Soraya Coelho Leal

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.

Untreated Cavitated Dentine Lesions: Impact on Children’s Quality of Life

The aim of the present investigation was to assess the impact of dental caries prevalence and the consequences of untreated cavitated dentine lesions on quality of life of 6- and 7-year-old Brazilian children. A total of 826 schoolchildren were assessed using ICDAS and pufa (to score consequences of dental caries on soft tissues) indices. History of extraction and toothache was recorded. Oral health-related quality of life was assessed using the Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS). A multiple logistic regression model was used to analyze the relationship between the prevalence of dentine carious lesions, pufa, history of extraction and toothache with the B-ECOHIS scores. A total of 587 questionnaires were analyzed. The prevalence of cavitated dentine lesions and pufa was 74.8 and 26.2%, respectively. Some 21.8% of children reported toothache and 9.2% had had at least one tooth extraction. The chance (OR) for children with cavitated dentine lesions, pufa ≥1, history of extraction and toothache of having higher B-ECOHIS scores than those not affected was 1.90 (95% CI: 1.18–3.06), 6.26 (95% CI: 3.63–10.83), 6.87 (95% CI: 2.75–17.16) and 3.68 (95% CI: 2.12–6.39), respectively. Children’s quality of life was negatively influenced by untreated cavitated dentine lesions and their consequences.

Photodynamic therapy disinfection of carious tissue mediated by aluminum-chloride-phthalocyanine entrapped in cationic liposomes: an in vitro and clinical study.

Photodynamic therapy (PDT) is a technique employed in the treatment of several superficial infections, such as caries. PDT uses a non-toxic drug termed photosensitizer (PS) followed by light irradiation. The cytotoxic effects of the therapy are related to the production of reactive species produced after light activation of a photosensitizer, which reacts with surrounding molecules and disrupts several of the cells functions. Within this context, this study aimed to develop a clinical protocol involving PDT application mediated by aluminum-chloride-phthalocyanine (AlClPc) entrapped in cationic liposomes against cariogenic bacteria in caries lesions. Cationic liposomes were used to delivery AlClPc preferentially to bacterial cells due to the strong anionic superficial charges of these cell types. The results are represented in two fundamental steps: (1) in vitro evaluation of AlClPc delivery to cariogenic bacteria and pulp cells, as well as its potential phototoxicity; (2) a clinical study involving volunteer patients that were treated with the PDT protocol mediated by AlClPc-cationic liposome. The main results showed that the AlClPc-cationic liposome was preferentially absorbed by bacterial cells compared to eukaryotic dental pulp cells, and it was efficient in the reduction of microbial load from bacterial cultures. In addition, the clinical study showed a mean reduction of 82% of total bacterial in the treated cavities after PDT application. Taken together, the results presented in this study showed that the antimicrobial PDT protocol mediated by cationic liposomes containing AlClPc is safety for clinical application and is efficient in the reduction of bacterial load in caries lesions.

Medication in elderly people: its influence on salivary pattern, signs and symptoms of dry mouth

OBJECTIVE To compare stimulated and non-stimulated salivary flow, pH, buffering capacity and presence of signs and symptoms of hyposialie and xerostomia in elderly patients, with senile dementia using medication and healthy elderly subjects not using medication. METHODS Forty individuals (mean age: 68.5 years) were divided into two groups, according to the use (G1) or non-use (G2) of medication and the presence (G1) or absence (G2) of senile dementia. Data with reference to the general health condition, use of medication and the patients complaints were collected during anamnesis. Clinical examination identified signs associated with hyposialie and xerostomia. Stimulated and non-stimulated saliva flow, pH and buffering capacity were verified. RESULTS The stimulated saliva flow in both groups was below normal parameters. The drugs used by individuals in G1 showed xerostomic potential. Individuals with a higher consumption of xerostomic medication presented with dry and cracked lips. A significant negative relationship was found between drugs consumption and the buffering capacity (p < 0.001), and the resting saliva flow rate (p = 0.002). CONCLUSION The use of medication increases the chance that an elderly person may present signs related to xerostomia and alterations in stimulated saliva flow and buffering capacity.

Efficacy and Safety of an Intraoral Electrostimulation Device for Xerostomia Relief: A Multicenter, Randomized Trial

OBJECTIVE To evaluate the efficacy and safety of an intraoral electrostimulation device, consisting of stimulating electrodes, an electronic circuit, and a power source, in treating xerostomia. The device delivers electrostimulation through the oral mucosa to the lingual nerve in order to enhance the salivary reflex. METHODS The device was tested on a sample of patients with xerostomia due to Sjögrens syndrome and other sicca conditions in a 2-stage prospective, randomized, multicenter trial. Stage I was a double-blind, crossover stage designed to compare the effects of the electrically active device with the sham device, each used for 1 month, and stage II was a 3-month open-label stage designed to assess the long-term effects of the active device. Improvement in xerostomia severity from baseline was the primary outcome measure. RESULTS A total of 114 patients were randomized. In stage I, the active device performed better than the sham device for patient-reported xerostomia severity (P<0.002), xerostomia frequency (P<0.05), quality of life impairment (P<0.01), and swallowing difficulty (P<0.02). At the end of stage II, statistically significant improvements were verified for patient-reported xerostomia severity (P<0.0001), xerostomia frequency (P<0.0001), oral discomfort (P<0.001), speech difficulty (P<0.02), sleeping difficulty (P<0.001), and resting salivary flow rate (P<0.01). CONCLUSION Our findings indicate that daily use of the device alleviated oral dryness, discomfort, and some complications of xerostomia, such as speech and sleeping difficulties, and increased salivary output. The results show a cumulative positive effect of the device over the period of the study, from baseline to the end of the trial.

Sugar-free chewing gum and dental caries: a systematic review

Objective: To appraise existing evidence for a therapeutic / anti-cariogenic effect of sugar-free chewing gum for patients. Method: 9 English and 2 Portuguese databases were searched using English and Portuguese keywords. Relevant articles in English, German, Portuguese and Spanish were included for review. Trials were excluded on lack of randomisation, control group, blinding and baseline data, drop out rate >33%, no statistical adjustment of baseline differences and no assessment of clinically important outcomes. Reviews were excluded on lack of information, article selection criteria, search strategy followed, search keywords, searched databases or lack of study-by-study critique tables. In cases of multiple reports from the same study, the report covering the longest period was included. Two reviewers independently reviewed and assessed the quality of accepted articles. Results: Thirty-nine articles were included for review. Thirty were excluded and 9 accepted. Of the 9 accepted, 2 trials of reasonable and good evidence value did not demonstrate any anti-cariogenic effect of sugar-free chewing gum. However, 7 articles, with 1 of strong, and 6 of good evidence value, demonstrated anti-cariogenic effects of chewing Sorbitol, Xylitol or Sorbitol/Xylitol gum. This effect can be ascribed to saliva stimulation through the chewing process, particularly when gum is used immediately after meals; the lack of sucrose and the inability of bacteria to metabolize polyols into acids. Conclusion: The evidence suggests that sugar-free chewing gum has a caries-reducing effect. Further well-designed randomised trials are needed to confirm these findings.

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 correct use of the ART approach.

Confusion exists amongst dentists and scientists about the correct use of the caries management approach termed atraumatic restorative treatment (ART). Inconsistent use of the original definition of ART and suggested modifications (mART) have led to misunderstanding, misconception and miscommunication in the dental literature over the last decade. The aim of this paper is to contribute to a uniform understanding and use of the term ART. Adherence to its original description is suggested and two major aspects were addressed: the use of hand instruments only and the use of adhesive materials and systems.

Prevalence and severity of clinical consequences of untreated dentine carious lesions in children from a deprived area of Brazil.

Disadvantaged children suffer because tooth cavities are not being treated and their clinical consequences not being surveyed. The present study aimed to assess the prevalence and severity of clinical consequences of untreated dentine carious lesions in schoolchildren from a deprived area of Brazil and to investigate the determinants of the pufa index. A sample of 835 children aged 6–7 years, from six public schools, was examined by 3 calibrated examiners. Clinical consequences of untreated dentine carious lesions in primary teeth were diagnosed using the four codes of the pufa index: ‘p’ (pulpal involvement), ‘u’ (ulceration), ‘f’ (fistulae), ‘a’ (abscess). Effects of gender, age, school, history of extraction, and toothache on the prevalence of pufa codes were tested. The prevalence of pufa codes was 23.7%. The mean pufa score was 0.4 ± 0.9. Code ‘p’ was the most prevalent (19.5%), whereas code ‘u’ was least prevalent (0.1%). Children with a history of extracted primary teeth due to caries had a 2.7 times higher chance to have a pufa code than children with no previous extraction. Children with toothache had a 5.6 times higher chance to have a pufa code than children without toothache. The prevalence of clinical consequences of untreated dentine carious lesions was moderate and the severity was low. The pufa index is an epidemiological tool complementary to existing caries indices aimed to assess dental caries. However, there appears to be no need to include code ‘u’ nor to score codes ‘f’ and ‘a’ separately.

Validity of MicroCT for in vitro detection of proximal carious lesions in primary molars

OBJECTIVE This study aimed to validate the MicroCT for detection of proximal carious lesions in primary molars, using histology as the gold standard. METHODS Forty-eight proximal surfaces of primary molars were examined. Two calibrated examiners conducted the examinations independently. Proximal surfaces were visually scored, using ICDAS. Bitewing radiographs, Micro-CT and histological analyses used caries scores: 0=sound; 1=outer enamel; 2=inner enamel; 3=not spread dentine; 4=outer dentine; 5=inner dentine. Axial and sagital images were used for Micro-CT analysis, whilst for histology, tooth sections (400μm) were analyzed stereomicroscopically (×15). RESULTS Inter-examiner agreement ranged from 0.87 to 0.93 kappa coefficient (k). Histological analysis revealed a frequency of sound tooth surfaces (18.8%) enamel carious lesions (E1) (48%) and dentine carious lesions (D1) (33.3%). MicroCT showed high correlation with histology (r(s)0.88). At both diagnostic thresholds (E1 and D1), sensitivity and accuracy were higher for MicroCT. Inter-device agreement between MicroCT and histology was k=0.81. No difference was found between MicroCT and histology as gold standards for detecting carious lesions using ICDAS. CONCLUSION MicroCT can be used as a gold standard for detecting carious lesions in proximal surfaces in primary molars.