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Objectives The objective was to evaluate the diagnostic accuracy of radiographic evaluation (XR), visual-tactile assessment (VT), laser-fluorescence (LF) (DIAGNOdent Pen/KaVo), and near-infrared-light transillumination (NILT) (DIAGNOcam/KaVo) on proximal root caries lesions in vitro. Methods Two-hundred extracted permanent premolars and molars with and without proximal root caries lesions were allocated to 50 diagnostic models simulating the proximal contacts between teeth and mounted in a phantom dummy head. Two independent examiners used the diagnostic approaches to detect any or advanced root caries lesions, with histologic evaluation of the lesions serving as reference. Receiver operating characteristic (ROC) curves were employed, and sensitivity, specificity, and the area under the ROC curve (AUC) are calculated. Significant differences in mean AUCs between approaches were assumed if p t-test). Results NILT was not applicable for proximal root caries detection. The sensitivity/specificity to detect any lesions was 0.81/0.63 for XR, 0.76/0.88 for VT and 0.81/0.95 for LF, and the sensitivity/specificity to detect advanced lesions was 0.43/0.94 for XR, 0.66/0.99 for VT, and 0.83/0.78 for LF, respectively. For both, any and advanced root caries lesions, mean AUCs for LF and VT were significantly higher compared to XR (p p = 0.01), but not for advanced root caries lesions (p = 0.59). Conclusions Under the in vitro conditions chosen, LF and VT were more accurate than XR to detect proximal root caries lesions, with LF being particularly useful for initial lesion stages. Clinical relevance LF might be a useful diagnostic aid for proximal root caries diagnosis. Clinical studies are necessary to corroborate the findings.

Objectives To define an expert Delphi consensus on when to intervene in the caries process and existing carious lesions. Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference. Results Lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations may be placed for form, function, aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated lesions which are cleansable. Cavitated lesions which are not cleansable usually require minimally invasive management. In specific circumstances, mixed interventions may be applicable. Occlusally, cavitated lesions confined to enamel/non-cavitated lesions extending radiographically into deep dentine may be exceptions. Proximally, cavitation is hard to assess tactile-visually. Most lesions extending radiographically into the middle/inner third of dentine are assumed to be cavitated. Those restricted to the enamel are not cavitated. For lesions extending radiographically into the outer third of dentine, cavitation is unlikely. These lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds. Conclusions Comprehensive diagnosis is the basis for systematic decision-making on when to intervene in the caries process and existing lesions.

Objectives: To develop a risk of bias tool for pre-clinical dental materials research studies that aims to support reporting of future investigations and improve assessment in systematic reviews. Methods: A four-stage process following EQUATOR network recommendations was followed, which included project launch, literature review, Delphi process and the tool finalization. With the support of the European Federation of Conservative Dentistry (EFCD) and the Dental Materials Group of the International Association for Dental Research (DMG-IADR), a total of 26 expert stakeholders were included in the development and Delphi vote of the initial proposal. The proposal was built using data gathered from the literature review stage. During this stage, recent systematic reviews featuring dental materials research, and risk of bias tools found in the literature were comprehensively scanned for bias sources. The experts thus reached a consensus for the items, domains and judgement related to the tool, allowing a detailed guide for each item and corresponding signalling questions. Results: The tool features nine items in total, spread between 4 domains, pertaining to the following types of bias: bias related to planning and allocation (D1), specimen preparation (D2), outcome assessment (D3) and data treatment and outcome reporting (D4). RoBDEMAT, as presented, features signalling questions and a guide that can be used for RoB judgement. Its use as a checklist is preferred over a final summary score. Conclusion: RoBDEMAT is the first risk of bias tool for pre-clinical dental materials research, supported and developed by a broad group of expert stakeholders in the field, validating its future use. Clinical significance: This new tool will contribute the study field by improving the scientific quality and rigour of dental materials research studies and their systematic reviews. Such studies are the foundation and support of future clinical research and evidence-based decisions. © 2022 The Author(s), This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The present study aimed to meta-analyze and evaluate the certainty of evidence for resin infiltration of proximal carious lesions in primary and permanent teeth. While resin infiltration has been shown efficacious for caries management, the certainty of evidence remains unclear. The protocol was registered with PROSPERO (CRD42018080895), and PRISMA guidelines have been followed. The databases PubMed, Embase, and Cochrane CENTRAL were systematically screened, complemented by hand searches and cross-referencing. Eleven relevant articles were identified and included, i.e., randomized controlled trials (RCTs) comparing the progression of resin infiltrated proximal caries lesions (combined with non-invasive measures) in primary or permanent teeth with non-invasive measures. Random-effects meta-analyses and trial sequential analyses (TSA) were performed for per-protocol (PP), intention-to-treat (ITT), and best/worst case (BC/WC) scenarios. Six included trials assessed lesions in permanent teeth and five trails assessed lesions in primary teeth. The trials had a high or unclear risk of bias. Risk of caries progression was significantly reduced for infiltrated lesions in the PP, ITT, and BC scenarios in both permanent teeth and primary teeth, but not in the WC scenario. According to the TSA, firm evidence was reached for all of the scenarios except the WC. In conclusion, there is firm evidence for resin infiltration arresting proximal caries lesions in permanent and primary teeth.

To compare the clinical performance and treatment times between glass hybrid (GH; EQUIA Forte Fil/EQUIA Forte Coat , GC) and adhesive/nanofilled resin composite restorations (RC; OptiBond FL , Kerr/Filtek Supreme XTE , 3M Oral Care) of sclerotic non-carious cervical lesions (sNCCL).This is an 18-month interim analysis of a 36-month cluster-randomized trial (ClinicalTrials.gov Identifier: NCT02631161). Eighty-eight patients (50-70 years) with 175 sNCCLs were randomized to receive GH or RC restorations. Restorations were placed without mechanical cavity preparation, and treatment time was recorded. After 18 months, restorations were evaluated using FDI criteria. Factors associated with restoration survival were evaluated using multi-level Cox-regression analysis. Generalized linear mixed modelling was used to analyze factors associated with treatment time.After a mean of 18 months (min/max: 8/25), 78 patients (160 restorations) were assessed. Fifteen restorations (18%) failed in GH, and 11 (12%) in the RC, without a significant difference in survival (p = 0.904/Cox). Retention loss was the most common reason for failure in both groups. Restorations placed in older patients showed lower risk of failure [OR (95% CI): 0.90 (0.81-0.99) per year], while mandibular teeth showed higher risks [2.89 (1.00-8.31)]. Treatment time was significantly shorter for GH (mean ± SD: 8.6 ± 4.3 min) than RC (11.7 ± 5.7 min; p0.001).GH may be a suitable alternative to RC for restoring sNCCLs, without any significant difference in survival between the two materials at this interim analysis. In addition, placing GH restorations required less chairtime than did placing RC restorations.

OBJECTIVE: Secondary caries is among the most frequent reasons for the failure of dental restorations. Glass ionomer cement (GIC) restorations have been proposed to protect the surrounding dental tissues from demineralization through the release of fluoride and by buffering the acid attack from dental biofilms. In contrast, the lack of buffering by composite resin (CR) restorations has been suggested as a promoting factor for the development of secondary caries.METHODS: The present study employed transversal microradiography and confocal microscopy based pH ratiometry to quantify mineral loss and map microscale pH gradients inside Streptococcus mutans biofilms grown on compound specimens consisting of enamel, dentin and either GIC or CR.RESULTS: Mineral loss in dentin was significantly lower next to GIC than next to CR, but no significant differences in local biofilm pH were observed between the two restorative materials.SIGNIFICANCE: The cariostatic effect of GIC relies predominantly on the provision of fluoride and not on a direct buffering action. The lack of buffering by CR did not affect local biofilm pH and may therefore be of minor importance for secondary caries development.

Background Due to exposure to potentially infectious aerosols during treatments, the dental personnel is considered being at high risk for aerosol transmitted diseases like COVID-19. The aim of this study was to evaluate aerosol exposure during different dental treatments as well as the efficacy of dental suction to reduce aerosol spreading. Methods Dental powder-jet (PJ; Air-Flow®), a water-cooled dental handpiece with a diamond bur (HP) and water-cooled ultrasonic scaling (US) were used in a simulation head, mounted on a dental unit in various treatment settings. The influence of the use of a small saliva ejector (SE) and high-volume suction (HVS) was evaluated. As a proxy of aerosols, air-born particles (PM10) were detected using a Laser Spectrometer in 30 cm distance from the mouth. As control, background particle counts (BC) were measured before and after experiments. Results With only SE, integrated aerosol levels [median (Q25/Q75) µg/m3 s] for PJ [91,246 (58,213/118,386) µg/m3 s, p 3 s], whilst HP [11,119 (7190/17,234) µg/m3 s, p > 0.05] and US [6558 (6002/7066) µg/m3 s; p > 0.05] did not increase aerosol levels significantly. The use of HVS significantly decreased aerosol exposure for PJ [37,170 (29,634/51,719) µg/m3 s; p 3 s; p p Conclusions To reduce the exposure to potentially infectious aerosols, HVS should be used during aerosol-forming dental treatments.

Confocal microscopy-based pH ratiometry is a powerful tool to study pH at the microscale inside dental biofilms. The aim of the present work was to investigate the influence of different underlying substrates – enamel (E), dentin (D), composite resin (C) and glass ionomer cement (G) – on local pH in highly standardized Streptococcus mutans biofilms. Biofilms were grown for 7 days in an artificial mouth model on compound specimens (n=18) consisting of bovine enamel, a restoration (C or G), and dentin. Then extracellular pH in the biofilms was monitored for 45 min after exposure to sucrose in fifteen fields of view (FOVs) in five locations on all specimens: On the enamel surface (E), at the border between enamel and restoration (EC/EG), on the restoration (C/G), at the border between restoration and dentin (DC/DG) and on the dentin surface (D). Mineral loss (ΔZ) in dentin and enamel was assessed by transversal microradiography.pH in all biofilms dropped rapidly upon exposure to sucrose, and steep chemical gradients with pH differences of up to one unit were observed inside individual biofilms. The mean±SD pH on dentin (5.39±0.15) and at the dentin/restoration border (5.47±0.15) was significantly higher than on the other substrates after 45 min (E: 5.21±0.32; EC/EG: 5.19±0.25; C: 5.25±0.38; G: 5.05±0.15; p

Objectives: We assessed the costs of dental services in statutorily insured, very old (geriatric) Germans. Methods: A comprehensive sample of very old (≥75 years) people insured at a large Northeastern statutory insurer was followed over 6 years (2012–2017). We assessed dental services costs for: (1) examination, assessments and advice, (2) operative, (3) surgical, (4) prosthetic, (5) periodontal, (6) preventive and (7) outreach services. Association of utilization with: (1) sex, (2) age, (3) region, (4) social hardship status, (5) International Disease Classification (ICD-10) diagnoses and (6) Diagnoses Related Groups (DRGs) was explored. Results: 404,610 individuals with a mean (standard deviation, SD) age 81.9 (5.4 years) were followed, 173,733 did not survive follow-up. Total mean costs were 129.61 (310.97) euro per capita, the highest costs were for prosthetic (54.40, SD 242.89 euro) and operative services (28.40, SD 68.38 euro), examination/advice (21.15, SD 28.77 euro), prevention (13.31, SD 49.79 euro), surgery (5.91, SD 23.91 euro), outreach (4.81, SD 28.56 euro) and periodontal services (1.64, SD 7.39 euro). The introduction of new fee items for outreach and preventive services between 2012 and 2017 was reflected in costs. Total costs decreased with increasing age, and this was also found for all service blocks except outreach and preventive services. Costs were higher in those with social hardship status, and in Berlin than Brandenburg and Mecklenburg-Western Pomerania. Certain general health conditions were associated with increased or decreased costs. Conclusions: Costs were associated with sex, social hardship status, place of living and general health conditions. Clinical significance: Dental services costs for the elderly in Germany are unequally distributed and, up to a certain age or health status, generated by invasive interventions mainly. Policy makers should incentivize preventive services earlier on and aim to distribute expenses more equally.

OBJECTIVES Efficacy of proximal caries infiltration to arrest lesion progression has been shown in university settings, but only once in a practice-based pragmatic design with a follow-up of 18 months. The aim of this randomized split-mouth placebo-controlled study was to follow-up this cohort for 3 years and those with high caries risk for 4 years. METHODS Originally, in 87 children and young adults pairs of 238 proximal caries lesions, radiographically extending into inner half of enamel (E2) or outer third of dentin (D1), were randomly allocated to two groups: infiltration (Icon; DMG) or mock (control) treatment by five dentists in four private practices. All subjects received risk-related instructions for diet, flossing and fluoridation. The primary outcome was radiographic lesion progression (pairwise comparison) evaluated by two evaluators independently being blinded to treatment allocation. RESULTS After 36 months [mean (SD): 1152 (166) days] 165 lesion pairs in 64 patients as well as after 48 months [mean (SD): 1496 (121) days] 71 lesion pairs in 20 high caries risk patients could be re-evaluated clinically as well as radiographically using individualized bitewing holders as at baseline. No adverse events could be observed. After 36 months, progression was recorded in 23/165 test (14%) and 64/165 control lesions (39%) [McNemar/Obuchowski test; p

Objectives We assessed dental service utilization in very old Germans. Methods A comprehensive sample of 404,610 very old (≥ 75 years), insured at a large statutory insurer (Allgemeine Ortskrankenkasse Nordost, active in the federal states Berlin, Brandenburg, Mecklenburg-Western Pomerania), was followed over 6 years (2012–2017). Our outcome was the utilization of dental services, in total (any utilization) and in five subgroups: (1) examinations and associated assessment or advice, (2) restorations, (3) surgery, (4) prevention, (5) outreach care. Association of utilization with (1) sex, (2) age, (3) region, (4) social hardship status, (5) ICD-10 diagnoses, and (6) German modified diagnosis-related groups (GM-DRGs) was explored. Results The mean (SD) age of the sample was 81.9 (5.4) years. The utilization of any dental service was 73%; utilization was highest for examinations (68%), followed by prevention (44%), surgery (33%), restorations (32%), and outreach care (13%). Utilization decreased with age for nearly all services except outreach care. Service utilization was significantly higher in Berlin and most cities compared with rural municipalities, and in individuals with common, less severe, and short-term conditions compared with life-threatening and long-term conditions. In multi-variable analysis, social hardship status (OR: 1.14; 95% CI: 1.12-1.16), federal state (Brandenburg 0.85; 0.84–0.87; Mecklenburg-Western Pomerania: 0.80; 0.78–0.82), and age significantly affected utilization (0.95; 0.95–0.95/year), together with a range of co-morbidities according to ICD-10 and DRG. Conclusions Social, demographic, regional, and general health aspects were associated with the utilization of dental services in very old Germans. Policies to maintain access to services up to high age are needed. Clinical significance The utilization of dental services in the very old in northeast Germany showed significant disparities within populations. Policies to allow service utilization for sick, economically disadvantaged, rural and very old populations are required. These may include incentives for outreach servicing, treatment-fee increases for specific populations, or referral schemes between general medical practitioners and dentists.

OBJECTIVE: This study compared survival, restoration quality and costs of glass hybrid (GH; EQUIA Forte Fil/EQUIA Forte Coat) and resin composite restorations (RC; OptiBond FL/Filtek Supreme XTE) of sclerotic non-carious cervical lesions. METHODS: This is a cluster-randomized trial (ClinicalTrials.gov: NCT02631161). 88 patients (50-70 years) with 175 sNCCLs were randomized to receive GH or RC. Restorations were placed without mechanical cavity preparation and followed for a mean 36 (min/max: 31/55) months (variable follow-up due to COVID-19 lockdown). Restoration quality was re-evaluated at 1-, 18- and 36-months using FDI-criteria. Survival was assessed using multi-level Cox-regression analysis. Costs were estimated from a payer's perspective in Germany. Initial costs were determined based on micro-costing using time recordings and hourly costs, and follow-up costs based on statutory insurance fee-item-catalogues. RESULTS: 88 patients (175 restorations) were treated; 43 received GH (83 restorations), 45 RC (92 restorations). 17  GH and 19 RC showed total retention loss, 5  GH were partially lost (p = 0.396/Cox). FDI ratings were not sufficiently different for any domain except surface luster, where RC showed higher score (p 

Caries preventive varnishes containing only fluoride might differ from those containing a combination of fluoride and antimicrobial components in terms of mineralization properties and their impact on the cariogenic biofilm. We compared a fluoride and a fluoride + chlorhexidine (CHX)/cetylpyridinium chloride (CPC) varnish on root caries formation in vitro. One hundred bovine root dentin samples were allocated to five groups (n = 20/group): (1) 7700 ppm fluoride varnish (Fluorprotector S (F)), (2) experimental placebo varnish for F (F-P), (3) 1400 ppm fluoride + 0.3% CHX/0.5% CPC varnish (Cervitec F (CF)), (4) experimental placebo varnish for CF (CF-P), (5) untreated control. Cariogenic challenge was provided using a multi-station, continuous-culture 3-species (Streptococcus mutans (SM), Lactobacillus rhamnosus (LR), Actinomyces naeslundii (AN)) biofilm model for 10 days. Mineral loss (ΔZ) was evaluated using transversal microradiography and bacterial counts in the biofilm assessed as colony-forming units. Fluorescence in situ hybridization (FISH) and confocal microscopy were performed to assess the three-dimensional biofilm architecture. Mean ± SD (vol% × μm) ΔZ was significantly lower for F (9133 ± 758) and CF (9835 ± 1677) compared to control (11362 ± 919) (p &lt, 0.05), without significant differences between F and CF. SM counts were significantly lower and LR counts significantly higher in F- and CF-biofilms compared to control. AN counts were significantly higher in the F-biofilms than in all other groups. According to FISH, SM and LR invaded dentinal tubules only in the control-group. In the CF-group, the basal biofilm layer did not contain SM and AN. Both F and CF varnishes had similar caries-preventive effects and a considerable impact on biofilm structure and composition.

Background: Self-assembling peptides (SAP) may prevent and/or arrest caries lesions. The aim of the study was to evaluate SAP for caries prevention and arrest in primary tooth enamel in vitro. Methods: 215 extracted primary teeth were used. In the prevention experiment, self-assembling peptide for prevention (SAPP), fluoride varnish/mouthwash (FV/FMW), casein-phosphopeptide amorphous-calcium phosphate (CPP-ACP), nanohydroxy-apatite (nHA) were applied. Samples were subjected to a demineralizing pH-cycling for 14-days. In the arrest experiment, 60 samples were pre-demineralized and induced lesions treated using self-assembling peptide for repair (SAPR), FV, CPP-ACP plus fluoride and resin infiltration (RI), and submitted to pH-cycling. Thirty-five samples were used as negative controls (NC). Mineral loss and its differences (Δ/ΔΔZ) were determined using transversal microradiography. Results: FV (ΔZ median: -46 [interquartile range: 189] vol%×µm) and FMW (-28 [129] vol%×µm) prevented caries significantly more effective than all other groups (p Conclusions: FV and FMW showed the largest caries-preventive effect, while RI and FV arrested lesion progression in primary tooth enamel in vitro. Clinical significance: Preventing and arresting caries lesion allows decreasing invasive treatment needs and patient’s morbidity and fosters the application of minimal invasive dentistry approach.

Objectives: COVID-19 infection control measures have been recommended for dental practices worldwide. This qualitative study explored barriers and enablers for the implementation of these measures in German dental practices. Methods: Semi-structured phone interviews were conducted in November/December 2020 (purposive/snowball sampling). The Theoretical Domains Framework (TDF) and the Capabilities, Opportunities and Motivations influencing Behaviors model (COM-B) were used to guide interviews. Mayring’s content analysis was employed to analyze interviews. Results: All dentists (28–71 years, 4/8 female/male) had implemented infection control measures. Measures most frequently not adopted were FFP2 masks, face shields (impractical), the rotation of teams (insufficient staffing) and the avoidance of aerosol-generating treatments. Dentists with personal COVID-19 experience or those seeing themselves as a role model were more eager to adopt measures. We identified 34 enablers and 20 barriers. Major barriers were the lack of knowledge, guidelines and recommendations as well as limited availability and high costs of equipment. Pressure by staff and patients to ensure infection control was an enabler. Conclusions: Dentists are motivated to implement infection control measures, but lacking opportunities limited the adoption of certain measures. Policy makers and equipment manufacturers should address these points to increase the implementation of infection control measures against COVID-19 and potential future pandemics.

Objectives We aimed to apply deep learning to detect white spot lesions in dental photographs. Methods Using 434 photographic images of 51 patients, a dataset of 2781 cropped tooth segments was generated. Pixelwise annotations of sound enamel as well as fluorotic, carious or other types of hypomineralized lesions were generated by experts and assessed by an independent second reviewer. The union of the reviewed annotations were used to segment the hard tissues (region-of-interest, ROI) of each image. SqueezeNet was employed for modelling. We trained models to detect (1) any white spot lesions, (2) fluorotic lesions and (3) other-than-fluorotic lesions. Modeling was performed on both the cropped and the ROI images and using ten-times repeated five-fold cross-validation. Feature visualization was applied to visualize salient areas. Results Lesion prevalence was 37 %; the majority of lesions (24 %) were fluorotic. None of the metrics differed significantly between the models trained on cropped and ROI imagery (p > 0.05/t-test). Mean accuracies ranged between 0.81−0.84, without significant differences between models trained to detect any, fluorotic or other-than-fluorotic lesions (p > 0.05). Specificities were 0.85−0.86; sensitivities were lower (0.58−0.66). Models to detect any lesions showed positive/negative predictive values (PPV/NPV) between 0.77−0.80, those to detect fluorotic lesions 0.67 (PPV) to 0.86 (NPV), and those to detect other-than-fluorotic lesions 0.46 (PPV) to 0.93 (NPV). Light reflections were the main reason for false positive detections. Conclusions Deep learning showed satisfying accuracy to detect white spot lesions, particularly fluorosis. Some models showed limited stability given the small sample available. Clinical significance Deep learning is suitable for automated classification of retro- or prospectively collected imagery and may assist practitioners in discriminating white spot lesions. Future studies should expand the scope into more granular multi-class detections on a larger and more generalizable dataset.

Objective To reevaluate proven strengths and weakness of glass ionomer cements (GICs) and to identify agreement versus conflicting evidence in previous reports regarding the transition between GIC and the tooth, and the existence of an “interphase”. Materials and methods Relevant electronic databases (PubMed, Embase via Ovid and Medline via Web of science) were searched for publications of evidence relating to the transition zone at the GIC-tooth interphase. Studies were examined and grouped according to characteristics of GIC-tooth attachment area quantified by X-ray and optical microscopy techniques in 2D and 3D. Results Inclusion criteria comprised of in vitro studies that showed images of the conventional GIC-tooth substrate attachments using at least one of the following techniques: SEM, CLSM, or μCT. The search identified 419 studies, from which 33 were included. Ten studies demonstrated the existence of an interphase layer and five studies quantified the layer thickness (1–15 μ). Twenty-nine publications studied different failure modes of the GIC-tooth interphase. Eleven studies described discontinuities inside the GIC bulk. Conclusion The GIC-tooth interphase attributes evolve with time. Good attachment is evident even under compromised surface preparation. The GIC-tooth attachment area is resistant to acidic dissolution as compared to both tooth and GIC bulk. In general, studies revealed mostly intact GIC-tooth interphases with only some cracked interphases. Clinical significance GIC bonds to the tooth structure and forms an acid resistant attachment zone that might enhance caries inhibition. Due to fluoride release and ease of use, GIC provides a cost effective treatment, ideal for low income or high caries populations.

Objectives For well-defined deep (> 2/3 dentin extension) carious lesions, selective (SE) or stepwise (SW) carious tissue removals have been recommended, while there is limited comparative evidence for both. We compared SE and SW over 24 months in a randomized controlled trial. Methods A two-arm superiority trial was conducted comparing SW/SE in primary molars without pulpal symptoms but well-defined deep lesions. Seventy-four children (1 molar/child) aged 3–9 years were recruited. In a first step, peripheral carious tissue was removed until hard dentin remained, while in proximity to the pulp, leathery dentin was left. An adhesive compomer restoration was placed and restorations re-examined after 6 months. In SW, re-entry and removal to firm dentin was conducted pulpo-proximally, followed by re-restoration. Molars were re-evaluated for a total of 24 months. Our primary outcome was success (absence of restorative/endodontic complications or pulp exposures). Secondary outcomes included total treatment and opportunity costs and restoration quality, assessed using modified USPHS criteria. Results After 24 months, 63 molars (31 SE, 32 SW) were re-assessed. Four failures occurred (2 exposures in SW; 2 pulpal complications in SE, 1 of them leading to extraction, p > 0.05). Restoration integrity was satisfying in both groups (USPHS A/B/C in 21/8/0 SE and 23/7/0 SW, p > 0.05). Treatment and opportunity costs were significantly higher in SW than SE (mean 171 ± 51 vs. 106 ± 90; p Conclusions After 2 years, SE and SW showed similar efficacy for managing deep carious lesions in primary molars. The higher costs for SW should be considered during decision-making. Clinical significance In primary molars with well-defined deep carious lesions SE was less costly and similarly efficacious like SW. From a cost and applicability perspective, SW may need to be indicated restrictively, e.g., for very deep (> 3/4 dentin extension) lesions only. Trial registration ClinicalTrials.gov Identifier: NCT02232828

Objectives To provide consensus recommendations on how to intervene in the caries process in adults, specifically proximal and secondary carious lesions. Methods Based on two systematic reviews, a consensus conference and followed by an e-Delphi consensus process were held with EFCD/ORCA/DGZ delegates. Results Managing an individual’s caries risk using non-invasive means (oral hygiene measures including flossing/interdental brushes, fluoride application) is recommended, as both proximal and secondary carious lesions may be prevented or their activity reduced. For proximal lesions, only cavitated lesions (confirmed by visual-tactile, or radiographically extending into the middle/inner dentine third) should be treated invasively/restoratively. Non-cavitated lesions may be successfully arrested using non-invasive measures in low-risk individuals or if radiographically confined to the enamel. In high-risk individuals or if radiographically extended into dentine, for these lesions, additional micro-invasive (lesion sealing and infiltration) treatment should be considered. For restoring proximal lesions, adhesive direct restorations allow minimally invasive, tooth-preserving preparations. Amalgams come with a lower risk of secondary lesions and may be preferable in more clinically complex scenarios, dependent on specific national guidelines. In structurally compromised (especially endodontically treated) teeth, indirect cuspal coverage restorations may be indicated. Detection methods for secondary lesions should be tailored according to the individual’s caries risk. Avoiding false positive detection and over-treatment is a priority. Bitewing radiographs should be combined with visual-tactile assessment to confirm secondary caries detections. Review/refurbishing/resealing/repairing instead of replacing partially defective restorations should be considered for managing secondary caries, if possible. Conclusions An individualized and lesion-specific approach is recommended for intervening in the caries process in adults. Clinical significance Dental clinicians have an increasing number of interventions available for the management of dental caries. Many of them are grounded in the growing understanding of the disease. The best evidence, patients’ expectations, clinicians’ expertise, and the individual clinical scenario all need to be considered during the decision-making process.

This paper provides recommendations for dentists for the treatment of dental caries in children, with an emphasis on early childhood caries (ECC), primary teeth, and occlusal surfaces in permanent teeth. A consensus workshop followed by an e-Delphi consensus process was conducted with an expert panel nominated by the European Organization for Caries Research (ORCA) and European Federation of Conservative Dentistry (EFCD)/German Association of Conservative Dentistry (DGZ) boards. Based on 3 systematic reviews and a nonsystematic literature search, recommendations were developed. The caries decline has led to a more polarized disease distribution in children and adolescents along social gradients which should be taken into account when managing the caries process at all levels, such as the individual, the group, or a population. The control or reduction of caries activity is the basis for successful caries management. In children, caries management requires adequate daily oral hygiene and fluoride application via toothpaste, ensured by caregivers, and especially for ECC prevention an emphasis on sugar intake reduction is needed. These noninvasive interventions are also suitable to arrest or control initial or even cavitated dentine caries lesions in the absence of irreversible pulpitis. Fluoride varnish or silver diammine fluoride can be added as supplementary agents. In pits and fissures, composite resin materials can be used as preventive sealants and for defect-oriented minimally invasive restorations. In primary molars, preformed metal crowns are more successful than multisurface fillings, especially in caries-active patients. With persisting high caries activity, multiple lesions, and limited cooperation, caries control should consist of robust measures with high success rates, even including extraction in selected cases. This applies especially to treatments performed under general anesthesia., info:eu-repo/semantics/published

Objectives We aimed to assess periodontal services utilization in very old Germans. Methods A comprehensive sample of very old (≥ 75 years), insured at a large Northeastern statutory insurer was followed over 6 years (2012–2017). We assessed periodontal service provision, entailing (1) periodontal screening index (PSI), (2) periodontal status/treatment planning, (3) periodontal therapy (scaling and root planning with or without access surgery), (4) postoperative reevaluation, and (5) any of these four services groups. Association of utilization with (1) sex, (2) age, (3) region, (4) social hardship status, (5) ICD-10 diagnoses, and (6) diagnoses-related groups was explored. Results 404.610 individuals were followed; 173,733 did not survive follow-up. The mean (SD) age was 81.9 (5.4) years. 29.4% (119,103 individuals) utilized any periodontal service, nearly all of them the PSI. Periodontal status/treatment planning, treatment provision, and reevaluation were provided to only a small fraction (1.54–1.57%, or 6224–6345) of individuals. The utilization of the PSI increased between 2012 and 2017; no such increase was observed for treatment-related services. Utilization decreased with age; those aged > 85 years received nearly no services at all. Decreases were more pronounced for treatment-related services. Utilization was lower in rural than urban areas, those with hardship status, and those severely ill (e.g., dementia, heart insufficiency). In multivariable analysis, a previous PSI measurement tripled the odds of receiving treatment-related services (OR: 3.2; 95% CI: 3.0-3.4). Conclusions Periodontal services utilization was low. Screening for periodontal disease significantly increased therapy provision. Social, demographic, regional, and general health aspects were associated with utilization. Clinical significance The utilization of periodontal services in the very old in Northeast Germany was low, and even screening was only performed in a minority of individuals. Policies to increase identification and management of periodontitis especially in the most vulnerable individuals are needed.

Objectives We assessed dental prosthetic services utilization in very old Germans. Methods A comprehensive sample of 404,610 very old (≥ 75 years), insured at one large statutory insurer (Allgemeine Ortskrankenkasse Nordost, acting in the federal states Berlin, Brandenburg, Mecklenburg-Vorpommern), were followed over 6 years (2012–2017). Our outcome was the utilization of prosthetic services, in total and seven subgroups: (1) Crowns/partial crowns, (2) fixed dental prostheses (FDPs), (3) partial removable prostheses (RDPs), (4) full RDPs, (5) temporary services, (6) relining/rebasing/repairing/extending RDPs, (7) repairing FDPs. Association of utilization with (1) gender, (2) age, (3) region, (4) social hardship status, (5) ICD-10 diagnoses and (6) German diagnoses related groups (G-DRG) was explored. Results The mean (SD) age of the sample was 81.9 (5.4) years; mean follow-up was 1689 (705) days. The mean utilization of any prosthetic service was 27.0%; the most often utilized service type were total RDPs (13.2% utilization), crowns (8.1%), and partial RDPs (7.1%). Utilization decreased with age for nearly all services (except relining/rebasing/repairing/extending RDPs) Utilization of prosthetic services was significantly higher in Berlin and most cities compared with rural municipalities and in individuals with common, less severe conditions according to ICD-10 and DRGs compared with life-threatening conditions or dementia. In multivariable analysis, gender (OR; 95% CI: 0.95; 0.93–0.98), social hardship status (1.19; 1.17–1.21), federal state (Brandenburg 0.57; 0.56–0.59; Mecklenburg-Vorpommern: 0.66; 0.64–0.67) and age significantly affected utilization (0.95; 0.95–0.95/year). Conclusions Patient-related and healthcare factors determine the utilization of prosthetic services in very old Germans. Interventions to maintain sufficient prosthetic care up to high age are required. Clinical significance The utilization of prosthetic services in the very old in Northeast Germany showed significant disparities within populations and service types. There seems to be great need to better understand the drivers of utilization, and to develop and evaluate interventions to maintain sufficient prosthetic care up to high age.

Phase-contrast enhanced micro-computed tomography reveals huge discontinuities at the interfaces between dental fillings and the tooth substrate. Despite the complex micromorphology, gaps in bonding could be visualized and quantified in 3D., Bonding of resin composite fillings, for example following root-canal treatment, is a challenge because remaining gaps grow and lead to failure. Here, phase-contrast-enhanced micro-computed tomography (PCE-CT) is used to explore methods of non-destructive quantification of the problem, so that countermeasures can be devised. Five human central incisors with damaged crowns were root-filled followed by restoration with a dental post. Thereafter, the crowns were rebuilt with a resin composite that was bonded conventionally to the tooth with a dental adhesive system (Futurabond U). Each sample was imaged by PCE-CT in a synchrotron facility (ID19, European Synchrotron Radiation Facility) with a pixel size of 650 nm. The reconstructed datasets from each sample were segmented and analysed in a semi-automated manner using ImageJ. PCE-CT at sub-micrometre resolution provided images with an impressive increased contrast and detail when compared with laboratory micro-computed tomography. The interface between the dental adhesive and the tooth was often strongly disrupted by the presence of large debonded gaps (on average 34% ± 15% on all surfaces). The thickness of the gaps spanned 2 µm to 16 µm. There was a large variability in the distribution of gaps within the bonding area in each sample, with some regions around the canal exhibiting up to 100% discontinuity. Although only several micrometres thick, the extensive wide gaps may serve as gateways to biofilm leakage, leading to failure of the restorations. They can also act as stress-raising ‘cracks’ that are likely to expand over time in response to cyclic mechanical loading as a consequence of mastication. The observations here show how PCE-CT can be used as a non-destructive quantitative tool for understanding and improving the performance of clinically used bonded dental restorations.

Purpose: While aiming at the use of Cold Atmospheric Plasmas (CAPs) in restorative dentistry, the present study intended to assess if plasma irradiation increases the Tensile Bond Strength (TBS) in non-demineralized and demineralized dentin. Materials and Methods: Forty-eight human dentin samples were assigned to three different treatment modalities: I: Plasma jet irradiation (CAP I); II: Dielectric barrier discharge plasma treatment (CAP II); and III: No plasma (control). In each group, half of the specimens had previously been demineralized. A fourth generation of adhesive and dental composite was applied to all of the samples. The testing of the TBS was performed after artificial aging. Results: In the non-demineralized dentin, the mean TBS values were significantly higher after using CAP II (16.95 MPa) than in the control samples (4.2 MPa; p = 0.001). Significantly higher TBS values were also obtained after irradiating the demineralized dentin with CAP I and CAP II (11.68 and 4.6 MPa) when compared to the control samples (0 MPa; p = 0.003 and 0.038). The differences between both of the plasma sources were only slightly significant (p = 0.05). Conclusion: CAPs can potentially enhance the adhesive/dentin interfacial bonding strength, whereby the underlying effects seem to depend on the type of plasma source and the degree of dentinal (de-) mineralization. In the non-demineralized dentin, after a complete caries excavation, dielectric barrier discharge devices might be favorable over the plasma jets, in order to improve the adhesive/dentin interfacial bonding. In contrast, the plasma jets could be more effective in the demineralized dentin after an incomplete caries excavation.

Objectives For deep carious lesions, selective or stepwise carious tissue removal (SE, SW) seem advantageous compared with non-selective removal. For primary molars, there is insufficient evidence comparing SE against SW. This randomized pilot trial compared SE and SW over 12 months. Methods A two-arm superiority trial was conducted comparing SE and SW in primary molars with deep lesions but without pulpal symptoms. We recruited 74 children (one molar/child) aged 3–9 years. In both groups, peripheral carious tissue removal was performed at T1 to hard dentin. In proximity to the pulp, leathery dentin was left followed by an adhesive compomer restoration. Blinded re-examination was performed after six months (T2). Molars allocated to SW were re-entered, removal to firm dentin carried out pulpo-proximally, and again restored. After another 6 months, all molars were re-examined (T3). Our primary outcome was success, defined as no restorative/endodontic complications (including pulp exposure) leading to reinterventions. Secondary outcomes included total treatment and opportunity costs. Patients’, dentists’ and parents’ subjective assessments were recorded. This trial was registered (ClinicalTrials.gov/NCT02232828). Results After 12 months a total of 72 children (36 SE, 36 SW) were analyzed. Three failures occurred (2 exposures in SW, 1 pulpal complication leading to extraction in SE) (p > 0.05). The subjective evaluation by patients, parents or dentists did not differ significantly. Combined treatment and opportunity costs were significantly higher in SW (mean;SD: 186;61 Euro) than SE (100;59) (p Conclusions The significantly increased costs for performing SW instead of SE in deep carious lesions in primary molars may not be justified. Clinical significance For primary molars with deep lesions, but vital pulps, SE was less costly at similar efficacy compared with SW. Dentists’ decision-making should consider this alongside further clinical aspects.

Objectives Dentists have a range of options for managing molars with severe molar-incisor hypomineralization (MIH), each with different long-term implications. The cost-effectiveness of managing molars with severe MIH was assessed. Methods A mixed public-private-payer perspective within German healthcare was adopted. Individuals with one to four severely MIH-affected molars were followed over their lifetime. We compared: (1) removal of the tooth/teeth and orthodontic alignment of the second and third molars (Ex/Ortho); (2) restoration of the tooth using resin composite (Comp); (3) restoration using an indirect metal crown after temporizing it using a preformed metal crown (PMC/IR). The health outcome was tooth retention years. Transition probabilities were estimated based on the best available evidence. Cost calculations were based on German dental fee catalogues. Monte-Carlo microsimulations were performed for cost-effectiveness-analysis. Results If extraction was performed at the optimal age (9.5/11 years for maxillary/mandibular molars), Ex/Ortho was most cost-effective (67 years, 446–938 Euro). Comp (51 years, 1911 Euro) and PMC/IR were dominated (50 years, 2033 Euro). This cost-effectiveness ratio was also determined when >1 molar was treated. If extraction was performed later, assuming no spontaneous alignment, Ex/Ortho was more costly than Comp, at least when only 1 molar was treated. Conclusions For molars with severe MIH, extraction at the optimal age and, if needed, orthodontic alignment can be cost-effective, especially when >1 molar is affected. For single molars where the chance of spontaneous alignment is low, Comp might also be considered. These findings apply to German healthcare and within the limitations of this study only. Clinical significance: When deciding how to manage molars with severe MIH, both tooth retention, with lower costs but higher needs for re-treatments, and tooth removal, with possible need for orthodontic alignment, can be considered. Considering cost-effectiveness, the latter may be preferable, especially if the age of extraction is chosen correctly, or several molars are affected.

The aim of the study was to investigate whether specific volatile organic compounds (VOCs) can be detected in oral candidiasis patients using breath analysis in order to develop a point-of-care diagnostic tool. Breath samples of 10 diseased patients and 10 subjects carrying no Candida spp. were analyzed using gas chromatography and mass spectrometry. In infected patients, breath tests were performed before and after antifungal therapy. Breath testing was positive for 143 volatiles in both healthy subjects and diseased patients. Among those, specific signature volatiles known to be emitted by Candida spp. in vitro were not detected. Even though no specific signature was retrieved from the diseased patients, a pattern containing nine compounds (2-methyl-2-butanol, hexanal, longifolene, methyl acetate, 1-heptene, acetophenone, decane, 3-methyl-1-butanol, chlorbenzene) was identified, which showed characteristic changes after antifungal therapy. Focusing on the identified pattern, breath analysis may be applied to confirm the absence of Candida spp. after therapy in terms of a confirmatory test supplementing clinical examination, thereby replacing microbial testing. However, microbial testing will still be needed to initially confirm clinical diagnoses, as no specific signature was found. Clinical relevance: A breath test may help in avoiding extended antifungal administration resulting in resistance development and might be useful in the monitoring of disease recurrences in vulnerable groups.

Objective To assess the feasibility of detecting signature volatile organic compounds in the breath of patients with oral squamous cell carcinoma. Study Design Prospective cohort pilot study. Setting University hospital. Subjects and Methods Using gas chromatography and mass spectrometry, emitted volatile organic compounds in the breath of patients before and after curative surgery (n = 10) were compared with those of healthy subjects (n = 4). It was hypothesized that certain volatile organic compounds disappear after surgical therapy. A characteristic signature of these compounds for diseased patients was compiled and validated. Results Breath analyses revealed 125 volatile organic compounds in patients with oral cancer. A signature of 8 compounds that were characteristic for patients with oral cancer could be detected: 3 from this group presented were absent after surgery. Conclusion The presented results confirmed the hypothesis of an absence of cancer-associated volatile organic compounds in the breath after therapy. In this pilot study, we proved the feasibility of this test approach. Further studies should be initiated to establish protocols for usage in a clinical setting.

SUMMARY Objectives: For deep carious lesions, selective carious tissue removal (leaving soft dentin close to the pulp) is suggested. Afterward, different restoration materials, such as resin composites or glass hybrids (GHs), can be placed. Many dentists also apply setting or non-setting calcium hydroxide liners before restoration. We compared margin integrity and susceptibility for secondary caries in differently restored premolars in vitro. Methods: In 48 extracted human premolars, artificial residual lesions were induced on pulpo-axial walls of standardized cavities. Teeth were restored using a GH (Equia Forte) or adhesively placed resin composite restoration (OptiBond FL and Tetric EvoCeram) without any liner (RC), resin composite restoration with a non-setting calcium hydroxide liner (RC_NCH), or resin composite restoration with a setting calcium hydroxide liner (RC_SCH). After thermomechanical cycling, groups (n=12) were compared regarding their gingivocervical margin integrity (proportion of irregularities, microgaps, gaps >5 μm, overhangs). Teeth were then submitted to a continuous culture Lactobacillus rhamnosus biofilm model. After 14 days, bacterial numbers in biofilms, along tooth-restoration margins and mineral loss (ΔZ) of secondary lesions, were determined. Results: GH and RC_NCH showed significantly higher proportions of irregularities than RC and RC_SCH (p0.05). Conclusions: GH and composites lined with non-setting calcium hydroxide showed reduced margin integrity compared with non-lined composites or composites lined with setting calcium hydroxide. This did not increase susceptibility for secondary caries.

Objectives The aim of this in vitro study was to evaluate three treatment modalities [infiltrant resin (IR), micro-filled infiltrant resin (MFIR), infiltrant-sealant-combination (ISC)] regarding both their abilities to penetrate lesions differing in ICDAS-codes and to fill fissures and cavities. Materials and methods Extracted human molars (n = 90) showing fissure caries lesions with and without cavitations were etched with 15% hydrochloric acid (HCl) that was mixed with abrasives and a 15% HCl-solution (1:1). The etching gel was rubbed for 30 s within the fissure and, if eligible, within the cavity using a brush. After this pretreatment an infiltrant (Icon; DMG; IR) or an infiltrant mixed with microfillers (MFIR) was applied. ISC included the application of an infiltrant followed by a fissure sealant (Helioseal; Ivoclar Vivadent) From each tooth slices showing a non-cavitated (based on ICDAS-2) or cavitated lesion part (based on ICDAS-3/5) were prepared. Lesion (LA) and penetration areas (PA) as well as the completeness of fissure and cavity filling were analyzed using dual staining and confocal laser scanning microscopy. Results Percentage penetration (PP) was calculated as 100 × PA/LA. PP [median (25th/75th)] did not differ significantly between IR [95 (86/100)%], MFIR [93 (62/100)%] or ISC [89 (67/97)%] (p > 0.05; Kruskal-Wallis test). All three materials filled about 90% of the dimensions of fissures and cavities (p > 0.05; Kruskal-Wallis test). Conclusion It can be concluded that MFIR seems to be suitable to fill fissures and cavities like a fissure sealant and that it penetrates fissure caries lesions similarly deep as the conventional infiltrant after an experimental etching regime. Clinical significance The MFIR seems to combine advantages of the fissure sealing and the caries infiltration procedure.

To exert anticaries effects, probiotics are described to inhibit growth and biofilm formation of cariogenic bacteria such as Streptococcus mutans (SM). We screened 8 probiotics and assessed how SM growth or biofilm formation inhibition affects cariogenicity of probiotic-SM mixed-species biofilms in vitro. Growth inhibition was assessed by cocultivating probiotics and 2 SM strains (ATCC 20532/25175) on agar. Probiotics were either precultured before SM cultivation (exclusion), or SM precultured prior to probiotic cultivation (displacement). Inhibition of SM culture growth was assessed visually. Inhibition of SM biofilm formation on bovine enamel was assessed using a continuous-flow short-term biofilm model, again in exclusion or displacement mode. The cariogenicity of mixed-species biofilms of SM with the most promising growth and biofilm formation inhibiting probiotic strains was assessed using an artificial mouth model, and enamel mineral loss (ΔZ) was measured microradiographically. We found limited differences in SM growth inhibition in exclusion versus displacement mode, and in inhibition of SM 20532 versus 25175. Results were therefore pooled. Lactobacillus acidophilus LA-5 inhibited significantly more SM culture growth than most other probiotics. L. casei LC-11 inhibited SM biofilm formation similarly to other alternatives but showed the highest retention of probiotics in the biofilms (p < 0.05). Mineral loss from SM monospecies biofilms (ΔZ = 9,772, 25th/75th percentiles: 6,277/13,558 vol% × µm) was significantly lower than from mixed-species SM × LA-5 biofilms (ΔZ = 24,578, 25th/75th percentiles: 19,081/28,768 vol% × µm; p < 0.01) but significantly higher than from SM × LC-11 biofilms (ΔZ = 4,835, 25th/75th percentiles: 263/7,865 vol% × µm; p < 0.05). Probiotics inhibiting SM culture growth do not necessarily reduce the cariogenicity of SM-probiotic biofilms. Nevertheless, SM biofilm formation inhibition may be relevant in the reduction of cariogenicity.

Objectives The risk of ‘caries adjacent to restorations’ (CAR) might depend on the used restorative materials. In situ studies are often used to compare the risk of caries adjacent to different materials. We aimed to review in situ studies to evaluate how different materials contribute to risk of CAR. Data sources We included in situ controlled trials comparing directly placed restorative materials, reporting on caries (mineral loss, measured via radiography or micro-hardness) adjacent to these materials. Medline, Embase and Cochrane CENTRAL were systematically searched. Screening and data extraction was performed independently by two authors. Materials were classified according to the used adhesive and restorative materials. Fixed-effects pairwise and frequentistic network meta-analyses were performed Study selection Nine studies (132 patients, 8 materials) were included, yielding inconsistent results. We could not identify underlying reasons, as confounders were only limitedly reported. The resulting material rankings come with great uncertainty, and raise doubts as to the validity and transferability of in situ studies as well as the applicability of their findings. Conclusions The current body of evidence of in situ studies is insufficient for firm conclusions as to the caries risk adjacent to different materials. The validity and applicability of included studies remain uncertain. Clinical significance While single in situ studies seem to convey consistent and applicable information, the overall body of evidence is inconsistent, limiting the conclusions which can be drawn from it.

Objectives We report efficacy of resin infiltration to arrest progression of caries lesions as compared with non-invasive measures and oral hygiene education alone after a mean observation time of seven years. Materials and methods This randomized split-mouth placebo-controlled clinical trial included 22 young adults having 29 pairs of interproximal non-cavitated caries lesions with radiographic extensions into inner half of enamel (E2) or outer third of dentin (D1). Lesion pairs were randomly allocated to two treatment groups: infiltration (Icon, pre-product; DMG) or mock (control) treatment. All subjects received risk-related instructions for diet, flossing and fluoridation. The primary outcome was radiographic (digital subtraction radiography) lesion progression after seven years. Secondly, Kaplan-Meier-analyses were applied to analyze time-to-failure additionally including patients followed up for less than 54 months as well. Results Two lesion pairs were excluded due to invasive treatment decision by another dentist, five lesion pairs were lost to follow-up prior to 54 months but included in the survival analysis. No unwanted effects could be observed. For the primary outcome in 17 patients followed up in mean for 84 months 2/22 infiltrated lesions (9 %) compared with 10/22 control lesions (45 %) progressed (p = 0.018). The relative risk reduction for test in relation to control was 80 % (CI 95 % = 19–95 %). For the survival analysis within a mean (SD) observation time of 73 (25) months mean failure rates of 1.3 % and 7.8 % could be observed for test and controls, respectively. Hazard risk (95 % CI) for caries progression was 6.6 (2–22) for the control compared with the test lesions (p = 0.002). Conclusions We conclude that resin infiltration of proximal caries lesions extending radiographically around the enamel dentin junction is efficacious to reduce lesion progression after a mean observation time of seven years. Clinical significance This randomized clinical trial proves that caries infiltration is highly efficacious compared with non-invasive measures and oral hygiene education alone after a considerably longer observation time of 7 years than studied so far before.