Jean-Pierre Attal

Clinical efficacy of composite versus ceramic inlays and onlays: A systematic review

OBJECTIVES Large tooth substance losses are frequent in posterior teeth because of primary caries or aging restorations. Inlays and onlays are often the minimal invasive solution in such cases, but the efficacy of the composite and ceramic materials used is unknown. We performed a systematic review of randomized controlled trials comparing the efficacy of composite and ceramic inlays or onlays. DATA SOURCES MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched without any restriction on date or language, as were references of eligible studies and ClinicalTrials.gov. STUDY SELECTION Eligible studies were randomized trials comparing the clinical efficacy of composite to ceramic inlays or onlays in adults with any clinical outcome for at least 6 months. From 172 records identified, we examined reports of 2 randomized controlled trials involving 138 inlays (no onlays evaluated) in 80 patients and exhibiting a high-risk of bias. Outcomes were clinical scores and major failures. The 3-year overall failure risk ratio was 2 [0.38-10.55] in favor of ceramic inlays although not statistically significant. The reported clinical scores (United States Public Health Services and Californian Dental Association) showed considerable heterogeneity between trials and could not be combined. CONCLUSIONS We have very limited evidence that ceramics perform better than composite material for inlays in the short term. However, this result may not be valid in the long term, and other trials are needed. Trials should follow Fédération dentaire internationale recommendations and enhance their methodology. Trials comparing composite and ceramic onlays are needed.

Development of a Core Set of Outcomes for Randomized Controlled Trials with Multiple Outcomes – Example of Pulp Treatments of Primary Teeth for Extensive Decay in Children

Objectives Evidence-based comparisons of interventions can be challenging because of the diversity of outcomes in randomized controlled trials (RCTs). We aimed to describe outcomes in RCTs assessing pulp treatments for primary teeth and to develop a core set of component outcomes to be part of composite outcome defining the failure of a pulp treatment. Methods We systematically reviewed articles of RCTs comparing pulp treatments for primary molars published up to February 2012. We abstracted all outcomes assessed in each trial, then used a small-group consensus process to group similar outcomes, which were reduced to a composite outcome of failure of a pulp treatment by a 3-round Delphi process involving expert authors and dentists. Results We included 47 reports of RCTs in the review, for 83 reported outcomes (median 11 outcomes per RCT). These outcomes were grouped into 24 overarching outcome categories. We contacted 210 experts for the Delphi process and 25% to 30% participated. The process identified the following 5 component outcomes as part of a composite outcome of failure of a pulp treatment: soft-tissue pathology, pain, pathologic mobility, pathologic radiolucency and pathologic root resorption. Conclusions RCTs of pulp treatments for primary teeth investigate diverse outcomes. Our consensus process, involving clinicians but no patient, allowed for compiling a core set of component outcomes to define the composite outcome failure of a pulp treatment for primary teeth.

White defects on enamel: Diagnosis and anatomopathology: Two essential factors for proper treatment (part 1)

Early-stage caries (white spots), fluoroses, traumatic hypomineralizations and molar incisive hypomineralization (MIH) all present, to differing degrees, clinical symptoms involving white marks on the enamel. This article shows that proper diagnosis leads to better understanding of the three-dimensional aspects of the lesion, thereby ensuring the appropriate choice of a specific treatment.

White spots on enamel: treatment protocol by superficial or deep infiltration (part 2).

In this 2nd part, the current treatment of white spot lesions by erosion/infiltration is presented, beginning with a reminder of the principle of superficial infiltration, which enables most early carious lesions, fluorosis and post-traumatic lesions to be treated. However, this technique has met with frequent failures in cases of MIH or deep lesions of traumatic origin or those associated with fluorosis. For this reason a new deep infiltration technique is proposed: thanks to its global treatment concept, this enables all white spots to be treated. The place of whitening in these treatment options is discussed, with explanations of the main reasons for its failures.

Randomization in clinical trials: stratification or minimization? The HERMES free simulation software

ObjectivesOperative clinical trials are often small and open-label. Randomization is therefore very important. Stratification and minimization are two randomization options in such trials. The first aim of this study was to compare stratification and minimization in terms of predictability and balance in order to help investigators choose the most appropriate allocation method. Our second aim was to evaluate the influence of various parameters on the performance of these techniques.Materials and methodsThe created software generated patients according to chosen trial parameters (e.g., number of important prognostic factors, number of operators or centers, etc.) and computed predictability and balance indicators for several stratification and minimization methods over a given number of simulations. Block size and proportion of random allocations could be chosen. A reference trial was chosen (50 patients, 1 prognostic factor, and 2 operators) and eight other trials derived from this reference trial were modeled. Predictability and balance indicators were calculated from 10,000 simulations per trial.ResultsMinimization performed better with complex trials (e.g., smaller sample size, increasing number of prognostic factors, and operators); stratification imbalance increased when the number of strata increased. An inverse correlation between imbalance and predictability was observed.ConclusionsA compromise between predictability and imbalance still has to be found by the investigator but our software (HERMES) gives concrete reasons for choosing between stratification and minimization; it can be downloaded free of charge.Clinical relevanceThis software will help investigators choose the appropriate randomization method in future two-arm trials.

HEMA release and degree of conversion from a resin-modified glass ionomer cement after various delays of light activation.

OBJECTIVE The setting of resin-modified glass ionomer cements (RMGIC) involves the acid-base reaction and the polymerization of HEMA monomers. Each setting mechanism may compete with the other. The aim of this study was to determine an optimum polymerization after various delays of light-activation, to minimize the release of free HEMA and to better understand the setting mechanism of RMGICs. The null hypothesis tested was: increasing the delay before light-activation of an RMGIC has no effect on HEMA release and on its degree of conversion (DC). METHODS Five groups were investigated: (a) control group with no light-curing; (b) light-curing delayed 1 min after mixing; (c) delayed 5 min; (d) delayed 10 min; (e) delayed 15 min. For each, HEMA release was analyzed with high performance liquid chromatography at 1 h, 6 h, 24 h, 7 days, 14 days and 28 days and the DC was tested by ATR-FTIR spectrometer. Data were analysed by one-way ANOVA, followed by Scheffe multiple mean comparisons. RESULTS A delay in light-activation caused a significant increase in the cumulative HEMA release. The highest release was determined for the group without light-curing. The DC increased significantly when the delay was increased, until a maximum value for 10 min delay, then decreased when the delay was more extended, with a minimum value for the group without light-curing. SIGNIFICANCE A short delay before light-curing could limit the HEMA release and could be more biocompatible. The results highlighted the competition between the acid-base and the polymerization reactions. They also showed there is no correlation between the monomer release and the DC.

A New Method Combining Finite Element Analysis and Digital Image Correlation to Assess Macroscopic Mechanical Properties of Dentin

A literature review points out a large discrepancy in the results of the mechanical tests on dentin that can be explained by stress and strain assessment during the tests. Errors in these assessments during mechanical tests can lead to inaccurate estimation of the mechanical properties of the tested material. On top of that, using the beam theory to analyze the bending test for thick specimens will increase these experimental errors. After summarizing the results of mechanical tests on dentin in the literature, we focus on bending tests and compare the stress assessment obtained by finite element analysis (FEA) and by beam theory application. We show that the difference between the two methods can be quite large in some cases, leading us to prefer the use of FEA to assess stresses. We then propose a new method based on coupling finite element analysis and digital image correlation (DIC) to more accurately evaluate stress distributions, strain distributions and elastic modulus in the case of a three-point bending test. To illustrate and prove the feasibility of the method, it is applied on a dentinal sample so that mean elastic modulus and maximum tensile stress are obtained (11.9 GPa and 143.9 MPa). Note that the main purpose of this study is to focus on the method itself, and not to provide new mechanical values for dentin. When used in standard mechanical testing of dentin, this kind of method should help to narrow the range of obtained mechanical properties values.

Efficacy of composite versus ceramic inlays and onlays: study protocol for the CECOIA randomized controlled trial.

BackgroundDental caries is a common disease and affects many adults worldwide. Inlay or onlay restoration is widely used to treat the resulting tooth substance loss. Two esthetic materials can be used to manufacture an inlay/onlay restoration of the tooth: ceramic or composite. Here, we present the protocol of a multicenter randomized controlled trial (RCT) comparing the clinical efficacy of both materials for tooth restoration. Other objectives are analysis of overall quality, wear, restoration survival and prognosis.MethodsThe CEramic and COmposite Inlays Assessment (CECOIA) trial is an open-label, parallel-group, multicenter RCT involving two hospitals and five private practices. In all, 400 patients will be included. Inclusion criteria are adults who need an inlay/onlay restoration for one tooth (that can be isolated with use of a dental dam and has at least one intact cusp), can tolerate restorative procedures and do not have severe bruxism, periodontal or carious disease or poor oral hygiene. The decayed tissue will be evicted, the cavity will be prepared for receiving an inlay/onlay and the patient will be randomized by use of a centralized web-based interface to receive: 1) a ceramic or 2) composite inlay or onlay. Treatment allocation will be balanced (1:1). The inlay/onlay will be adhesively luted. Follow-up will be for 2 years and may be extended; two independent examiners will perform the evaluations. The primary outcome measure will be the score obtained with use of the consensus instrument of the Fédération Dentaire Internationale (FDI) World Dental Federation. Secondary outcomes include this instrument’s items, inlay/onlay wear, overall quality and survival of the inlay/onlay. Data will be analyzed by a statistician blinded to treatments and an adjusted ordinal logistic regression model will be used to compare the efficacy of both materials.DiscussionFor clinicians, the CECOIA trial results may help with evidence-based recommendations concerning the choice of materials for inlay/onlay restoration. For patients, the results may lead to improvement in long-term restoration. For researchers, the results may provide ideas for further research concerning inlay/onlay materials and prognosis.This trial is funded by a grant from the French Ministry of Health.Trial registrationClinicalTrials.gov Identifier:NCT01724827

Effect of Chlorhexidine Application on the Long-term Shear Bond Strength to Dentin of a Resin-modified Glass Ionomer

PURPOSE The aim of this study was to investigate the effect of chlorhexidine digluconate (CHX) application on the shear bond strength (SBS) of a resin-modified glass ionomer cement (RMGIC) to polyalkenoic acid-preconditioned dentin after 24 hours, six months, and 12 months of water storage at 37°C. MATERIALS AND METHODS Cylindrical molds, placed on flat, polyalkenoic acid (Cavity Conditioner® [GC]) preconditioned dentin surfaces of 90 human teeth embedded in resin, were filled with Fuji II LC® (GC), a RMGIC, with (n=45) or without (n=45) the prior application of a 0.05% CHX solution. Within each group, SBS was determined after 24 hours (n=15), six months (n=15), and 12 months (n=15) of storage in water at 37°C. The results were analyzed with two-way analysis of variance followed by Tukey multiple means comparisons (p<0.05). The type of bond failure (adhesive/cohesive/mixed) was noted and the results were analyzed with chi-square test (p<0.05). RESULTS After 24 hours, the SBS of RMGIC was not significantly different with (9.0 ± 2.8 MPa) or without (8.3±0.6 MPa) the application of CHX. After six months, however, SBS increased significantly in the group without CHX (12.7±3.4 MPa) but remained unchanged in the CHX group (9.4±4.0 MPa). Similar results without CHX (12.6±3.8 MPa) and with CHX (9.5±3.2 MPa) were obtained after 12 months. No significant differences in the type of debonding were found between the various groups tested. CONCLUSION The application of 0.05% CHX after dentin preconditioning did not seem to have affected the 24-hour SBS of RMGIC. However, the six- and 12-month SBS was significantly lower for CHX-treated samples, possibly as a result of CHX interference with both the bonding mechanism and the maturation reaction of RMGIC.

Three-dimensional pore-scale modelling of dentinal infiltration.

Dentine is the fundamental substrate of restorative dentistry, and its properties and characteristics are the key determinants of restorative processes. In contemporary restorative techniques, bonding to Dentine is created by the impregnation of the demineralised dentine by blends of resin monomers. In this paper, a numerical model of dentinal infiltration is proposed. The aim is to follow the resin front and to point out the optimal parameter set. The main tool is a level set technique to follow the evolving interface. It is coupled with the Navier–Stokes equation where capillary effect gives rise to the appearance of a new term in the variational approach than discretised by finite elements. Using an appropriate geometry representing demineralised dentine, the moving front is observed. First, a simulation of porosimetry test is achieved in order to validate the model. The two expected pore sizes are detected and the simulation also points out limitations of mercury intrusion porosimetry test in an educational way. Then a wetting fluid (representing the dental resin) is numerically infiltrated. In the dentinal porous network, capillarity is taken into account in our model by including a capillary term. A crucial conclusion is drawn from this study: resin application time by practitioners is sufficient if, in the infiltration process, the wetting phase is the resin.