Pulp exposure occurrence and outcomes after 1- or 2-visit indirect pulp therapy vs complete caries removal in primary and permanent molars. A clinical and histological evaluation of conservative pulpal therapy in human teeth. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. The Hall Technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months. A clinical, radiographic, and scanning electron microscopic evaluation of adhesive restorations on carious dentin in primary teeth. Reversal of incipient and radiographic caries through the use of sodium and stannous fluoride dentifrices in a clinical trial. Clinical evaluation of three different materials used as pit and fissure sealant: 24-months results. An investigation of the relative efficacy of Buckley's Formocresol and calcium hydroxide in primary molar vital pulp therapy. Caries preventive effect of a fluoride-containing varnish (Duraphat) after 1 year's study.
The purpose of this study was to examine whether 1- or 2-visit indirect pulp therapy (IPT) is more successful and to determine if the operator can successfully decide when to stop removing caries without exposing the pulp.
                A total of 154 teeth (94 primary second molars and 60 young permanent first molars) were included in the study from a total of 123 4- to 15-year-old patients. The teeth had deep carious lesions but lacked the preoperative signs and symptoms of irreversible pulpitis. The teeth were randomly selected and treated either with 1-visit IPT, 2-visit IPT, or direct complete excavation (DCE). Follow-up examinations were conducted on the teeth over 1 year at 3-month intervals.
                The pulp was exposed in 12 teeth (22%) treated by DCE, whereas 3 teeth (6%) were treated by 1-visit IPT and 4 teeth (8%) with 2-visit IPT. A statistically significant difference was found between IPT and DCE groups in terms of pulp exposure (P<.05). The teeth without pulp exposure showed normal clinical and radiographic conditions during the 1-year follow-up, except for 3 primary teeth.
                Indirect pulp therapy in both primary and young permanent teeth can be used successfully with a 1- or 2-visit approach. Three intermediary base materials, a zinc oxide-eugenol (Cavitec) and two calcium hydroxide liners (Life and Dycal), were selected at random for use as a base beneath amalgam or composite restorations on humans following complete caries removal. Life and Dycal, selected at random, were also used as direct and indirect pulp capping agents as clinically indicated. Clinical evaluations of signs and symptoms were made before treatment and at one-week, six-month, and one-year intervals following treatment. Histological evaluations were performed on three complete caries removal teeth and 18 direct pulp capping teeth six months following treatment. No significant differences in clinical symptomatology resulted between the materials in the complete caries removal group or the indirect and direct pulp capping groups. The aim was to assess the prevalence of pulp exposure after stepwise versus direct complete excavation of permanent posterior teeth with deep carious lesions. The material, representing 116 patients aged 6-16 yrs (mean = 10.2 yrs), consisted of 127 teeth with radiographs revealing carious lesions to such a depth that pulp exposure could be expected if direct complete excavation was performed. Teeth with clinical symptoms, other than transient pain shortly before treatment, were not accepted. The teeth were randomly selected for either treatment procedure. Stepwise excavation implied removal of the bulk of carious tissue and application of calcium hydroxide, followed by sealing of the cavity with zinc-oxide eugenol cement. After a period of 8-24 weeks the rest of the carious dentin was removed and the cavity sealed with calcium hydroxide, zinc-oxide-eugenol (ZOE) and a restorative material. Direct complete excavation entailed removal of all carious dentin followed by sealing as mentioned above. In case of pulp exposure, pulp treatment was performed. The pulp was exposed in 40 of the teeth treated by direct complete excavation. The corresponding figure for those treated by stepwise excavation was 17.5%. The difference was statistically significant. The teeth with no pulp exposure after direct or stepwise excavation showed normal clinical and radiographic conditions at the last check-up (mean = 43 months). 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. The purpose of this project was to evaluate the performance of a dentin adhesive system on carious and noncarious primary dentin in vivo.
                Forty-eight primary molars with carious lesions were randomly assigned to 2 different treatments: group 1 (control, n = 24)--All identifiable, irreversibly infected dentin was removed prior to the application of the bonding agent and restorative material; group 2 (experimental, n = 24)--Irreversibly infected dentin was partially removed prior to the application of the bonding agent and restorative material. The control and experimental teeth were clinically monitored every 3 months and evaluated 12 months after restoration. The teeth were extracted around the time of exfoliation and processed for scanning electron microscopy.
                Retention rate, marginal integrity, and pulpal symptoms were identical in both groups. Radiographically, the radiolucent area associated with the experimental restorations did not increase with time in 75% of the cases. For the control group, the adhesive system formed a hybrid layer. In the experimental group, there was morphologic evidence of the formation of an acid-resistant "altered hybrid layer." An acid-resistant tissue, resulting from the interdiffusion of adhesive resin within the area of carious dentin, was observed adjacent to and under the altered hybrid layer.
                Application of an adhesive restorative system to irreversibly infected dentin did not affect the clinical performance of the restoration. Experimental evidence has clearly demonstrated that the early stages of lesion formation (enamel demineralization) are reversible following exposure to saliva and/or fluoride. Clinical evidence for remineralization has also been reported extensively in the literature. However, the literature is lacking with respect to data from well-controlled clinical studies regarding the quantitative contribution of remineralization to arrestment and reversal of caries. Retrospective analysis of an existing clinical trial database provided an opportunity to examine the incidence of clinical lesion reversals in a placebo-controlled, double-blinded caries clinical study. The clinical study examined three treatment groups: 1) 0.243% sodium fluoride/silica dentifrice, 2) 0.4% stannous fluoride/calcium pyrophosphate (positive control) dentifrice and 3) non-fluoridated placebo/calcium pyrophosphate (negative control) dentifrice. Clinical measures in this study included both radiographic and visual-tactile assessments of caries. Examination of all subjects revealed a statistically greater frequency for caries reversals in the sodium fluoride group as compared to the placebo group at Year 3, for both total and radiographic caries. In contrast, while caries reversals in the stannous fluoride group occurred with greater frequency than in the placebo group at Year 3, for both total and radiographic caries, the differences were not statistically significant. When only subjects who were "at risk" for potential reversals (i.e., those with a minimum of one carious lesion at baseline) were examined, a statistically greater frequency in caries reversals was observed in both the sodium fluoride (total, incipient, and radiographic caries) and stannous fluoride (total and radiographic caries) groups as compared to the placebo group at Year 3. Collectively, these data confirm the ability of both 0.243% sodium fluoride/silica and 0.4% stannous fluoride/calcium pyrophosphate dentifrices to clinically reverse caries. The results suggest that sodium fluoride may deliver a greater frequency of caries reversals than stannous fluoride, although these treatments were not found to be significantly different. To evaluate the retention and caries experience effects of three different materials used as fissure sealants after 24 months of clinical application: a resin-modified glass ionomer cement (A), a flowable resin composite (B) and a compomer (C). One hundred and seventeen (117) teeth were sealed with material A, 119 teeth with material B and 120 teeth with material C. Children were randomly assigned. Each one received only one of the materials studied. Plaque index, dmft score and socioeconomic level were scored at baseline. The clinical exams were conducted 6, 12 and 24 months after application of the sealant. Statistical analysis (Kruskal-Wallis) revealed that there were statistically significant differences between the retention rates of groups A and B and between groups B and C after 2 years, with material B showing better results. After 2 years, 3.1% of the teeth of group A, 4.3% of group B and 6.7% of group C were Carious+Filled. There was no evidence of association between caries presence after 2 years and plaque index, dmft score and socioeconomic level. These results suggest that flowable resin composite had a satisfactory retention after this period of evaluation and all three materials were effective on occlusal caries prevention. To compare the clinical and radiological outcomes following two different, single visit vital pulp therapy techniques, in cariously exposed primary molar teeth.
                A paediatric dental clinic within the Dental Hospital, Newcastle upon Tyne, UK.
                Fifty two child patients were sequentially enrolled in the clinical investigation, 26 males and 26 females with an age range of 3.3-12.5 years. Primary molar teeth requiring vital pulp therapy were randomly allocated to either the formocresol group (F) or the calcium hydroxide group (C). The total number of teeth treated was 84.
                Recruitment was on the basis of strict inclusion criteria. Coronal pulp amputation was prescribed only in teeth with vital, cariously exposed pulp tissue. Treatment was undertaken between October 1994 and December 1996. All cases were reviewed using predefined clinical and radiological criteria. The statistical tests used were logistic regression of a triple nested data structure, chi-squared analysis of equality of treatment and probability of success with relation to subject age.
                Eighty-four cariously exposed primary molars required vital pulp therapy. Forty six (55%) teeth were included in the F group and 38 (45%) allocated to the C group. Five teeth were lost to follow-up, leaving 79 teeth: forty four (56%) in group F and 35 (44%) in group C. Eighty four percent (37/44) of teeth treated with formocresol and 77 percent (27/35) treated with calcium hydroxide were classed as clinically and radiographically successful at the cut-off date, December 1997, after a mean clinical review of 22.5 months (range 6.1-38.5 months) and a mean radiographic review of 18.9 months (range 1.3-36.9 months).
                This investigation confirms the clinical efficacy of a one-fifth dilution of Buckley's Formocresol as an agent in pulp treatment of cariously exposed, vital primary molar teeth. However, calcium hydroxide in its pure, powder form is a clinically acceptable alternative when combined with strict selection criteria for this method of restorative care. There was a statistically insignificant difference in successful clinical and radiological outcome between the two treatment groups. Success was unrelated to the duration of time taken to achieve haemostasis and the presence or absence of bleeding after placement of the medicament. The caries prophylactic effect of semi-annual applications of a fluoride-containing varnish (Duraphat) was tested in 121 15-year-old children. The children were divided into a test (60 subjects). The teeth of the children in the test group were coated with fluoride varnish at the beginning of the experimental period and again 6 months later. A clinical and radiographic examination of all children was performed immediately prior to the first application of varnish and 1 year later. The mean caries increment was 0.9 new DMFS in the test group and 4.0 in the control group. The difference was statistically significant at the 0.1% level. The caries prophylactic effect on different tooth surfaces was statistically significant both on proximal and on occlusal surfaces at the 0.1% level. Analyzing the material with respect to the caries prophylactic effect against the background of caries prevalence at the start of the investigation showed a better effect in the group of children with low and medium initial DMFS values.
It was disappointing that there were so few studies which could be considered as being suitable for inclusion in this review. The findings from this review do not suggest that there should be any significant change from accepted conventional practice procedures when the pulp of the carious tooth is considered. Further well designed RCTs are needed to investigate the potential of contemporary materials which may be suitable when used in the management of carious teeth. It is recognised that it is difficult to establish the 'ideal' clinical study when ethical approval for new materials must be sought and strict attention to case selection, study protocol and interpretation of data is considered. It is also not easy to recruit sufficient numbers of patients meeting the necessary criteria.