Sophie Doméjean

Managing Carious Lesions: Consensus Recommendations on Carious Tissue Removal

The International Caries Consensus Collaboration undertook a consensus process and here presents clinical recommendations for carious tissue removal and managing cavitated carious lesions, including restoration, based on texture of demineralized dentine. Dentists should manage the disease dental caries and control activity of existing cavitated lesions to preserve hard tissues and retain teeth long-term. Entering the restorative cycle should be avoided as far as possible. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious lesions either are noncleansable or can no longer be sealed are restorative interventions indicated. When a restoration is indicated, the priorities are as follows: preserving healthy and remineralizable tissue, achieving a restorative seal, maintaining pulpal health, and maximizing restoration success. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissues close to the pulp do not need to be removed. In deeper lesions in teeth with sensible (vital) pulps, preserving pulpal health should be prioritized, while in shallow or moderately deep lesions, restoration longevity becomes more important. For teeth with shallow or moderately deep cavitated lesions, carious tissue removal is performed according to selective removal to firm dentine. In deep cavitated lesions in primary or permanent teeth, selective removal to soft dentine should be performed, although in permanent teeth, stepwise removal is an option. The evidence and, therefore, these recommendations support less invasive carious lesion management, delaying entry to, and slowing down, the restorative cycle by preserving tooth tissue and retaining teeth long-term.

Managing Carious Lesions: Consensus Recommendations on Terminology

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided. Dental caries is the name of the disease, and the carious lesion is the consequence and manifestation of the disease—the signs or symptoms of the disease. The term dental caries management should be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereas carious lesion management controls the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions’ clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1) selective removal of carious tissue—including selective removal to soft dentine and selective removal to firm dentine; 2) stepwise removal—including stage 1, selective removal to soft dentine, and stage 2, selective removal to firm dentine 6 to 12 mo later; and 3) nonselective removal to hard dentine—formerly known as complete caries removal (technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

The contemporary approach to tooth preservation: minimum intervention (MI) caries management in general practice.

The minimum intervention (MI) approach summarises a clinical, evidence-based rationale for the preventive and cause-related approach to oral diseases in general and to caries in particular. MI oral care with respect to the management of patients suffering from dental caries is a concept based on an updated understanding of the histopathological carious process as well as the development of diagnostic technologies and adhesive, bioactive restorative materials. A patient-centred MI care plan for use in general dental practice is described, detailing the four phases of identifying disease, controlling/preventing disease, refurbishing/repairing tooth surfaces/restorations and recall consultations.

Caries risk/susceptibility assessment: its value in minimum intervention oral healthcare

This narrative review describes the intimate connection between minimum intervention (MI) oral healthcare and caries risk/susceptibility assessment (CRA). Indeed CRA is the corner stone of an MI care plan, allowing the determination of the appropriate interventions (non-invasive as well as invasive [restorative]) and recall consultation strategies. Various CRA protocols/models have been developed to assist the oral healthcare practitioner/team in a logical systematic approach to synthesising information about a disease that has a multifactorial aetiology. Despite the criticisms toward the lack of clear-cut validation of the proposed protocols/models, CRA still has great potential to enhance patient care by allowing the oral healthcare practitioner/team and the patient to understand the specific reasons for their caries activity and to tailor their care plans and recall intervals accordingly.

The use of FDI criteria in clinical trials on direct dental restorations: A scoping review

OBJECTIVES A scoping review was conducted to explore the use of FDI criteria 10 years after their introduction. The first aim was to compare the amount of studies using the FDI and/or the modified USPHS criteria. The second aim was to analyse the use of the FDI criteria in clinical trials evaluating direct dental restorations. DATA Listing of studies using FDI and/or USPHS criteria per year since 2007. Clinical studies related to the assessment of direct restorations using FDI criteria. SOURCE Two systematic searches - regarding the use of FDI and modified USPHS criteria - were carried out on Medline/Pubmed in order to identify the studies published between 2007 and 2017. Authors of the included articles were contacted to clarify their choice of FDI criteria in their studies. ClinicalTrials.gov database was also queried for the on-going studies that use FDI and modified USPHS criteria. STUDY SELECTION In the first review, all the clinical trials (randomized/non-randomized, controlled, prospective/retrospective studies) that used FDI criteria to evaluate direct restorations on primary or permanent teeth were included. CONCLUSIONS 16.3% of the studies used FDI criteria. The percentage of studies using them increased from 4.5% in 2010 to 50.0% in 2016. In average, 8.5 FDI criteria were used. The most employed criteria were: marginal adaptation (96.7%), staining (90.0%), fracture of material and retention (90.0%), recurrence of caries/erosion/abfraction (90.0%), post-operative sensitivity/tooth vitality (86.7%) and surface luster (60.0%). In addition, among the 27 on-going studies from ClinicalTrials.gov database, 51.9% use FDI criteria (including 87.5% with an open recruitment status). CLINICAL SIGNIFICANCE FDI criteria were reported as practical (various and freely selectable), relevant (sensitive as well as appropriate to current restorative materials and clinical studies design), standardized (making comparisons between investigations easier). Investigators should go on using them for a better standardization of their clinical judgment, allowing comparisons with other studies.

Invasive and Noninvasive Therapies

Prevention is the cornerstone of the concept of minimal intervention (MI) in dentistry in general and in cariology in particular. MI aims to prevent and intercept caries disease and to avoid relapses by acting on the modifiable pathological and protective risk factors mentioned above (Sheiham 2002).