The prevention of dental caries and periodontal disease from the cradle to the grave: what is the best available evidence?

Increasing weight is being given to applying an evidence-based approach to clinical practice. There is evidence to support a range of preventive measures which the profession and patients can apply to maximize the control of caries and periodontal disease. This paper examines the strength of evidence to support the advice and procedures that may be used by dental professionals to provide an effective preventive programme of advice and procedures for patients of all ages. A hierarchy of evidence is used ranging from Cochrane Reviews at the top, observational studies in the middle, and opinion at the bottom. Whilst the evidence to support preventive advice and procedures in children and adolescents is relatively strong, few studies have been conducted in adults and the elderly.     

Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects?

The most widely used sugar alcohols are: xylitol, sorbitol, mannitol, maltitol, lactitol and the products Lycasin and Palatinit. It is often claimed that xylitol is superior to the other sugar alcohols for caries control. This paper examines clinical studies on the caries-preventive and therapeutic effects of sugar alcohols with emphasis on sorbitol and xylitol. It is concluded that chewing sugar-free gum 3 or more times daily for prolonged periods of time may reduce caries incidence irrespective of the type of sugar alcohol used. It may be sufficient to do this only on school days. Sucking xylitol-containing candies or tablets may have a similar effect as chewing xylitol chewing gum. Clinical trials suggest greater caries reductions from chewing gums sweetened with xylitol than from gums sweetened with sorbitol. However, the superiority of xylitol was not confirmed in 2 out of 4 clinical trials comparing the caries-preventive effect of xylitol- with sorbitol-sweetened gums. The caries-preventive effects of polyol-containing gums and candies seem to be based on stimulation of the salivary flow, although an antimicrobial effect cannot be excluded. There is no evidence for a caries-therapeutic effect of xylitol. These conclusions are in line with those of recent reviews and with the conclusions of the Scientific Committee on Medicinal Products and Medical Devices of the EU Commission.     

Manual versus powered toothbrushes: what is the evidence?

Powered toothbrushes are a significant segment of the oral care market. Numerous clinical trials have compared the effectiveness of manual and powered toothbrushes for their effectiveness in improving oral health and the results are often conflicting. Recent Systematic Reviews by the Cochrane Oral Health Group have distilled this information and provided unbiased conclusions, namely that: powered toothbrushes with an oscillating rotating action are more effective than manual toothbrushes in reducing plaque and gingivitis; other types of powered toothbrushes produced less consistent reductions in plaque and gingivitis than manual brushes. Further studies are required to determine the relative effectiveness of manual and powered toothbrushes in improving the status of patients with periodontitis. CLINICAL RELEVANCE: This review provides the dental professional with an unbiased summary of current evidence regarding the relative effectiveness of manual and powered toothbrushes.     

Mechanical versus chemical retention for restoring complex restorations: what is the evidence?

This article reports the findings from a study conducted to answer this research question: can adhesive resin liners provide retention that is the same as dentinal pins or pots and slots when restoring complex amalgam restorations? The study methodology consisted of two components: a review of the literature and a survey to assess methods and materials that general practitioners use in their clinical practice for restoring complex amalgam restorations. Even though a vast majority of the general practitioners surveyed reported using dentinal pins or pots and slots, the occurrence or frequency of use was under 50 percent. It was also reported from the survey that over half the respondents are using adhesive resin liners exclusively when restoring complex restorations. New and improved materials allow general practitioners to restore complex restorations without the risks associated with the placement of pins or pots and slots. A review of the available literature indicates that adhesive resin liners may be used as an alternative or adjunct to mechanical retention. Because of the improvements of bonding strength of adhesive resin liners, dentinal pins and pots and slots should not be the only methods considered when faculty assist students in the development of treatment plans for patients who need complex amalgam restorations.     

What is the current evidence for antibiotic prophylaxis in orthopaedic surgery?

Surgical site infections (SSI) continue to represent a significant postoperative burden. SSI is associated with an increased risk of morbidity and mortality. Systemic antibiotic prophylaxis (SAP) is used to reduce the risk of SSI. Several factors must be considered for appropriate antibiotic use: antibiotic selection, timing, and duration. The evidence and use of antibiotics differs between closed fractures, open fractures, arthroplasty and percutaneous fixation. The use of SAP is a balance between reducing the incidence of SSI whilst maintaining proper antibiotic stewardship to limit adverse effects and the emergence of antibiotic resistance. This paper will discuss the evidence for the use of SAP in orthopaedic surgery and the potential adverse effects of the injudicious use of antibiotics.     

Emerging technologies for the prevention of dental caries. Are current methods of prevention sufficient for the high risk patient?

Fluorides and chlorhexidine are technologies that are 65 and 40 years old, respectively. This overview argues that current methods of caries prevention are not effective for the high caries risk patient. In this review examples, arguments and recommendations are provided to address the high caries risk patient that include: failure of comprehensive chemical modalities treatments to address the high caries risk patient; ecological alteration - would this be an effective approach?; and biomaterials and oral microbiome research to address the high caries risk patient.     

What is the evidence for paediatric dental sedation?

BACKGROUND AND RATIONALE: Sedation can be used to relieve anxiety and manage behaviour in children, unfortunately it is difficult to determine from published research which agents, dosages and techniques are effective. OBJECTIVE: To evaluate the relative efficacy of the various conscious sedation techniques and dosages for behaviour management in paediatric dentistry. DESIGN AND KEY METHODS: Relevant databases and reference lists from articles were searched up to December 2005. Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in anxious children up to 16 years of age. RESULTS: Sixty-five studies were included with 3372 subjects in total. Overall quality of studies was found to be disappointing with poor reporting often the main problem. CONCLUSIONS: Authors were not able to reach any definitive conclusion on which was the most effective drug or method of sedation used for anxious children due to issues with the quality and validity of published studies to date.     

Salivary clinical data and dental caries susceptibility: is there a relationship?

Caries onset and progression is influenced by diverse bacterial, dietary, environmental, socioeconomic and physiological risk factors. The most significant markers include caries experience, the concentrations of mutans-group streptococci and lactobacilli, as well as protective factors, such as the buffering capacity of saliva. The aim of this study was to evaluate and compare caries risk factors. The salivary parameters determined include: buffer capacity, cariogenic bacteria counts, pH, flow rate and total protein content. Individual aspects including hygiene and diet habits were also considered. Results showed that the value corresponding to the difference of stimulated saliva pH and resting saliva pH is positively correlated with DMFT index. Lactobacilli were positively correlated with mutans streptococci, as previously described for caries diagnostics. However, the results of this study were inconclusive, showing that salivary tests parameters either as single test or even in combination are incapable of predicting caries emphasising the importance of saliva composition.     

How effective is ART in the management of dental caries?

The ART approach involves excavating cavitated dentine caries with hand instruments, then restoring the cavity and sealing any associated fissures and pits with an adhesive restorative material, resulting in a sealant restoration. Until recently, ART has mainly been used under field conditions, and thus the adhesive restorative material used has been glass ionomer which does not require mixing machines and curing lights. Since the inception of ART, a growing number of studies world-wide have taken place. A total of four studies have reported 3-year survival percentages for one-surface ART restorations. The highest 3-year survival percentage in permanent teeth was 88%, which is comparable to the 85% survival of one-surface amalgam restorations placed under the same field conditions after 3 years. The outcomes depend to some extent on the material used, operator experience and presence of caries. The presence of caries as a reason for failure was higher in the early than in the most recent studies. Only one study has reported on the use of ART restorations in the deciduous dentition. It is concluded that: a very large proportion of dentine lesions in the permanent teeth can be treated using the ART approach; the 3-year survival rate of the more recently placed one-surface ART restorations in permanent teeth was higher than that of ART restorations placed in the beginning; the survival of one-surface ART restorations in the permanent dentition with newer glass ionomers is comparable to that of one-surface conventional restorations placed using amalgam in a comparable setting after 3 years; more studies of longer duration are needed to confirm these findings; ART should be considered a caries treatment modality that benefits people; and educational courses need to be organised before the approach is applied in the clinic.     

Malocclusion and caries prevalence: is there a connection in the primary and mixed dentitions?

The purpose of this epidemiological cross-sectional study was to determine the prevalence of malocclusion and caries in children and to investigate whether a relationship exists between prevalence of caries and studied malocclusion. The study consisted of 8,864 preschool and schoolchildren with primary dentitions (mean age 4.5 years) and mixed dentitions (mean age 8.9 years). 1997 WHO dental caries criteria were applied to both groups. The existence of an increased caries risk was deducted from the dmft and DMFT indices related to age. Malocclusion in primary and mixed dentitions was classified into seven types. Fifty-seven percent of all children had some form of malocclusion. Prevalence of malocclusion increased and was significantly greater in the mixed dentition sample (p<0.001) than in the primary dentition sample. Seventy-four percent of children with primary dentitions and 23% of children with mixed dentitions had zero dmft and DMFT scores. Mean dmft indices in subjects with primary and mixed dentitions were 1.02 and 1.53, respectively. No positive correlation between prevalence of caries and malocclusion could be established in the sub sample with primary teeth only. However, statistically significant parallelism in prevalence of malocclusion and caries were found for posterior cross-bite (p=0.050) and mandibular overjet (p=0.013) in children with mixed dentitions.     

Palpation of the lateral pterygoid region in TMD--where is the evidence?

OBJECTIVE: Palpation of the lower head of the lateral pterygoid muscle is included in many study protocols and examination schemes of the masticatory system. The aim of this investigation was to search the medical/dental literature to find evidence for the validity and reliability of this diagnostic procedure. METHODS: A systematic search was carried out using different electronic databases (Medline Ovid, PubMed, Cochrane Library, Embase, Current Contents Connect, Science Citation Index, Web of Science, Japana Centra Revuo Medicina), supplemented by handsearch in selected journals and by examination of the bibliographies of the identified articles. RESULTS: Validity: As far as the palpability of the inferior head of the lateral pterygoid muscle is concerned, five publications representing four studies could be identified. According to these investigations, the lateral pterygoid muscle is practically inaccessible for intraoral palpation due to topographical and anatomical reasons. Other anatomical structures, such as the superficial head of the medial pterygoid muscle, may be palpated instead in this region. Reliability: Determination of the palpability of the lateral pterygoid muscle is characterized by poor interexaminer agreement. Studies investigating the presence of pain in response to palpation of the lateral pterygoid area revealed a moderate intra- and interindividual reliability. Because of the tenderness of the lateral pterygoid region even among healthy subjects, positive findings may lead to wrong conclusions with regard to the need of treatment. CONCLUSIONS: Considering the lack of validity and reliability associated with the palpation of the lateral pterygoid area, this diagnostic procedure should be discarded.