- Email: [email protected]
Deep carious lesion management
at risk or high risk was SDF both more effective and less costly than providing no preventive action. CHX and daily fluoride rinsing were not cost-effective.
Clinical Significance.—SDF varnish might be desirable for its highly antibacterial and remineralizing properties, but it has some esthetic disadvantages, which undercut its value for patients. Fluoride rinses offer similar efficacy but are more expensive. The cost feature must be
considered as well as efficacy because of clinical concerns and healthcare service level decisions.
€stemeyer G: Cost-effectiveness of root caries preSchwendicke F, Go ventive treatments. J Dent 56:58-64, 2017 €stemeyer, Charit Reprints available from G Go e – Universit€atsmedizin Berlin, Dept for Operative and Preventive Dentistry, Aßmannshauser Str 4-6, 14197 Berlin, Germany; e-mail: [email protected]
Restorative Dentistry Deep carious lesion management Background.—The management of deep carious lesions in teeth with vital pulps can be challenging for dental practitioners, who must weigh the advantages of removing all soft dentin against the risks associated with exposing the pulp and causing complications. Alternative treatment options to address the situation include stepwise or selective excavation (indirect pulp capping), which can leave some carious dentin and bacteria sealed beneath a restoration. Increasing evidence supports these alternative approaches, but dentists often harbor reservations about leaving carious dentin and bacteria behind. For years, dental schools have taught practitioners to remove all the infectious material, and it can be hard to go against this teaching. The current practices and beliefs of dental practitioners in France, Germany, and Norway were surveyed to determine if evidence or tradition is winning the day in this situation. Methods.—The questionnaire distributed to the dentists was a compilation of questionnaires used in previous studies. Closed response modes were used. The questionnaire was mailed to simple random samples of dentists. Response rate was 33% from France, 25% from Germany, and 33% from Norway. Results.—Seventy percent of the 661 French, 77% of the 622 German, and 69% of the 199 Norwegian dentists selected hardness as the criterion used most often for evaluating how much carious tissue to remove. Sixty-six percent of the dentists had the goal of only hard dentin remaining at the pulpal wall. Fifty percent of the Norwegian and French general dental practitioners (GPs) thought moisture was not a relevant criterion, but only 7% of the German GPs held this view. Color was not considered relevant by most respondents.
302
Dental Abstracts
Between 73% and 84% chose to use metal burs and 50% to 75% selected hand excavators for these deep carious lesions. Ceramic burs were used by 4% to 36%, and chemomechanical excavation was used by 6% to 19% of the practitioners. The use of a rubber dam, cavity disinfection, and dye solution varied considerably between the three countries. Deep lesions in a permanent tooth with a vital and painless pulp were not addressed by many French or German GPs using a stepwise excavation technique. The Norwegian dentists tended to prefer this treatment strategy in this situation, with 84% of them choosing it. Only 9% of the French and 15% to 20% of the Norwegian and German GPs would use selective excavation. Between 63% and 68% of respondents from all the countries stated their main reason for choosing their excavation technique was based on the principle that complete removal of carious tissue and bacteria was required to prevent lesion progression. However, these GPs were unable to be certain whether carious lesions could be arrested if bacteria were sealed in a cavity. The Norwegian GPs were less likely to believe carious tissues should always be completely removed to protect the vitality of the pulp compared to those from France and Germany. All three countries had over 50% of their dentists who expressed the belief that incomplete removal of carious tissues was a threat to the vitality of the pulp. Seventy percent of the French and 71% of the Norwegian GPs thought that carious pulpo-proximal dentin could be left in place in order to avoid pulp exposure. The factors that influenced treatment decisions were GP satisfaction with it through prior experience, for example, and familiarity or ease of handling. Evidence
base and guideline support were less influential, but financial aspects and peer recommendations were even less important in selecting an approach. GP profiles associated with choosing stepwise excavation less often included French or German GP, male gender, and private practice setting. GPs who believed sealing cavities would arrest carious lesions chose either stepwise or selective excavation more often than those who feared leaving bacteria in place. Male GPs and those in Germany were more likely to perform selective excavation. Discussion.—Existing dentists’ clinical behavior, attitudes, and beliefs need to be understood and guided toward evidence-based behavior, attitudes, and beliefs. Comparing practices between countries can bring out influences that shape behavior, such as educational standards and healthcare systems. Most of the GPs who responded to this survey selected dentin hardness as the criterion for removing carious tissue. Leaving bacteria in place in a cavity was often avoided to protect from infection. These practices were often shaped by the beliefs of the practitioners, which are based on what they are comfortable with and how they have been taught.
Clinical Significance.—Changing the management decisions of dentists can be difficult. Often their choices are based on their years in dental school, what they have learned from senior dentists they’ve known and worked with, and personal preference. There is an urgent need to educate dentists about the advantages of less invasive strategies and the evidence that supports this approach, as well as alternative strategies to minimize complications.
Schwendicke F, Stangvaltaite L, Holmgren C, et al: Dentists’ attitudes and behaviour regarding deep carious lesion management: A multi-national survey. Clin Oral Invest 21:191-198. 2017 Reprints available from S Dom ejean, Univ Clermont1, UFR d’Odontologie, Ctr de Recherche en Odontologie Clinique EA 4847, F-63100 Clermont-Ferrand, France, 2 rue de Braga, 63100 Clermont-Ferrand, France; e-mail: [email protected]
Temporomandibular Disorders OPPERA study results Background.—The Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project has conducted studies of the incidence and risk factors for temporomandibular disorders (TMDs) for a decade. A total of 4346 subjects participated over the course of 10 years, and the results of the investigations have verified some factors already considered as increasing the risk of TMD, refuted others, and revealed new information about TMD etiology. Selected findings were discussed from OPPERA’s 35 papers, noting what has been discovered and what needs further study about TMDs. Study Methods.—The studies fell into three designs: prospective cohort study, case-control study, and nested case-control study. The participants were age 18 to 44 years and lived in one of four locations: Baltimore, MD; Buffalo, NY; Chapel Hill, NC; or Gainesville, FL. The prospective cohort study evaluated the incidence rate of first-onset TMD and included 3258 subjects. All completed a plethora of psychosocial questionnaires; had autonomic function and sensitivity to experimental pain measured; and donated blood samples. Follow-up a median
of 2.8 years later included completion of quarterly health questionnaires to identify TMD symptoms. Those who had symptoms were examined at research clinics, with a complete orofacial examination. These investigations identified 260 incident cases of first-onset TMD myalgia and/or arthralgia. A case-control study recruited an additional 1088 participants who had chronic TMD, had a history of facial pain for at least 5 days a month over the past 6 months, and had examiner-verified myalgia and/or arthralgia. The baseline data collection processes were the same as those for the prospective cohort study. More detailed information from the 260 incident cases and a sample of subjects from the prospective cohort study who were TMD free was sought in the nested case-control study. Controls were matched to incident cases by time since enrollment, study site, and sex, and they and the incident case patients repeated most of the data collection procedures of the prospective cohort study. After 6 months, clinical TMD examinations were conducted along with the same data collection procedures.
Volume 62
Issue 5
2017
303
Clinical Significance.—SDF varnish might be desirable for its highly antibacterial and remineralizing properties, but it has some esthetic disadvantages, which undercut its value for patients. Fluoride rinses offer similar efficacy but are more expensive. The cost feature must be
considered as well as efficacy because of clinical concerns and healthcare service level decisions.
€stemeyer G: Cost-effectiveness of root caries preSchwendicke F, Go ventive treatments. J Dent 56:58-64, 2017 €stemeyer, Charit Reprints available from G Go e – Universit€atsmedizin Berlin, Dept for Operative and Preventive Dentistry, Aßmannshauser Str 4-6, 14197 Berlin, Germany; e-mail: [email protected]
Restorative Dentistry Deep carious lesion management Background.—The management of deep carious lesions in teeth with vital pulps can be challenging for dental practitioners, who must weigh the advantages of removing all soft dentin against the risks associated with exposing the pulp and causing complications. Alternative treatment options to address the situation include stepwise or selective excavation (indirect pulp capping), which can leave some carious dentin and bacteria sealed beneath a restoration. Increasing evidence supports these alternative approaches, but dentists often harbor reservations about leaving carious dentin and bacteria behind. For years, dental schools have taught practitioners to remove all the infectious material, and it can be hard to go against this teaching. The current practices and beliefs of dental practitioners in France, Germany, and Norway were surveyed to determine if evidence or tradition is winning the day in this situation. Methods.—The questionnaire distributed to the dentists was a compilation of questionnaires used in previous studies. Closed response modes were used. The questionnaire was mailed to simple random samples of dentists. Response rate was 33% from France, 25% from Germany, and 33% from Norway. Results.—Seventy percent of the 661 French, 77% of the 622 German, and 69% of the 199 Norwegian dentists selected hardness as the criterion used most often for evaluating how much carious tissue to remove. Sixty-six percent of the dentists had the goal of only hard dentin remaining at the pulpal wall. Fifty percent of the Norwegian and French general dental practitioners (GPs) thought moisture was not a relevant criterion, but only 7% of the German GPs held this view. Color was not considered relevant by most respondents.
302
Dental Abstracts
Between 73% and 84% chose to use metal burs and 50% to 75% selected hand excavators for these deep carious lesions. Ceramic burs were used by 4% to 36%, and chemomechanical excavation was used by 6% to 19% of the practitioners. The use of a rubber dam, cavity disinfection, and dye solution varied considerably between the three countries. Deep lesions in a permanent tooth with a vital and painless pulp were not addressed by many French or German GPs using a stepwise excavation technique. The Norwegian dentists tended to prefer this treatment strategy in this situation, with 84% of them choosing it. Only 9% of the French and 15% to 20% of the Norwegian and German GPs would use selective excavation. Between 63% and 68% of respondents from all the countries stated their main reason for choosing their excavation technique was based on the principle that complete removal of carious tissue and bacteria was required to prevent lesion progression. However, these GPs were unable to be certain whether carious lesions could be arrested if bacteria were sealed in a cavity. The Norwegian GPs were less likely to believe carious tissues should always be completely removed to protect the vitality of the pulp compared to those from France and Germany. All three countries had over 50% of their dentists who expressed the belief that incomplete removal of carious tissues was a threat to the vitality of the pulp. Seventy percent of the French and 71% of the Norwegian GPs thought that carious pulpo-proximal dentin could be left in place in order to avoid pulp exposure. The factors that influenced treatment decisions were GP satisfaction with it through prior experience, for example, and familiarity or ease of handling. Evidence
base and guideline support were less influential, but financial aspects and peer recommendations were even less important in selecting an approach. GP profiles associated with choosing stepwise excavation less often included French or German GP, male gender, and private practice setting. GPs who believed sealing cavities would arrest carious lesions chose either stepwise or selective excavation more often than those who feared leaving bacteria in place. Male GPs and those in Germany were more likely to perform selective excavation. Discussion.—Existing dentists’ clinical behavior, attitudes, and beliefs need to be understood and guided toward evidence-based behavior, attitudes, and beliefs. Comparing practices between countries can bring out influences that shape behavior, such as educational standards and healthcare systems. Most of the GPs who responded to this survey selected dentin hardness as the criterion for removing carious tissue. Leaving bacteria in place in a cavity was often avoided to protect from infection. These practices were often shaped by the beliefs of the practitioners, which are based on what they are comfortable with and how they have been taught.
Clinical Significance.—Changing the management decisions of dentists can be difficult. Often their choices are based on their years in dental school, what they have learned from senior dentists they’ve known and worked with, and personal preference. There is an urgent need to educate dentists about the advantages of less invasive strategies and the evidence that supports this approach, as well as alternative strategies to minimize complications.
Schwendicke F, Stangvaltaite L, Holmgren C, et al: Dentists’ attitudes and behaviour regarding deep carious lesion management: A multi-national survey. Clin Oral Invest 21:191-198. 2017 Reprints available from S Dom ejean, Univ Clermont1, UFR d’Odontologie, Ctr de Recherche en Odontologie Clinique EA 4847, F-63100 Clermont-Ferrand, France, 2 rue de Braga, 63100 Clermont-Ferrand, France; e-mail: [email protected]
Temporomandibular Disorders OPPERA study results Background.—The Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project has conducted studies of the incidence and risk factors for temporomandibular disorders (TMDs) for a decade. A total of 4346 subjects participated over the course of 10 years, and the results of the investigations have verified some factors already considered as increasing the risk of TMD, refuted others, and revealed new information about TMD etiology. Selected findings were discussed from OPPERA’s 35 papers, noting what has been discovered and what needs further study about TMDs. Study Methods.—The studies fell into three designs: prospective cohort study, case-control study, and nested case-control study. The participants were age 18 to 44 years and lived in one of four locations: Baltimore, MD; Buffalo, NY; Chapel Hill, NC; or Gainesville, FL. The prospective cohort study evaluated the incidence rate of first-onset TMD and included 3258 subjects. All completed a plethora of psychosocial questionnaires; had autonomic function and sensitivity to experimental pain measured; and donated blood samples. Follow-up a median
of 2.8 years later included completion of quarterly health questionnaires to identify TMD symptoms. Those who had symptoms were examined at research clinics, with a complete orofacial examination. These investigations identified 260 incident cases of first-onset TMD myalgia and/or arthralgia. A case-control study recruited an additional 1088 participants who had chronic TMD, had a history of facial pain for at least 5 days a month over the past 6 months, and had examiner-verified myalgia and/or arthralgia. The baseline data collection processes were the same as those for the prospective cohort study. More detailed information from the 260 incident cases and a sample of subjects from the prospective cohort study who were TMD free was sought in the nested case-control study. Controls were matched to incident cases by time since enrollment, study site, and sex, and they and the incident case patients repeated most of the data collection procedures of the prospective cohort study. After 6 months, clinical TMD examinations were conducted along with the same data collection procedures.
Volume 62
Issue 5
2017
303