Current Concepts in Carious Tissue Removal

Abstract

Purpose of Review

To summarize current concepts in carious tissue removal.

Recent Findings

Traditionally, caries has been seen as an infectious disease and was treated by attempted complete removal of all cariogenic bacteria. The logical traditional aim of carious tissue removal—removing all bacteria from carious lesions—no longer applies. The contemporary aim of carious tissue removal is to maximize restoration longevity, without unnecessarily removing sound or remineralizable dentin. This is based on recent perspectives that dental caries is a biofilm-based and lifestyle-mediated disorder. In shallow lesions, as much carious tissue as possible should be removed, with removal until hard dentin is felt around the periphery of a cavity (to maximize restoration survival and seal the cavity) while centrally firm dentin is left (to retain remineralizable dentin). For deep lesions in teeth with vital pulps (without irreversible pulpitis or pulp necrosis), maintaining pulp vitality is the priority. Dentists should aim to avoid pulp exposure and accept leaving soft or leathery dentin in areas close to the dental pulp, while at the periphery, carious tissue should be removed until hard tissue is felt, ensuring that any remaining bacteria are sealed and inactivated and that the restoration has sufficient mechanical support against masticatory forces. An alternative for deep lesions is stepwise removal. Carious tissue strategies where no carious tissue removal at all is performed include sealing using plastic materials or stainless steel crowns, or non-restorative cavity control.

Summary

A range of carious tissue removal strategies are available and should be applied according to lesion characteristics, pulp vitality, and other patient related factors. Always striving to remove carious tooth tissue until hard dentin remains is not in line with current evidence and not recommended.

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Recent Trends in Tricalcium Silicates for Vital Pulp Therapy

Abstract

Purpose of Review

Tricalcium silicates are considered as materials of choice for vital pulp therapy. Recent development improved their mechanical and bioactive properties and broadened their clinical application fields. Incorporating resins to tricalcium silicates further decreased the setting time and simplified clinical procedures but raised questions about their potential toxicity.

Recent Findings

Tricalcium silicates represent an added value in vital pulp therapy. This is ascribed to the pulp high regeneration potential, material byproducts production upon hydration and growth factor release from target cells. Adding resins to tricalcium silicates decreases their hydration and subsequently leads to pulp toxicity.

Summary

Tricalcium silicates can be successfully used for vital pulp therapy in a broad range of clinical applications. Although long-term clinical studies are still required with these new materials, adding resins to tricalcium silicates is responsible for pulp disorganization and toxicity and cannot be recommended for direct pulp capping.

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The Future of Payment for Dental Care

Abstract

Purpose of Review

To examine the literature on dental reimbursement methods, with emphasis on paying for value (e.g., health care outcomes) rather than procedure. To make recommendations that would facilitate the expansion of access to dental care for those most in need and improve the oral health of the US population.

Recent Findings

Although the health care system is moving toward paying for performance and outcomes, dentistry lags behind. We review publications that identify obstacles to payment for outcomes in oral health as well as moving away from traditional fee-for-service reimbursement.

Summary

Payment for value in dentistry is a long way from becoming a reality; however, the testing of models within Medicaid that set aside a small percentage of the fee for a procedure to be reimbursed based on the improved oral health of the patient and/or the population of the practice may facilitate its adoption. A similar set aside in capitation-based programs could ensure the delivery of essential services and avoid the underutilization traditionally associated with this type of reimbursement system. Similar incentives could be tested in group practices and perhaps even community health centers. Widespread adoption of diagnostics code, missing in dental records, would enable better tracking of met needs. Educational systems that foster intra- and interprofessional teamwork and the appropriate use of personnel operating at the top of their competency would increase efficiency while adding value at the same or lower cost.

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Smear Layer-Deproteinization: Improving the Adhesion of Self-Etch Adhesive Systems to Caries-Affected Dentin

Abstract

Purpose of review

This paper reviews a new method of dentin surface modification, smear layer-deproteinization for self-etch adhesive systems, particularly in relation to improving the adhesion to caries-affected dentin.

Recent Findings

Remnants of smear debris, which forms hybridized smear layer with self-etch adhesives, can prevent monomer infiltration and interfere with the chemical interaction of adhesive monomers and the underlying dentin. The hybridized smear layer weakens the physical and chemical properties of the resin-dentin hybridized complex both immediately and over time. Smear layer-deproteinization with NaOCl and HOCl solutions can improve the quality of resin-dentin interface of self-etch adhesives through elimination of the hybridized smear layer, development of monomer infiltration, and enhancement of the chemical interaction of adhesive monomers with hydroxyapatite due to an increase in the mineral/organic ratio on the dentin surface. These positive effects are influenced by the types of oxidizing solution and their application time and also depend upon the adhesive materials used because compromising effects of residual oxidized-byproducts at the dentin surface on the polymerization behavior of the adhesives are different between the materials. However, applying antioxidant/reducing agents can eliminate this problem.

Summary

Smear layer-deproteinization is more effective for improving the bonding efficacy of self-etch adhesives to caries-affected dentin than normal dentin because caries-affected dentin produces a thicker organic-rich smear layer. Smear layer-deproteinization with HOCl solution, which has a rapid and broad-spectrum antimicrobial activity with less irritating and sensitizing properties, along with the subsequent application of antioxidant/reducing agents could enhance the longevity of composite restoration with self-etch adhesives.

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Fracture Toughness Testing of Dental Restoratives: a Critical Evaluation

Abstract

Purpose of Review

We intend by this short critical review to highlight important aspects regarding the mechanical testing of fracture toughness. The final aim is to increase the awareness to the test sensitivity, ultimately increasing the quality and reliability of reported testing results.

Recent Findings

In a well-intended attempt to facilitate testing procedures or provide alternatives for testing material interfaces, authors are resorting to adaptation of testing methodologies without proper theoretical and experimental validation. The assumption of validity in such cases endangers the perpetration of testing strategies that are not safeguarded by sound theoretical bases. The use of improper statistical treatments based on extreme-value distributions further aggravates this scenario.

Summary

We supply here some directions for authors concerning method selection, interpretation of data scatter, statistical treatment, and possibilities for test validation.

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Eighteen-year-old man with autism, obsessive compulsive disorder and a SHANK2 variant presents with severe anorexia that responds to high-dose fluoxetine

The SHANK2 gene codes for a protein involved in organising the postsynaptic density and disruptions have been associated with autism spectrum disorders (ASDs). ASDs are frequently comorbid with intellectual disability and anxiety disorders and emerging evidence suggests potentially common aetiologies. Here, we report the case of an 18-year-old man with ASD who presented with severe anorexia due to fear of food contamination, food avoidance and stereotypies attributable to underlying obsessive compulsive disorder (OCD). The patient was found to be heterozygous for c.2518C>T (p.Pro840Ser), a likely damaging coding variant in the proline rich region of SHANK2. Interestingly, the patient's disordered eating behaviour began to improve only after high-dose fluoxetine was initiated to target OCD symptoms. Overall, this case highlights the utility of molecular genetic testing in clinical psychiatry and provides an example of how genetic information can inform clinicians in the treatment of complex neuropsychiatric syndromes.

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Extremely common radiographic finding of cochlear nerve deficiency among infants with prelingual single-sided deafness and its clinical implications

Publication date: Available online 10 July 2018

Source: International Journal of Pediatric Otorhinolaryngology

Author(s): Woongsang Sunwoo, Won-Wook Lee, Byung Yoon Choi

Abstract

Objectives

To clarify the common radiographic findings of audiologically documented prelingual single-sided deafness (SSD) and identify the prevalence of cochlear nerve deficiency (CND) in SSD infants referred from the newborn hearing screening program.

Methods

Between March 2012 and March 2017, the records of all infants referred to our otology clinic after undergoing newborn hearing screening program were retrospectively reviewed. Twenty-four consecutive well infants without risk factors who had a confirmed diagnosis of prelingual SSD under the age of 1 year and who underwent internal auditory canal (IAC) magnetic resonance imaging (MRI) were included. The sizes of cochlear nerve (CN), IAC, and cochlear nerve canal (CNC) were measured on MRI. The presence of CND was visually determined by comparing the CN size to the ipsilateral facial nerve (FN) in the affected side via an oblique sagittal view of IAC MRI and defined when CN was absent or smaller than FN.

Results

CND was seen in all 24 deaf ears (100%) on MRI. There was one with incomplete partition type I, and another with combined cochleovestibular nerve absence. Twenty-four subjects demonstrated either an absent (20/24, 83.3%) or small (4/24, 16.7%) CN. When the absent and small CN groups were compared, the former group had a higher prevalence of narrow CNC and narrow IAC. Of the 20 infants without identifiable CN on the affected side, 17 (85%) had narrow IAC and 17 (85%) had narrow CNC. In the 20 ears with absent CN, only one had both normal-sized IAC and CNC.

Conclusion

The contribution of CND to prelingual SSD in Korean infants reached 100%, according to IAC MRI alone.

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