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The longevity of Dental Restorations: A Systematic Review
... The PMCs were cemented over carious primary molars, with a glass-ionomer (GI) luting cement, with no caries removal, tooth preparation, or local anesthesia. A retrospective analysis of Dr. Hall's practice records (Innes et al., 2006) showed that the outcomes for this technique (the Hall Technique) were similar to those reported for more conventional restorations (Chadwick et al., 2002). The RCT reported here found the Hall Technique to be significantly more successful, at two-year follow-up, than conventional restorations GDPs were providing (Innes et al., 2007). ...
... This number approaches those reported in another Primary Care-based study where carious primary teeth were left unrestored (Levine et al., 2002). Restoration survival rates for the Hall Technique were comparable with those of conventional restorations placed by specialists, and in Secondary Care settings (Chadwick et al., 2002). One explanation for the poor performance of GDPs' restorations was their extensive use of GI (used for 73% of restorations , with 68% of the lesions being proximal). ...
The Hall Technique (HT) is a method for managing carious primary molars. Decay is sealed under pre-formed metal crowns without any caries removal, tooth preparation, or local anesthesia. The aim of this study was to compare HT clinical/radiographic failure rates with General Dental Practitioners' (GDPs) standard (control) restorations. We conducted a split-mouth, randomized control trial (132 children, aged 3-10 yrs, GDPs n = 17) in Scotland. There were 264 study teeth with initial lesions, 42% of which were radiographically > half-way into dentin, and 67% of which had Class II restorations. Teeth were randomized to HT (intervention) or GDPs' usual treatment (control). Annual clinical/radiographic follow-up data were recorded. Ninety-one patients (69%) had 48 months' minimum follow-up. At 60 months, 'Major' failures (irreversible pulpitis, loss of vitality, abscess, or unrestorable tooth) were recorded: HT, 3 (3%); control restorations, 15 (16.5%) (p = 0.000488; NNT 8); and 'Minor' failures (reversible pulpitis, restoration loss/wear/fracture; or secondary caries): HT, 4 (5%); control restorations, 38 (42%) (p < 0.000001; NNT 3). Overall, there were follow-up data for 130 patients (2-60 mos): 'Major' failures: HT, 3 (2%); control restorations, 22 (17%) (p = 0.000004; NNT 7); and 'Minor' failures, HT, 7 (5%); control restorations, 60 (46%) (p < 0.000001; NNT 3). Sealing in caries by the Hall Technique statistically, and clinically, significantly outperformed GDPs' standard restorations in the long term (Trial registration no. ISRCTN 47267892).
... Hall PMCs were not only a more successful restorative technique for carious primary molars than the conventional techniques used by this sample of GDPs, they were also a successful restoration in their own right, achieving comparable survival rates to conventional restorations placed under more favourable conditions [55] (and see relatedFigure 18). This is intriguing, as there was no caries removal at all, and in 42% of cases the caries was assessed radiographically as being > 1/2 way through dentine, a stage at which it is very likely there would be some pulpal involvement [45]. ...
Scotland has high levels of untreated dental caries in primary teeth. The Hall Technique is a simplified method of managing carious primary molars using preformed metal crowns (PMCs) cemented with no local anaesthesia, caries removal or tooth preparation. This study compared the acceptability of the Hall Technique for children, their carers, and dentists, and clinical outcomes for the technique, with conventional restorations.
General dental practice based, split mouth, randomized controlled trial (132 children, aged 3-10). General dental practitioners (GDPs, n = 17) in Tayside, Scotland (dmft 2.7) placed conventional (Control) restorations in carious primary molars, and Hall Technique PMCs on the contralateral molar (matched clinically and radiographically). Dentists ranked the degree of discomfort they felt the child experienced for each procedure; then children, their carers and dentists stated which technique they preferred. The teeth were followed up clinically and radiographically.
128 conventional restorations were placed on 132 control teeth, and 128 PMCs on 132 intervention teeth. Using a 5 point scale, 118 Hall PMCs (89%) were rated as no apparent discomfort up to mild, not significant; for Control restorations the figure was 103 (78%). Significant, unacceptable discomfort was recorded for two Hall PMCs (1.5%) and six Control restorations (4.5%). 77% of children, 83% of carers and 81% of dentists who expressed a preference, preferred the Hall technique, and this was significant (Chi square, p < 0.0001). There were 124 children (94% of the initial sample) with a minimum follow-up of 23 months. The Hall PMCs outperformed the Control restorations:a) 'Major' failures (signs and symptoms of irreversible pulpal disease): 19 Control restorations (15%); three Hall PMCs (2%) (P < 0.000);b) 'Minor' failures (loss of restoration, caries progression): 57 Control restorations (46%); six Hall PMCs (5%) (P < 0.000)c) Pain: 13 Control restorations (11%); two Hall PMCs (2%) (P = 0.003).
The Hall Technique was preferred to conventional restorations by the majority of children, carers and GDPs. After two years, Hall PMCs showed more favourable outcomes for pulpal health and restoration longevity than conventional restorations. The Hall Technique appears to offer an effective treatment option for carious primary molar teeth.
Current Controlled Trials ISRCTN47267892 - A randomized controlled trial in primary care of a novel method of using preformed metal crowns to manage decay in primary molar teeth: the Hall technique.
When prevention of dental caries fails, and a child is exposed to the risk of pain and infection, the disease must be managed to reduce this risk. There is growing evidence supporting more ‘biological’ and fewer ‘surgical’ approaches to managing dental caries in primary teeth. These biological methods include partial and stepwise caries removal procedures, as well as techniques where no caries is removed. An overview of clinical trials comparing these biological methods to complete caries removal shows that they perform as well as traditional methods and have the advantage of reducing the incidence of iatrogenic pulpal exposures. The Hall Technique is one biological approach to managing caries in primary molars which involves sealing caries beneath preformed metal (stainless steel) crowns. The crown is cemented over the tooth without caries removal, tooth preparation or use of local anaesthesia. The clinical steps for the Hall Technique are straightforward but, as with all dental care provision, appropriate treatment planning for the procedure requires skill. The Hall Technique offers another method of managing early to moderately advanced, active carious lesions in primary molars, with good evidence of effectiveness and acceptability. This evidence aligns with the positive findings of other studies on biological strategies for managing caries in primary teeth.
When prevention of dental caries fails, and a child is exposed to the risk of pain and infection, the disease must be managed to reduce this risk. There is growing evidence supporting more 'biological' and fewer 'surgical' approaches to managing dental caries in primary teeth. These biological methods include partial and stepwise caries removal procedures, as well as techniques where no caries is removed. An overview of clinical trials comparing these biological methods to complete caries removal shows that they perform as well as traditional methods and have the advantage of reducing the incidence of iatrogenic pulpal exposures. The Hall Technique is one biological approach to managing caries in primary molars which involves sealing caries beneath preformed metal (stainless steel) crowns. The crown is cemented over the tooth without caries removal, tooth preparation or use of local anaesthesia. The clinical steps for the Hall Technique are straightforward but, as with all dental care provision, appropriate treatment planning for the procedure requires skill. The Hall Technique offers another method of managing early to moderately advanced, active carious lesions in primary molars, with good evidence of effectiveness and acceptability. This evidence aligns with the positive findings of other studies on biological strategies for managing caries in primary teeth.
Background:
There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme’s commissioning brief and research question “What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?” It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations.
Methods/design:
This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3-7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists’ preferences.
Discussion:
FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients.
Trial registration:
Protocol ID: NCTU: ISRCTN77044005.
To review the literature concerning the restoration of primary teeth with glass ionomer (GIC) or resin modified glass ionomer cement (RMGI) used in conventional class II cavities.
A search of the literature identified through Medline between 1966 and 2006 using the key words: glass ionomer, resin modified, glass polyalkenoate, deciduous/primary teeth. Studies that used ART or tunnel preparations were excluded. Papers of relevant clinical studies (prospective and retrospective) were assessed and graded using predetermined criteria. Papers were graded according to the number of criteria met as (A >90%, B1 = 75%, B2 = 50%, C <50%).
The search identified 411 papers, from which an application of the inclusion criteria yielded 20 studies. Of these, 2 were rated B1 and 18 B2. Failure rates varied from 6.6% to 60% for GIC, and from 2% to 24% for RMGI.
GIC cannot be recommended for class II cavities in primary molars. There is evidence that RMGIC can perform successfully in small to moderate sized class II restorations.
Unlabelled:
Stress generation at tissue/resin composite interfaces is one of the important reasons for failure of resin-based composite (RBC) restorations owing to the inherent property of polymerization shrinkage. Unrelieved stresses can weaken the bond between the tooth structure and the restoration, eventually producing a gap at the restoration margins. This can lead to postoperative sensitivity, secondary caries, fracture of the restorations, marginal deterioration and discoloration. As polymerization shrinkage cannot be eliminated completely, various techniques and protocols have been suggested in the manipulation of, and restorative procedures for, RBCs to minimize the shrinkage and associated stresses. Introduction of various newer monomer systems (siloranes) may also overcome this problem of shrinkage stress. This review emphasizes the various material science advances and techniques advocated that are currently available or under trial/testing phase to deal with polymerization shrinkage in a clinical environment.
Clinical relevance:
Minimizing the shrinkage stresses in RBC restorations may lead to improvement in the success rate and survival of restorations. Thus, it is important for dental practitioners to be aware of various techniques and materials available to reduce these shrinkage stresses and be updated with the current knowledge available to deal with this issue.
The authors describe and evaluate the short-term effectiveness of a community-based program for dental caries prevention in children.
The authors enrolled pupils in the ForsythKids program after receiving informed consent. They targeted children at six Massachusetts elementary schools, grades 1 through 3, with pupil populations at high risk of developing caries. The children underwent examination by dentists using calibrated technique and received comprehensive preventive care from dental hygienists. The authors determined effectiveness by means of comparing results of the initial examination with those of a second examination performed six months later.
At baseline, 70 percent of the 1,196 participating children had decayed or filled teeth. More troublingly, 42.1 percent of the primary teeth and 31.1 percent of the permanent teeth had untreated decay. Six months after preventive intervention, the proportion of teeth with new decay was reduced 52 percent in primary teeth and 39 percent in permanent teeth. Furthermore, the percentage of children with newly decayed or restored primary and permanent teeth was reduced by 25.4 percent and 53.2 percent, respectively.
These results indicate that this care model relatively quickly can overcome multiple barriers to care and improve children's oral health.
If widely implemented, comprehensive caries prevention programs such as ForsythKids could accomplish national health goals and reduce the need for new care providers and clinics.
The aim of this randomized clinical study was to compare the longevity and the cariostatic effects of conventional glass ionomer and amalgam restorations in primary teeth placed in everyday practice in the Danish Public Dental Health Service. All restorations inserted during a 7-month period by 14 clinicians in 2 municipalities were included in the study. The sample consisted of 515 conventional glass ionomer restorations and 543 amalgam restorations in 666 children aged between 2.8 and 13.5 years. The restorations were in contact with 592 unrestored surfaces in primary and permanent teeth. The study was terminated after 8 years, with 2% of the restorations in function and 7% patient dropouts. Fifty percent of the teeth restored with glass ionomer and 63% of those with amalgam were exfoliated with the restoration in situ, while 42% of the glass ionomer and 20% of the amalgam restorations had been repaired or replaced. Fracture of restoration, endodontic complication, and loss of retention were the major reasons for failure. The 50% survival time for glass ionomer restorations in all cavity types was 42 months, while the median survival time for amalgam restorations could not be estimated but exceeded 7.8 years (P < 0.001). Progression of caries lesions on tooth surfaces adjacent to amalgam restorations required operative treatment on 30% of the teeth, while only on 16% of teeth adjacent to glass ionomer restorations. The 75% survival time was 40 months for surfaces in contact with glass ionomer compared to 25 months for surfaces in contact with amalgam (P = 0.005). Multivariate analyses were performed in order to assess the influence of a number of factors on the longevity of restorations, occurrence of prevalent failures, and caries treatment of surfaces in contact with the restorations. Owing to the high frequency of failures of the conventional glass ionomer restorations, it was concluded that they are not an appropriate, universal alternative to amalgam for restorations in primary teeth, although they reduce caries progression and the need for operative treatment of adjacent surfaces.
More research is needed to determine whether tooth-coloured ceramic inlays compare well over the long term with amalgam, resin or gold inlays. When tooth decay (caries) has caused cavities in the back (posterior) teeth, various materials can be used as fillings. These include amalgam, gold inlays, composite resin inlays and ceramic inlays. Amalgam is commonly used on back teeth for its longevity, although some are concerned about its dark appearance and mercury content. Other concerns about fillings include relative costs and pain during or after treatment. Ceramic inlays are tooth-coloured, and may be preferred for this reason. The review found that there is not enough strong evidence to compare ceramic inlays with other types of fillings.
Data sources Medline was the only data source for this review.Study selection Only studies that dealt with inlays, onlays or crowns and that were published in English were included. Studies that lasted less than 2 years were excluded, as were those published in abstract form only.Data extraction and synthesis The studies were divided into two categories: those that considered inlay and onlay restorations and those that considered crowns. Qualitative assessment was conducted.Results Nine studies were selected, six of which assessed the performance of inlays and onlays made with the pressable glass matrix IPS-Empress system (Ivoclar Vivadent, Schaan, Liechtenstein; IPS- Empress is the registered trade name of this ceramic restoration) and three of which examined the performance of IPS-Empress crowns. Survival for inlays and onlays ranged from 96% at 4.5 years to 91% at 7 years, with most failures being caused by bulk fracture. The survival of crowns ranged from 92% to 99% at 3–3.5 years, with failure again being caused primarily by fracture.Conclusions Use of IPS-Empress crowns is not recommended in the posterior region of the mouth until the results of a sufficient number of long-term clinical trials of premolars and molars are available.
Amalgam has been the material of choice for restoring posterior teeth for more than 100 years. The past 25 years have witnessed significant advances in restorative materials themselves and in the bonding systems for retaining a restoration in the prepared tooth. As a result, there has been a shift toward resin composite materials during this same period because of concerns about the esthetics and biocompatibility of dental amalgam. In addition, other materials such as glass ionomer cements, ceramic inlays and onlays, and gold alloys have been used as alternatives to amalgam. This article will review recent studies on the longevity and biocompatibility of these alternatives to dental amalgam.
There are few Australian data on the reasons for placement and replacement of restorations, and the extent to which these are carried out in general practice.
A survey was carried out of approximately 100 consecutive restorations placed by each of 28 general dental practitioners. The data were coded and statistically analyzed for various associations.
Resin composite was used twice as frequently as amalgam as a restorative material, and nearly four times as often as glass-ionomer cement. Secondary caries was the principal reason for replacing restorations, affecting predominantly amalgam restorations in Class I and Class V cavities. Teeth restored with amalgam fractured nearly twice as often as teeth restored with resin composite. The average ages of amalgam, resin composite and glass-ionomers at replacement were 13.6, 7.1 and 5.7 years respectively.
Amalgam has the longest clinical service life, but is associated with more tooth fracture. Secondary caries is the main reason for replacing restorations. The anti-cariogenic effect of glass-ionomer cement is equivocal.
Spurred by an initiative by the National Institute of Dental and Craniofacial Research in the USA, this article presents the need for a change in clinical dental research towards practice-based research. It outlines the shortcomings of past and present-day research in dentistry, with emphasis on the lack of clinical relevance of much of the research performed. The slow transfer of sound research findings to clinical practice is also a major problem. The article reviews some problems related to restorative dentistry and how they have adversely affected general dental practice. Practice-based research places emphasis on the problems experienced by clinicians in the routine care of patients. Clinicians should be linked together in research networks. The problems they face in dental practice and the clinical experience they have will form the basis for studies by the network. Experienced clinical researchers will provide guidance and statistical support for the studies initiated by the clinicians.
Background: There are few Australian data on the reasons for placement and replacement of restorations, and the extent to which these are carried out in general practice. Methods: A survey was carried out of approximately 100 consecutive restorations placed by each of 28 general dental practitioners. The data were coded and statistically analyzed for various associations. Results: Resin composite was used twice as frequently as amalgam as a restorative material, and nearly four times as often as glass-ionomer cement. Secondary caries was the principal reason for replacing restorations, affecting predominantly amalgam restorations in Class I and Class V cavities. Teeth restored with amalgam fractured nearly twice as often as teeth restored with resin composite. The average ages of amalgam, resin composite and glass-ionomers at replacement were 13.6, 7.1 and 5.7 years respectively. Conclusions: Amalgam has the longest clinical service life, but is associated with more tooth fracture. Secondary caries is the main reason for replacing restorations. The anti-cariogenic effect of glass-ionomer cement is equivocal.
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