Article

Operative caries management in adults and children

Dundee Dental School, University of Dundee, Park Place, Dundee, Tayside, UK, DD1 4HN.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 03/2013; 3(3):CD003808. DOI: 10.1002/14651858.CD003808.pub3
Source: PubMed

ABSTRACT

The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

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Available from: Nicola P Innes, Dec 22, 2013
    • "However, published success rates from prospective studies are heterogeneous and range from 31.8% (Bjørndal et al. 2010) to 98% (Innes 2010). This has been confirmed by systematic reviews dealing with the treatment of deep carious defects and pulp exposures (Miyashita et al. 2007, Ricketts et al. 2013). "
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    ABSTRACT: Zielstellung: Studien zur Erfolgsbewertung von direkten Überkappungen liefern sehr heterogene Ergebnisse. Ziel der vorliegenden Untersuchung war es daher, den Erfolg direkter Überkappungen in einer großen Stichprobe unter Praxisbedingungen zu untersuchen. Methode: Zur Analyse standen Abrechnungsdaten einer großen deutschen gesetzlichen Krankenkasse zur Verfügung. Nur Versicherte, die über den gesamten Beobachtungszeitraum von drei Jahren (2010 – 2012) dort versichert waren, wurden in die Analyse einbezogen. Alle Zähne dieser Versicherten, die im entsprechenden Zeitraum eine direkte Überkappungsbehandlung erfuhren, wurden im Rahmen einer Überlebenszeitanalyse nach Kaplan und Meier auf das Zielereignis „Initiierung einer Wurzelbehandlung“ hin untersucht. Potenzielle Zusammenhänge zu Alter und Zahnart wurden analysiert und mittels Log-Rank-Test auf Signifikanz hin überprüft (p = 0,05). Ergebnisse: 148.312 Zähne entsprachen den Einschlusskriterien. Die kumulative Erfolgsrate zum Dreijahreszeitpunkt betrug 71,6 %. Sehr junge und sehr alte Patienten zeigten höhere Erfolgsraten. Einwurzelige Zähne zeigten signifikant höhere Erfolgsraten als mehrwurzelige. Konklusion: Mehr als zwei Drittel der direkt überkappten Zähne mussten im Rahmen der Beobachtungszeit keine endodontische Behandlung erfahren. Die direkte Überkappung kann daher auch im Praxisalltag als eine einfache Methode zur Vitalerhaltung mit gutem Erfolgspotenzial angesehen werden. Im Hinblick auf die methodischen Limitationen der Analyse sollten die Ergebnisse der Altersverteilung der Erfolgsraten mit Vorsicht interpretiert werden.
    No preview · Conference Paper · Nov 2015
    • "Sealing carious dentine beneath a restoration deprives the caries biofilm of nutrients and alters the environment sufficiently to slow or arrest lesion progression. This has the added benefit of avoiding pulp exposure and subsequent treatment (Griffin et al. 2008, Ricketts et al. 2013). By sealing all carious dentine beneath a stainless steel crown, the Hall Technique overcomes both pulpal complications (by avoiding pulp exposure and inactivating remaining bacteria by sealing them) and restorative failures (by placing a stainless steel crown) (Innes et al. 2009, 2011). "
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    ABSTRACT: AimTo compare the cost-effectiveness of three strategies for treating primary molars with cavitated carious lesions and sensible (vital), asymptomatic pulps.MethodologyConventional excavation and restoration, Hall Technique (caries sealing using a preformed crown), and pulpotomy were compared As the latter would not be applied to all teeth in clinical reality, decision-making under perfect information was modelled, with teeth at-risk for pulpal complications receiving immediate pulpotomy, while all others were treated conventionally. A Markov model was constructed and transition probabilities derived from randomized trials or systematic reviews. A carious molar in a 5-year old was followed until exfoliation. Cost-effectiveness was assessed within the German healthcare system using a public-payer perspective. Monte-Carlo microsimulations were performed to evaluate the primary outcome, costs (in Euro) per year of tooth retention.ResultsConventional treatment was least effective and more expensive than the Hall Technique. Risk-based pulpotomy was more costly, but also more effective than alternatives. Overall, the Hall Technique was most cost-effective (9.77 Euro/year), followed by pulpotomy (11.75 Euro/year) and conventional treatment (13.31 Euro/year). For payers willing to invest >59 Euro per additional year of tooth retention, risk-based pulpotomy was most cost-effective. Providing pulpotomy to all teeth was not cost-effective.Conclusions The Hall Technique was most cost-effective, while conventional treatment was least effective and most costly. Performing pulpotomy for molars at-risk of pulpal complications might be effective, but was more expensive than alternatives. Moreover, accurately predicting such pulpal complications is currently not possible. Risk-based decision-making does not necessarily reduce costs.This article is protected by copyright. All rights reserved.
    No preview · Article · Aug 2015 · International Endodontic Journal
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    • "For decades, the treatment of caries lesions involved lining of the cavity floor in proximity to the pulp, most often using calcium hydroxide [1]. The development of new restorative materials [2] and changes in the perceived need to remove all carious, i.e., demineralized or infected dentine [3] [4], have raised doubts regarding the need of cavity lining for maintaining pulpal vitality [5] [6] [7] [8] [9]. However, the use of liners, especially those based on calcium hydroxide, remains popular amongst general practitioners [10] [11], possibly as dentists fear that adhesive restorations placed without any liner might compromise pulpal vitality [11]. "
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    ABSTRACT: Objectives: After removal of dentin caries lesions, cavity lining has been advocated. Non-clinical data support this approach, but clinical data are sparse and ambiguous. We aimed at evaluating the benefits and harms of cavity lining using meta-analysis and Trial Sequential Analysis. Data: We included randomized clinical trials comparing restorations without versus with cavity lining for treating primary caries lesions. Only trials reporting failure (defined as need to re-retreat) after ≥1 year follow-up were included. Trial selection, data extraction, and risk of bias assessment were conducted independently by two reviewers. We conducted random-effects intention-to-treat and per-protocol meta-analyses, and Trial Sequential Analysis to control for random errors. Sources: Electronic databases (PubMed, Embase, CENTRAL) were systematically screened, and hand searches and cross-referencing performed. Study selection: From 128 studies, three randomized trials (89/130 patients or teeth), all treating primary teeth, were included. The trials had high risk of bias. All trials compared no lining versus calcium hydroxide lining after selective caries removal followed by adhesive restoration. Follow-up was 36 to 53 months. Restoring the cavity without lining did not significantly affect the risk of failure (intention-to-treat relative risk (RR) [95% confidence interval] 0.71 [0.49 to 1.04], per-protocol RR 0.52 [0.24 to 1.10). According to Trial Sequential Analysis, no firm evidence was reached. The quality of evidence was very low. Conclusions: Strong recommendations for using cavity liners are unsubstantiated, but firm evidence for omitting lining is also unavailable. Our findings apply only to primary teeth and calcium hydroxide liner. Clinical significance: Whilst lining is frequently performed in dental practice, very few randomized clinical trials investigated this issue. The three trials included in this review treated deciduous teeth and did not find lining with calcium hydroxide beneficial. Lining is not supported by sufficient clinical evidence.
    Full-text · Article · Jul 2015 · Journal of dentistry
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Questions & Answers about this publication

  • Nicola P Innes added an answer in Enamel:
    Can anybody send me details about tooth "Filling without Drilling"

    Caries has conventionally been treated with drlling and fillling keeping GV Black's rule of extension for prevention in mind. Contemporarily, caries is recommended to be treated with minimal intervention (MID) keeping prevention of extension in mind.In near future, caries will be treated without drill or any other method which involves loss of tooth structure as protien has been synthesized which replaces enamel. I will appreciate if someone elaborate on it in this forum.

    Nicola P Innes

     Hi there,

    you should try (for dentistry in Children) the Scottish Dental Clinical Effectiveness Programmes manual (although it is currently being updated, it is still contemporaneous). This document has been adopted for use in several other countries and is meant to be international in its scope although produced by a Scottish Group. It is very much about 'how to' do minimal intervention dentistry. 

    http://www.sdcep.org.uk/published-guidance/caries-in-children

    There is VERY little evidence for lasers and ozone both of which are expensive and, from the research would seem to be unnecessary.  I would urge caution in adopting these when simpler, proven, effective methods are available.

    Again, if it is primary teeth you are interested in, you could look at http://en.wikipedia.org/wiki/Hall_Technique

    http://www.sdcep.org.uk/published-guidance/caries-in-children/

    Also, please find a link to the Cochrane review on minimal caries removal techniques and the evidence for them.

    If you wish, I'd be happy to send you more literature or point to more information.

    Kind regards,

    Nicola

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      [Show abstract] [Hide abstract]
      ABSTRACT: The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.
      Full-text · Article · Mar 2013 · Cochrane database of systematic reviews (Online)