Monographs in Oral Science最新文献

Dental caries, the most common chronic disease in the world, affects over 3 billion people globally. Its management comprises a large proportion of dental care providers' clinical responsibility, yet despite the extensive evidence base for the management of cavitated carious lesions, gaps in the evidence persist. This promotes uncertainty and debate among providers. This chapter reiterates the 3 key components of evidence-based practice (EBP): clinical expertise, an awareness and appreciation of patient values, and use of best available evidence. Secondly, we give a brief summary of current best evidence pertaining to some key areas of caries excavation in the context of lesion management, and highlight respective gaps in the evidence. Consideration is given to the state of the evidence for: how carious-lesion excavation is best achieved, the extent to which excavation should occur, contemporaneous practice, the timing of dental intervention in relation to the extent of the disease, and some areas of contention. Finally, there is discussion around how dental care providers might proceed when high-quality evidence does not exist to inform that part of the EBP collective.

In line with reducing the invasiveness of interventions in permanent teeth and changes towards more biological approaches, there have also been moves away from traditional restorative approaches to managing primary teeth where carious dentine/lesions were completely excised and a restoration placed. The Hall Technique is a method for managing carious primary molar teeth where a preformed stainless-steel crown, also known as a preformed metal crown, is seated over a tooth, sealing in, and not removing carious tissue. This chapter discusses the rationale behind the Hall Technique, an outline of the clinical procedure to carry it out, its indications and contraindications, together with the evidence supporting its use. The Hall Technique has been found to be acceptable to children and preferred to more invasive treatment options. Like all dental treatment options, it requires careful case selection, precise carious lesion and pulpal status diagnosis (clinically and radiographically), good patient management, and excellent parental cooperation. The Hall Technique has been shown to be a durable (being likely to last the lifespan of the primary molar) and economical management option for primary molars with carious lesions, which in addition offers the benefit of full coronal coverage, reducing the risk of future carious lesion development. As part of our everyday armamentarium in paediatric dentistry, the Hall Technique is an effective management option for controlling carious lesions in primary molars.

The difference between carious lesion diagnosis and carious lesion detection is discussed here. Concerning carious lesions, 3 diagnostic requirements should be fulfilled: to detect lesions, to assess surface integrity, and to assess lesion activity to support clinical decision making. The first and most important diagnostic method is meticulous visual-tactile inspection. This is the only method that potentially contributes to all 3 diagnostic requirements. All other methods that are presented in this chapter, i.e., bitewing radiography, fluorescence-based technologies, and transillumination methods, are limited to assessing lesion depth in surfaces that are not visible to the eye and thus contribute to lesion detection only. At the end of the chapter, recent developments in objective lesion activity assessment are presented.

Understanding the carious process as a biofilm disease rather than an infectious disease has changed lesion management focus towards less invasive options. This has led to new and ongoing changes in recommendations for practitioners. However, the lack of clarity over what to do, and when, is complicated by different teaching, research, and policy documents containing different terms and definitions for carious lesions and management strategies. Lack of clear messages and communication over recommendations hampers moving evidence into practice. The International Caries Consensus Collaboration (ICCC) recommendations on terminology are one part of improving communication for discussing the diagnosis and management of dental caries and dental carious lesions. The term dental caries is the name of the disease, its use being limited to situations involving control of the disease using preventive and noninvasive measures at the patient level. Carious lesion management should be used where management is directly related to disease symptoms at the tooth level. As terminology cannot be used to directly relate the visual appearance of the carious lesion to the histopathology, the terms have been based around the clinical consequences of the disease: soft, leathery, firm and hard dentine. The 3 main carious tissue removal options are described as: (1) selective removal of carious tissue (to both soft and firm dentine), (2) stepwise removal, and (3) non-selective removal to hard dentine (previously known as complete removal and no longer recommended). Use of these terms across clinicians, researchers, dental educators, and even with patients, will help improve understanding and communication.

Describing and quantifying how much carious tissue should be removed prior to placing a restoration has been a long-debated issue stretching back as far as G.V. Black's "complete caries removal," now known as non-selective carious tissue removal. Originating in the 1960s and 1970s, from the differentiation between different layers of carious dentine, an outer contaminated ("infected") layer and an inner demineralised ("affected") layer, the former of which needed to be removed during cavity preparation and the latter not, selective carious tissue removal was born. Currently, it is termed selective removal to firm dentine. This chapter describes different selective carious tissue removal techniques (to firm, to leathery, to soft dentine) and how they can be achieved appropriately with conventional and novel techniques. Selective removal to firm dentine is recommended for shallow or moderately deep lesions, while for deep lesions (extending close to the pulp) in teeth with vital pulps, selective removal to soft dentine is recommended to avoid pulpal exposure and to preserve the health of the pulp. Leaving soft carious dentine beneath a restoration does, however, raise certain issues regarding how we truly assess pulpal health, what would other dental practitioners think if the patient moved practice, and how do we monitor such sealed residual caries in the future. These issues will all be discussed in this chapter but should at present not preclude dental practitioners from adopting such a minimally invasive evidence-based approach to carious tissue removal.

Caries is no longer seen as an infectious disease, and the aim of treating carious lesions is to control their activity, not to remove the lesion itself. Such control can be implemented by sealing off the lesion from the environment, with sealed bacteria being deprived from carbohydrates and thus inactivated. For cavitated lesions, controlling them usually involves the placement of restorations to rebuild the cleansability of the surface. In this case, dental practitioners have traditionally removed carious tissues prior to the restoration. This has historically been for a number of reasons, while today the main reason for restoring a cavity is to maximise restoration longevity. In shallow lesions, dental practitioners should aim to remove as much carious tissue as possible (to allow adequate depth for the restorative material) without unnecessarily removing sound or remineralisable dentine. This means removal to hard dentine around the periphery, to firm dentine centrally for optimising restoration longevity and allowing a tight cavity seal. For deep lesions in teeth with vital pulps (without irreversible pulpitis), maintaining pulp vitality is critical. Dental practitioners should aim to avoid pulp exposure, leaving soft or leathery dentine in pulpoproximal areas. Peripherally, hard tissue is left, again to ensure a tight seal and sufficient mechanical support of the restoration. As an alternative to the selective removal to soft dentine, stepwise removal can be used. With this approach, the soft dentine is temporarily rather than permanently sealed in, and removed in a second step after 6-12 months. Strategies where carious tissue in cavitated lesions is not removed at all, but sealed or managed non-restoratively, are currently restricted to primary teeth.

Carious lesion dynamics are dependent predominantly on the availability of fermentable sugars, other environmental conditions, bacteria, and host factors. Our current understanding of the microorganisms involved in the initiation and progression of caries is still rather incomplete. The most relevant acidogenic-aciduric bacterial species known to date are Streptococcus mutans, bifidobacteria, and lactobacilli. Whereas mutans streptococci are initiators, bifidobacteria and lactobacilli are more enhancers for progression. Boosters for microbial activity are specific environmental conditions, such as the presence of fermentable dietary sugars and the absence of oxygen. Based on these conditions, the necrotic and/or contaminated zone fulfils all criteria for disease progression and has to be removed. For those deep lesions where the pulp vitality is not affected, a selective removal of the contaminated leathery dentine should take place as this approach lowers the risk of regrowth of the few embedded microbial cells here. In repelling the microbial attack and repairing damage, the host has developed several ingenious strategies. A major resistance to carious lesion progression is mounted by the dentine-pulp tissues. The signalling molecules and growth factors released upon dentine demineralisation upregulate the odontoblast activity and act as sensor cells. After carious stimulation, odontoblasts initiate an inflammatory reaction by producing chemokines and synthesise a protective tertiary dentine. After the destruction of these cells, the pulp still has a high capacity to synthesise this tertiary dentine thanks to the presence of adult stem cells within the pulp. Also, in addition to the systemic regulation, the pulp which is located within inextensible the confines of the dentine walls has a well-developed local regulation of its inflammation, regeneration, and vascularisation. This local regulation is due to the activity of different pulp cell types, mainly the fibroblasts, which secrete soluble molecules that regulate all these processes.

The most recent inspiration for stepwise carious tissue removal in 2 stages originates from the knowhow on intralesion changes in deep carious lesions. The environmental change that takes place during the first stage of carious tissue removal is aiming for the arrest of the deep lesion, by placing a temporary restoration on top of the soft carious dentine. The cavity is optimised during the second stage for a final restoration, as potential shrinkage of the retained dentine may occur during the period of carious dentine arrestment. However, basic clinical limitations on the objective evaluation of pulp inflammation creates dilemmas in treating the deep lesions. Also, a global consensus is lacking for the definition of a so-called deep lesion. Finally, an optimal evidence goal for choosing the best approach for deep lesion treatment in adults has still not been fully defined. Taken together, it may not be a surprise that treatment variation is reported amongst general dental practitioners on deep caries treatment. Here, facts are presented supporting the treatment, including some drawbacks, as well as updated guidelines for the procedure. Recent clinical high evidence data from randomised clinical trials significantly favour the stepwise approach as a predictable and reliable treatment for well-defined deep carious lesions located in the pulpal quarter of the dentine in terms of avoiding pulp exposure, keeping the tooth vital and without the development of apical pathosis.

Clinical trials are the cornerstone of evidence-based medicine. By directly comparing different interventions they produce evidence on their relative efficacy and effectiveness This, in turn, can inform secondary research and guideline development to facilitate evidence-based clinical decision making. However, the quality of evidence stemming from clinical trials is frequently poor. Here, the pathway of evidence from basic research to the generation of implementable clinical guidelines will be described. Relevant factors related to trial design and reporting, such as the choice of trial comparators, outcomes and outcome measures, will be described and their influence on evidence synthesis will be discussed. Finally, recommendations on how to improve trials in order to increase their usefulness for evidence generation will be given.

Despite their limitations, caries epidemiology continues to rely predominantly on visual/tactile indices for detecting and assessing carious lesion-related conditions. Over the last 4 to 5 decades, the prevalence and severity of dental caries in primary and permanent dentitions have been reduced in a number of countries based on the published studies. Despite this achievement, the prevalence and severity of dental caries remains too high at a world level. Pits and fissures in occlusal surfaces of first molars and pits in buccal surfaces of lower first molars are most vulnerable for developing a carious lesion. Dental caries is a preventable, behavioural/life-style disease that is age related and life-long. Preventing dental caries should start at mother-and-child clinics in conjunction with the available educational and health care programmes. Oral health (caries) epidemiological surveys should be held periodically.