusalem Hebrew-University and Tel Aviv University dental schools graduates in various restorative dentistry, endodontics and oral surgery issues. A survey was conducted among 52 dentists during a dental military convention. Most of the dentists stated they will not recommend of re-treatment of endodontic-treated tooth with asymptomatic peri-apical pathology that does not need further rehabilitation. The study reveals over treatment and over-medication in restorative and surgery decisions. More than half of the dentists decided to treat caries lesions that extend to the dentino enamel junction, in low and moderate caries risk patients. More Hebrew University graduates than Tel Aviv University graduates recommend of removal of asymptomatic horizontal fully impacted mandibular third molar and disease-free maxillary third molar antagonist. Most of Tel Aviv graduates routinely prescribe antibiotic coverage after complicated tooth extraction. This study supports the need for continuing education on daily performed dental procedures.     

Should deciduous teeth be restored? Reflections of a cariologist

Whether deciduous teeth should be restored has caused controversy for at least 150 years and the argument rages on. Dental caries is a controllable process. The role of operative dentistry and restorations, as far as caries control is concerned, is to make cavitated, uncleansible lesions accessible to plaque control. However, deciduous teeth are exfoliated and perhaps non-operative treatments (plaque control, fluoride, diet) are all that are required to take cavitated teeth pain-free to exfoliation. Are such techniques child-friendly, obviating the need for anaesthesia or the use of handpieces? Alternatively, are they wanton neglect? This paper is written by a cariologist who never treated children, to present alternative managements and rehearse these arguments from a cariological perspective. Clinical Relevance: This paper might serve as a discussion document for a group of dentists deciding practice policy with regard to the management of caries in deciduous teeth.     

Iatrogenesis in the treatment of dental caries.

Traditional restorative dental treatment has many shortcomings and has not been shown to be an effective method for managing caries. In spite of this, many dentists continue to be powered by an aggressive restorative approach which, in the light of changing "rules" of operative dentistry, must now be seen as inappropriate and as a form of iatrogenesis. Many things have changed in recent years, including: the prevalence of caries; understanding of the science of the caries process; a fuller appreciation of the problems inherent in restoring teeth; cavity design; restorative materials; and the demands of patients. Dental practice needs to change very dramatically if iatrogenesis is truly to be reduced to a minimum and dentistry is to provide the sort of preventive-based care the modern consumer is increasingly realising makes most sense.     

Minimal intervention concept: a new paradigm for operative dentistry

The current treatment philosophy is to prevent and detect dental disease at the earliest stage in order to avoid invasive treatment. With the current understanding of the nature of dental disease and its process, the treatment philosophy is now changing to a more conservative approach and the concept of minimal intervention is gaining popularity in modern dentistry throughout the world. It is now established that demineralized but non-cavitated enamel and dentine can be healed and traditional surgical approach of drilling and filling may no longer be necessary as this only treats the symptoms of the disease and not the cause. However, when surgical intervention is indicated, the least invasive techniques such as preventive resin restoration and minimal cavity preparation are utilized. The aim of this article is to give dental professionals an overview of the concepts of minimal intervention dentistry and recent innovations in dental technology in both the diagnosis and treatment of dental caries.     

Restorative treatment strategies reported by French university teachers

Disparities among dental schools concerning the teaching and practice of cariology and operative dentistry can lead to variations in students' treatment modalities that can have health and economic consequences for patients and third party providers. The purpose of this study was to assess caries management strategies taught in French dental schools employing a questionnaire used in a previous study involving private dentists. The study population consisted of 180 teachers of operative dentistry. Each teacher received a questionnaire and a reply-paid envelope. The questionnaire assessed their treatment strategies, knowledge and beliefs about selected aspects of diagnosis, and treatment of dental caries. After one reminder, the response rate was 49.1 percent. The results illustrate a wide disparity among French teachers concerning restorative treatment thresholds for approximal surfaces, opinions about the rate of caries progression, and the need to monitor lesions near the DEJ. The teachers' attitudes differed from those of private practitioners: they tended to intervene surgically at a later stage, but they would intervene earlier in the treatment of the carious process than would Scandinavian dentists. This study may help in encouraging dental faculties to develop a consensus on issues related to diagnosis and management of dental caries.     

Caries management decision: Influence of dentist and patient factors in the provision of dental services

Objectives

Little is known about how dentists implement caries management and provide restorative dental services in everyday practice. This study explored whether or not recent concepts in caries management were implemented in practice by private practitioners. The influence of patient and practitioner characteristics on the provision of restorative dental services was also investigated through multidimensional analyses.

Methods

A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth. The data collection form was designed to explore dentists’ attitudes towards caries management and their use of minimally invasive therapies.

Results

Twenty-six practitioners recorded the characteristics of 921 treatments performed on 457 patients. Results indicate that participants rarely performed non-invasive treatments. They used an inappropriate detection tool, as most of decisions to treat were based on visual inspection frequently associated with probing. Multidimensional analysis showed that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice.

Conclusions

Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors.