Vita Machiulskiene

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.

Dental Caries Increments and Related Factors in Children with Type 1 Diabetes Mellitus

The aim of this study was to analyse possible associations between caries increments and selected caries determinants in children with type 1 diabetes mellitus and their age- and sex-matched non-diabetic controls, over 2 years. A total of 63 (10–15 years old) diabetic and non-diabetic pairs were examined for dental caries, oral hygiene and salivary factors. Salivary flow rates, buffer effect, concentrations of mutans streptococci, lactobacilli, yeasts, total IgA and IgG, protein, albumin, amylase and glucose were analysed. Means of 2-year decayed/missing/filled surface (DMFS) increments were similar in diabetics and their controls. Over the study period, both unstimulated and stimulated salivary flow rates remained significantly lower in diabetic children compared to controls. No differences were observed in the counts of lactobacilli, mutans streptococci or yeast growth during follow-up, whereas salivary IgA, protein and glucose concentrations were higher in diabetics than in controls throughout the 2-year period. Multivariable linear regression analysis showed that children with higher 2-year DMFS increments were older at baseline and had higher salivary glucose concentrations than children with lower 2-year DMFS increments. Likewise, higher 2-year DMFS increments in diabetics versus controls were associated with greater increments in salivary glucose concentrations in diabetics. Higher increments in active caries lesions in diabetics versus controls were associated with greater increments of dental plaque and greater increments of salivary albumin. Our results suggest that, in addition to dental plaque as a common caries risk factor, diabetes-induced changes in salivary glucose and albumin concentrations are indicative of caries development among diabetics.

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.

Caries Management Strategies for Primary Molars: 1-Yr Randomized Control Trial Results

Minimal invasive approaches to managing caries, such as partial caries removal techniques, are showing increasing evidence of improved outcomes over the conventional complete caries removal. There is also increasing interest in techniques where no caries is removed. We present the 1-yr results of clinical efficacy for 3 caries management options for occlusoproximal cavitated lesions in primary molars: conventional restorations (CR; complete caries removal and compomer restoration), Hall technique (HT; no caries removal, sealing in with stainless steel crowns), and nonrestorative caries treatment (NRCT; no caries removal, opening up the cavity, teaching brushing and fluoride application). In sum, 169 children (3-8 yr old; mean, 5.56 ± 1.45 yr) were enrolled in this secondary care–based, 3-arm, parallel-group, randomized clinical trial. Treatments were carried out by specialist pediatric dentists or postgraduate trainees. One lesion per child received CR, HT, or NRCT. Outcome measures were clinical failure rates, grouped as minor failure (restoration loss/need for replacement, reversible pulpitis, caries progression, etc.) and major failure (irreversible pulpitis, abscess, etc.). There were 148 children (87.6%) with a minimum follow-up of 11 mo (mean, 12.23 ± 0.98 mo). Twenty teeth were recorded as having at least 1 minor failure: NRCT, n = 8 (5%); CR, n = 11 (7%); HT, n = 1 (1%) (p = .002, 95% CI = 0.001 to 0.003). Only the comparison between NRCT and CR showed no significant difference (p = .79, 95% CI = 0.78 to 0.80). Nine (6%) experienced at least 1 major failure: NRCT, n = 4 (2%); CR, n = 5 (3%); HT, n = 0 (0%) (p = .002, 95% CI = 0.001 to 0.003). Individual comparison of NRCT and CR showed no statistically significant difference in major failures (p = .75, 95% CI = 0.73 to 0.76). Success and failure rates were not significantly affected by pediatric dentists’ level of experience (p = .13, 95% CI = 0.12 to 0.14). The HT was significantly more successful clinically than NRCT and CR after 1 yr, while pairwise analyses showed comparable results for treatment success between NRCT and CR (ClinicalTrials.gov NCT01797458).

Susceptibility of Endodontic Pathogens to Antibiotics in Patients with Symptomatic Apical Periodontitis

INTRODUCTION The aim of this study was to evaluate susceptibility of predominant endodontic pathogens isolated from teeth with symptomatic apical periodontitis to most commonly prescribed antibiotics. METHODS Among 58 patients with symptomatic apical periodontitis, 47 and 11 cases were caused by primary and secondary root canal infection, respectively. The microbial samples were taken either from the root canals (35 cases) or by aspiration from apical abscesses (23 cases). Culture methods were used to identify the microorganisms present in the samples. Antibiotic susceptibilities of all isolates were evaluated by using the E-test method. RESULTS Microorganisms were isolated from 49 of the 58 samples studied and included facultative and obligate anaerobes. Streptococci and obligate anaerobes were the predominant microorganisms in cases of primary infection. Enterococcus faecalis dominated in cases of secondary infection. All tested microorganisms were highly sensitive to penicillin G, amoxicillin, and ampicillin. Susceptibilities to clindamycin and erythromycin were 73.8% and 54.7%, respectively. About 40% of the isolates were resistant to tetracycline. More than 50% of all anaerobes were resistant to metronidazole. All E. faecalis isolates were resistant to clindamycin. CONCLUSIONS Based on the study results, penicillin and amoxicillin are suitable antibiotics for treatment of endodontic infection when conventional root canal treatment alone is insufficient. Clindamycin could be advised for penicillin-allergic patients with primary endodontic infections.

Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases

BACKGROUND The non-communicable diseases dental caries and periodontal diseases pose an enormous burden on mankind. The dental biofilm is a major biological determinant common to the development of both diseases, and they share common risk factors and social determinants, important for their prevention and control. The remit of this working group was to review the current state of knowledge on epidemiology, socio-behavioural aspects as well as plaque control with regard to dental caries and periodontal diseases. METHODS Discussions were informed by three systematic reviews on (i) the global burden of dental caries and periodontitis; (ii) socio-behavioural aspects in the prevention and control of dental caries and periodontal diseases at an individual and population level; and (iii) mechanical and chemical plaque control in the simultaneous management of gingivitis and dental caries. This consensus report is based on the outcomes of these systematic reviews and on expert opinion of the participants. RESULTS Key findings included the following: (i) prevalence and experience of dental caries has decreased in many regions in all age groups over the last three decades; however, not all societal groups have benefitted equally from this decline; (ii) although some studies have indicated a possible decline in periodontitis prevalence, there is insufficient evidence to conclude that prevalence has changed over recent decades; (iii) because of global population growth and increased tooth retention, the number of people affected by dental caries and periodontitis has grown substantially, increasing the total burden of these diseases globally (by 37% for untreated caries and by 67% for severe periodontitis) as estimated between 1990 and 2013, with high global economic impact; (iv) there is robust evidence for an association of low socio-economic status with a higher risk of having dental caries/caries experience and also with higher prevalence of periodontitis; (v) the most important behavioural factor, affecting both dental caries and periodontal diseases, is routinely performed oral hygiene with fluoride; (vi) population-based interventions address behavioural factors to control dental caries and periodontitis through legislation (antismoking, reduced sugar content in foods and drinks), restrictions (taxes on sugar and tobacco) guidelines and campaigns; however, their efficacy remains to be evaluated; (vii) psychological approaches aimed at changing behaviour may improve the effectiveness of oral health education; (viii) different preventive strategies have proven to be effective during the course of life; (ix) management of both dental caries and gingivitis relies heavily on efficient self-performed oral hygiene, that is toothbrushing with a fluoride-containing toothpaste and interdental cleaning; (x) professional tooth cleaning, oral hygiene instruction and motivation, dietary advice and fluoride application are effective in managing dental caries and gingivitis. CONCLUSION The prevention and control of dental caries and periodontal diseases and the prevention of ultimate tooth loss is a lifelong commitment employing population- and individual-based interventions.

Occlusal Caries: Biological Approach for Its Diagnosis and Management

The management of occlusal caries still remains a major challenge for researchers as well as for general practitioners. The present paper reviews and discusses the most up-to-date knowledge and evidence of the biological principles guiding diagnosis, risk assessment, and management of the caries process on occlusal surfaces. In addition, it considers the whole spectrum of the caries process on occlusal surfaces, ranging from the molecular ecology of occlusal biofilms to the management of deep occlusal caries lesions. Studies using molecular methods with focus on biofilms in relation to occlusal caries should explore the relationship between the function and the structural composition of these biofilms to understand the role of occlusal biofilms in caries development. State-of-the-art measures to evaluate risk for occlusal caries lesion activity, caries incidence, and progression should include the assessment of the occlusal biofilm and the stage of tooth eruption. Careful clinical examination of non-cavitated lesions, including assessment of the lesion activity status, remains the major tool to determine the immediate treatment need and to follow on the non-operative treatment outcome. Even medium occlusal caries lesions in the permanent dentition may be treated by non-invasive fissure sealing. By extending the criteria for non-invasive treatments, traditional restoration of occlusal surfaces can be postponed or even avoided, and the dental health in children and adolescents can be improved. Selective removal (incomplete) to soft dentin in deep carious lesions has greater success rates than stepwise excavation. Selective (complete) removal to firm dentin has a lower success rate due to increased pulp exposure.

Change in dental pulp parameters in response to different modes of orthodontic force application

OBJECTIVES (1) To evaluate dental pulp sensitivity by electrical pulp testing and measure aspartate aminotransferase activity in the pulp after 14 days of orthodontic intrusion, and (2) to compare those measurements with measurements obtained in teeth after 7 days of intrusion and 7 days of rest. MATERIALS AND METHODS The study sample included 13 subjects (mean age = 16.5 +/- 2.7 years). For every subject, before extraction, two contralateral premolars were included in a spring and loaded by a force. Two study groups were formed: Group A, teeth with 14 days of mechanical load, and Group B, teeth with 7 days of mechanical load plus 7 days of rest. Electrical pulp testing and aspartate aminotransferase activity measurements were performed after 14 days in all tested teeth. After extraction, aspartate aminotransferase activity in the pulp was determined spectrophotometrically at 20 degrees C. RESULTS Mean aspartate aminotransferase activity values were 0.21 U/mg (SD = 0.15) in Group A and 0.27 U/mg (SD = 0.17) in Group B. Mean electrical pulp testing readings were 38.92 microA (SD = 24.61) in Group A and 36.77 microA (SD = 26.84) in Group B. Mean values of the intrusive force magnitude did not differ in both groups. CONCLUSIONS Different durations of orthodontic intrusion, defined as 14 days of load and 7 days of load followed by 7 resting days, were not reflected by electrical pulp testing or by aspartate aminotransferase activity levels in the pulp of the affected teeth. However, the response threshold to electrical pulp stimulation was elevated in all tested teeth.

Alternative Caries Management Options for Primary Molars: 2.5-Year Outcomes of a Randomised Clinical Trial

Less invasive caries management techniques for treating cavitated carious primary teeth, which involve the concept of caries control by managing the activity of the biofilm, are becoming common. This study aimed to compare the clinical efficacy (minor/major failures) and survival rates (successful cases without any failures) of 3 carious lesion treatment approaches, the Hall Technique (HT), non-restorative caries treatment (NRCT), and conventional restorations (CR), for the management of occlusoproximal caries lesions (ICDAS 3-5) in primary molars. Results at 2.5 years are presented. A total of 169 children (3- to 8-year-olds) were enrolled in this secondary care-based, 3-arm parallel-group, randomised controlled trial. Participants were allocated to: HT (n = 52; sealing caries with stainless-steel crowns without caries removal), NRCT (n = 52; opening up the cavity and applying fluoride varnish), CR (n = 65; control arm, complete caries removal and compomer restoration). Statistical analyses were: non-parametric Kruskal-Wallis analysis of variance, Mann-Whitney U test and Kaplan-Meier survival analyses. One hundred and forty-two participants (84%; HT = 40/52; NRCT = 44/52; CR = 58/65) had follow-up data of 1-33 months (mean = 26). Overall, 25 (HT = 2, NRCT = 9, CR = 14) of 142 participants (17.6%) presented with at least 1 minor failure (reversible pulpitis, caries progression, or secondary caries; p = 0.013, CI = 0.012-0.018; Mann-Whitney U test). Ten (HT = 1, NRCT = 4, CR = 5) of 142 participants (7.04%) experienced at least 1 major failure (irreversible pulpitis, abscess, unrestorable tooth; p = 0.043, CI = 0.034-0.045). Independent comparisons between 2 samples found that NRCT-CR had no statistically significant difference in failures (p > 0.05), but for CR-HT (p = 0.037, CI = 0.030-0.040) and for NRCT-HT (p = 0.011, CI = 0.010-0.016; Kruskal-Wallis test) significant differences were observed. Cumulative survival rates were HT = 92.5%, NRCT = 70.5%, and CR = 67.2% (p = 0.012). NRCT and CR outcomes were comparable. HT performed better than NRCT and CR for all outcomes. This study was funded by the Paediatric Dentistry Department, Greifswald University, Germany (Trial registration No. NCT01797458).

Leachables and cytotoxicity of root canal sealers

This in vitro study aimed to detect leaching components from an epoxy resin- and a methacrylate-based endodontic sealer and correlate them to cytotoxicity induced by material extracts for up to 36 weeks. We qualitatively determined the substances released by aged AH Plus and RealSeal SE specimens at seven intervals between 0 and 36 weeks. Quantification was performed by ultra-performance liquid chromatography/mass spectrometry (UPLC/MS). We determined the viability of murine macrophage J774 cells after 24 h exposure to material extracts, at each interval, using a fluorescence staining/microscopy method. The leachables detected were 1-adamantylamine and bisphenol A diglycidyl ether from AH Plus and N-(p-tolyl) diethanolamine and caprolactone-2-(methacryloyloxy) ethyl ester from RealSeal SE. The largest UPLC/MS chromatogram peak areas of the leachables were detected within 72 h. Induction of cytotoxicity after exposure to AH Plus and RealSeal SE extracts coincided with leachant detected within the first 72 and 24 h, respectively. The clinical impact of the cytotoxicity due to resin-based endodontic sealers is unknown.