An In Vitro Evaluation of the Effect of Sealant Characteristics on Laser Fluorescence for Caries Detection

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: An In Vitro Evaluation of the Effect of Sealant Characteristics on Laser Fluorescence for Caries Detection.

Author(s): Gostanian et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2006. 28(5). 445-450.

Major topic: Laser Fluorescence

Overview of method of research: Scientific Article

Background:
A previous study found that 82% of dentists who offer sealants did not place sealants over incipient or superficial lesions although literature suggests such properly sealed lesions arrested over time (became 89% inactive). If practitioners were able to “quantitatively monitor” caries progression under sealants they may be more open to sealant placement over these borderline lesions.

Purpose:
1. Assess ability of laser fluorescence (LF) to detect simulated caries under sealants
2. Determine effect of opacifying agent in various sealants on LF values
3. Determine interexaminer reproducibility values in lab setting

Methods:
2 unfilled and 1 filled sealant materials were used. Titanium dioxide powder was used as an opacifying agent and added to the 3 sealant materials. Discs of 0.5mm think sealants were prepared and placed over varying amounts of protoporphyrin IX, a material which mimics dental caries. A total of 270 LF readings were taken of the various discs.

Findings:
Readings from the LF were highly reproducible. Clear sealants which had no opacifying agents significantly depreciated LF readings. Filled sealants weakened LF readings significantly more than the unfilled sealants. The addition of titanium dioxide (opacifying agent) also attenuated LF values with concentrations approaching 0.5% being almost completely attenuated.

Key points/Summary:
-The use of LF to detect dental caries underneath sealants is not recommended due to unreliable readings as a result of attenuating signals by sealants and intrinsic fluorescence of the sealant material itself.
-Intrinsic fluorescence of a sealant may produce false positives.
-False negatives may be obtained due to scattering caused by filler.
-Previous studies conducted on human teeth found that sealants on permanent first molars did not affect DIAGNOdent values and that it was easy to detect caries under sealants.
-More studies should be done on human teeth with pre-existing caries.

Assessment of Article:
Although this study isolates several important characteristics of sealant materials, due to the fact that this was an in vitro study it limits it clinical application. Good groundwork article, but need more research.

Marginal Microleakage of a Sealant Applied to Permanent Enamel: Evaluation of 3 Application Protocols

Resident: Swan

Article Title: Marginal Microleakage of a Sealant Applied to Permanent Enamel: Evaluation of 3 Application Protocols

Journal: Pediatric Dentistry

Volume (Number): 30 (1) 2008

Major Topic: Sealant Microleakage Using different application protocols

Main Purpose: Compare microleakage after placement of light-curing sealant to unground permanent enamel that has been conditioned with 1) phosphoric acid, 2) phosphoric acid and a bonding agent, or 3) a self-etching adhesive (L-Pop).

Type of Article: In vitro study

Overview of method of research: 60 intact 3^rd molars were embedded in resin blocks. The occlusal surfaces were cleaned using pumice slurry and rubber cups, rinsed, and air dried. 20 teeth were randomly assigned to each of three treatment groups

1) Clinpro sealant following acid etching with 38% phosphoric acid

2) Clinpro sealant following etching and application of Adper Single Bond Plus Adhesive

3) Clinpro sealant following application of Adper Prompt L-Pop self-

Materials were applied according to manufacturers’ instructions. Samples were thermocycled and immersed in methyl blue for 24 hours. Marginal leakage was determined by sectioning each tooth mesiodistally through the center of the sealant, then taking a photograph of each section. Each slide was twice show randomly on a screen to two independent evaluators, who scored dye penetration based on this scale:

0= no dye penetration

1=penetration down mesial OR distal wall

2=penetration down mesial AND distal wall

3=penetration underneath sealant and down mesial or distal wall

4=penetration all around the sealant

**Within- and between-examiner reliability was determined using Cohen’s kappa and ANOVA was used to evaluate the significance of the results

Findings: Etch and sealant group—25% had no microleakage. Etch, bond, sealant group—59% had no microleakage. L-pop and sealant group—40% had no leakage.

Only statistically significant difference was that between groups 1 and 2.

Key Points/Summary:

1) Use of an adhesive prior to sealant placement significantly reduces microleakage in vitro; its clinical application is supported

2) Use of self etch adhesives is a good alternative in specific situations, as it reduces chair time and the risk of salivary contamination

3) This is an in vitro study, so long-term clinical studies are still needed

Assessment of Article: A solid study, with limitations a) subjectivity of scoring using a number system, b) in vitro, thus done under perfectly controlled circumstances (a bit different than what we encounter). This study highlights the fact that even under perfect circumstances (zero saliva), there was still substantial leakage with ALL three groups. Highlights importance of excellent isolation. We should be aware of L-pop technique but wait for longer-term clinical studies to come out.

Effect of a NONrinse Conditioner on the Durability of a Polyacid-modified Resin Composite Fissure Sealant

Resident: Adam J. Bottrill
Date: 27AUG10
Region: Providence
Article title: Effect of a NONrinse Conditioner on the Durability of a Polyacid-modified Resin Composite Fissure Sealant
Author(s): Lampa, Ewa DDS et al
Journal: Journal of Dentistry for Children
Page #s: 152-157
Year: 71:2, 2004
Major topic: Conditioners and Sealants
Minor topic(s): NA
Type of Article: Comparative Study
Main Purpose: The aim of the study was to evaluate the effects of the simplified conditioning on durability of poly-acid-modified resin composite (PMRC) fissure sealants. The effectiveness of a non-rinsing conditioner (NRC) on retention of PMRC sealants was studied in a split-mouth design.

Key points in the article discussion:

I. Methods:

A. 92 teeth treated in Sweden.
1. Split-mouth study design.
2. First Side: NRC+PMRC (prime&bond NT)
3. Second Side: Acid etch+Sealant
B. An additional 49 treated with etch and PMRC
C. Performed by TWO SEPARATE PRACTITIONERS
1. ...but both were "experienced" so they must have the EXACT same technique... right?
D. Teeth evaluated at baseline, 3, 6, 12 and 24 months.
1. given a score based on presence, fracture, caries etc...

II. Results:

A. The argument used in favor of NRC+PMRC is: sensitive steps are eliminated from the procedure leading to a more efficient chair-side experience.
B. HOWEVER... SIGNIFICANTLY higher loss rate was found for the NRC+PMRC method when compaired to the acid etch+sealant method. Even the etch+PMRC showed better sucess than the NRC method.
C. The article concludes... "Conditioning with NRC prior to sealant application cannot be recommended."
D. Bottom line?.... NRC=Shenanigans

Assessment of article: Nice to know, but we don't use it at St Joseph. Closest thing to it might be the L-POP self etching adhesive... but even that is only used at the ED in emergent situations.

Microleakage at Sealant/Enamel Interface of Primary Teeth: Effect of Er:YAG Laser Ablation of Pits and Fissures

Resident: Cho

Author(s): Borsatto, M et al.

Journal: Journal of Dentistry for Children

Year. Volume (number). Page #’s: 2004. 71. 143-147.

Major topic: Sealant, Er-YAG Laser

Minor topic: Acid Etch

Type of Article: Scientific Article

Main Purpose: The purpose of this study was to assess microleakage at the sealant/enamel interface on primary molars after treatment of occlusal pits and fissures with 3 different techniques: conventional acid etching; Er:YAG laser ablation + acid etching; Er:YAG laser ablation.

Overview of method of research: Human primary molars extracted within a 6 month period were cleaned and examined under a x20 magnifier to discard those with structural defects. Thirty teeth were selected for the study and stored in 0.9% saline solution with a 0.4% sodium azide at 4^oC. The apices were sealed with a light-cured resin composite and teeth were assigned randomly into 3 groups. Group I was treated with 37% phosphoric acid gel for 30 seconds. Group II was treated with Er:YAG laser device emitted at 2.94um wavelength for 40 seconds and then treated with 37% phosphoric acid gel for 30 seconds. Group III was treated with Er:YAG laser device emitted at 2.94um wavelength for 40 seconds. Afterwards, all groups were treated with a uniform layer of pit-and-fissure sealant (Fluroshield, Dentsply/Caulk, Milford, Del); the sealant was light cured for 20 seconds. The retention of the sealant was verified with an explorer. Microleakage was assessed by staining the teeth with 0.2% rhodamine B solution and viewing them at x25 magnification. Axion Vision 3.1 software was used to obtain quantitative data of dye penetration at the enamel/sealant interface.

Findings: The microleakage percentage recorded for Er:YAG laser ablation (group III) was higher than those that incorporated phosphoric acid etch as one of the steps (groups I and II). No significant difference was found between group I and II.

Key points/Summary: The use of phosphoric acid etching led to less marginal leakage in sealants than Er:YAG laser ablation. Er:YAG laser beam does not have continuous emission and does not provide homogeneous etching of the tooth surface, leaving nonlased areas between pulses.

Assessment of Article: This article reinforces the value of acid etching prior to sealant placement and informs us that Er:YAG laser ablation is not an effective substitute for acid etch. However, one must also recognize that this is an in-vitro study and does not take into consideration other factors including saliva contamination.

Effectiveness of Primer and Bond in Sealant Retention and Caries Prevention

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence

Article title: Effectiveness of Primer and Bond in Sealant Retention and Caries Prevention
Author(s): Mascarenhas BDS PhD, Ana Karina. Huda Nazar, BDS. Sabiha Al-Mutawa, BDS MSD. Et al.
Journal: AAPD Journal
Year. Volume (number). Page #’s: 2008. Vol 6(1). 25-29
Major topic: Sealants effectiveness of preventing caries and retention w/ either bond or no bond

Overview of method of research: The purpose of this study was to test the use of a primer and bonding agent to increase the retention of a fissuresealant in a group of Kuwati children. 78 6-9 yo children were used for the study. 2 first molars in opposite arches were sealed either w. primer and bonding agent, and the other 2 w/o. The teeth were
1. Isolated with RDI
2. Pumiced with a rubber cup and rinsed
3. Etched for 15 seconds and rinsed thoroughly for 15 seconds
4. Dried.
One examiner, who was blind in the study was used to gather the data 2 years post sealant placement.

Findings:
Success with sealants is extremely technique sensitive. Factors affecting sealant retention are the eruption status of the tooth, isolation, tooth surface, and which arch the tooth is in. Previous studies and various articles have stated that the use of a primer/bonding agent can help sealant retention, and thus help prevent caries.
In this study, the following was found.
Teeth filled w/ Primer and bond
64% completely retained
23% partially lost
13% completely lost

Teeth sealed w/o Primer and bond
68% completely retained
20% partially lost
12% completely lost
There was no overall difference in sealant retention (p=.22), or in caries (p=.56).

Key points/Summary: When proper technique is used, primer and bonding agent does not enhance the retention of the sealant

Assessment of Article: Good article for us to review for our clinical treatment of patients. Limitations of the study include small sample size, and the fact that they only used one type of sealant(3m Plus).

08/27/2010 Sealing Ability of New Generation Adhesive Systems in Primary Teeth: An In Vitro Study

Resident: J. Hencler
Date: 08/27/2010

Article title: Sealing Ability of New Generation Adhesive Systems in Primary Teeth: An In Vitro Study

Author(s): Atash, Vanden Abbeele

Journal: Pediatric Dentistry-26: 4, 2004

Major topic: Evaluation of restorative dental adhesives

Type of Article: In vitro study

Main Purpose:
To evaluate micro-leakage at enamel and cementum margins of class V resin-based comp restorations in primary molars using 6 sixth-generation adhesive systems and 2 fifth-generation systems. (XE=Xeno III; LP=Adapter Prompt L Pop; IB=I Bond; SB=Scotch Bond I; EP=Etch & Prime 3.0; AS=AdheSE; OB=Optibond Solo plus self-etch primer; CS=Clearfil SE Bond)

Overview of method of research:
120 primary teeth extracted for pulp disease or ortho reasons were used in this study. Cavity preps were made at the CEJ, half in enamel and half in cementum. Teeth were randomly assigned into 8 grps of 15 in which different adhesive systems were used. Methylene blue dye was applied for 24 hrs, than teeth were embedded in epoxy resin and section for microscopic examination. The degree of micro-leakage at the tooth/restoration margin was evaluated.

Findings:
In the enamel and cementum, the best seals were obtained with XE and LP, followed by CS, AS, IB, OB, SB, and EP. No significant differences were found in the micro-leakage degree b/t the cementum and enamel margins.

Key points in the article discussion:
Micro-leakage is defined as the undetectable passage of bacteria, fluids, molecules, or ions at a tooth/restoration margin and is considered to be a major factor influencing the longevity of a dental restoration causing marginal breakdown and recurrent caries. 3 adhesion mechanisms are currently used in modern adhesion procedures and differ in treatment of the smear layer. In the 1st grp, the smear layer is modified and incorporated in the bonding process. In the 2nd grp, the smear layer is completely removed (SB). In the 3rd grp (self-etching primers) the smear layer and the underlying dentin surface are partially demineralized w/o removing the dissolved smear layer remnants or unplugging the tubule orifices. In these systems the bonding agent is either applied after the self-etching primer (CS, EP, AS, IB) or mixed together w/ the self-etching primer before a single application (XE, LP). 3 step bonding systems are often considered to be too complicated and time-consuming, especially in pediatric dentistry, and tend to be replaced by “self-etching” or 6th generation adhesives. The advantage of these systems is that they etch and prime simultaneously. There is no discrepancy b/t the demineralization depth and resin infiltration depth since both processes occur at the same time. The rationale is to superficially demineralize the dentin and simultaneously penetrate with monomers, which can be polymerized in situ. These systems also are reported to reduce the incidence of post-treatment sensitivity.

Summary of conclusions:
Among the different self-etching products used in this study, Xeno III provided the best seal in enamel and cementum. The two single-step self-etch adhesives analyzed (Xeno III and L Pop) in this study, presented lower micro-leakage scores when compared to a total-etch system (Scotch Bond I) or self-etch, 2 step adhesive systems (OB). The authors conclude that different adhesive systems can affect the sealing ability of class V restorations.

Assessment of article:
Good article and review of current dental adhesive systems. It is important to be very familiar with all dental materials to insure successful tx outcomes.

SEM and Microleakage Evaluation of 3 Flowable Composites as Sealants Without using Bonding Agents

Resident: Roberts

Date: 8/27/10

Title: SEM and Microleakage Evaluation of 3 Flowable Composites as Sealants Without using Bonding Agents

Author: Kwon, Ho et al.

Journal: Pediatric Dentistry

Volume: 26: 5

Year: 2005

Purpose: The purpose of this study was to determine if flowable composites can be used as pit and fissure sealants without bonding agents.

Methods: Three flowable composites (Filtek Flow, Tetric Flow, Charmfil Flow) and a filled sealant (Ultraseal XT Plus) were used. The patterns of resin tag formation in the 4 sealant materials were compared using scanning electron microscopy. For the microleakage assessment, 54 extracted human premolar teeth were randomly divided into 3 groups. In each group, a conventional fille sealant and 1 of the 3 flowable composites were applied to occlussal fissures. The teeth were thermocycled and immersed in a 1% methylene blue solution for 48 hours. Each tooth was sectioned and examined to determine the extent of dye penetration.

Results. Three flowable composites and a filled sealant showed a similar resin tag formation pattern. The 3 flowable composites showed significantly more microleakage in each group than the filled sealant. The level of microleakage was similar in the 3 flowable composites.

Conclusions: Concerning the microleakage data, use of the filled sealant is more effective in sealing mechanically prepared occlusal fissures in comparison to the flowable composites.

Microleakage and Bond Strength of Sealant to Primary Enamel Comparing Air Abrasion and Acid Etch Technique

Meghan Sullivan Walsh August 21, 2010

Literature Review - LMC/ Providence Pediatric Dentistry

Microleakage and Bond Strength of Sealant to Primary Enamel Comparing Air Abrasion and Acid Etch Techniques

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center - Providence

Article Title: Microleakage and Bond Strength of Sealant to Primary Enamel Comparing Air Abrasion and Acid Etch Techniques

Authors: Lisa A. Knobloch, DDS, MS; Tyra Meyer, DDS, MS; Ronald E. Kerby, DDS; William Johnston, PhD

Journal: Pediatric Dentistry

Volume Number, Month, Year, Pages ; Volume 27/Number 6, 2005, Pages 463-469

Major Topic: Comparison of bond strength and microleakage on pit and fissure sealants of primary teeth using preparations of air abrasion, acid etching and a combination of both.

Overview of Method of Research: Fourth extracted primary teeth were divided into four groups; Group 1 (control), Group 2 (acid etch group), Group 3 (KCP - air abrasion) and Group 4 (KCP plus acid etch). Each tooth was debrided, cleaned with pumise and water stored in chloramine solution. The teeth were mounted in a plastic mold and the exposed enamel surfaces were fine sanded with silison carbide paper and water to produce a flat enamel surface. The teeth were then aagin pumiced, rinsed and air dried. The enamel surfaces of each group were then either not touched (Group 1), etched rinsed and dried (Group 2), prepared with the KCP air abrasion system (Group 3) or prepared with KCP as well as etch. Clear plastic tubes were placed on the flat surface over the exposed area with adhesive tape. The tubes were there filled with sealant. The bonded specimens were stored for 7 days and then exposed to thermocycling.

Each specimen was inserted into a steel jig and a shear probe was used to test shear strength. Shear bond values were then calculated.

To test microleakage, fourty extracted primary molars were prepared exactly as above and following the thermocycling the teeth were immersed in silver nitrate dye then placed into a radiographic developer solution. The teeth were then washed and sectioned to examine leakage using digital imaging.

Findings: All ten of the control specimens failed during thermocycling. The mean shear strength of group 4 (KCP plus etch) exhibited 50% higher bong strength than group 2 (acid etch). In addition specimens bonded to enamel conditioned with etch (group 2) exhibited bond strengths that were twice those in Group 3 (KCP).The majority of bond failures in KCP were adhesive where as the acid etch and KCP plus etch exhibited both adhesive and cohesive failures. In terms of microleakage the differences of each group were not significantly different from one another. However the ranking of dye penetration as a function of occlusal conditioning from high to low is KCP>control>etch>KCPplus etch.

Key Points: For preparation of sealants in primary teeth, acid etch is the minimum requirement for retention. Air abrasion may improve the retention of sealant bond strength and microleakage. Shear bond strength was found to be higher following air abrasion and acid etching when compared to just air abrasion or acid etch alone. Microleakage may be decresed when using acid etch or a combination of acid etch and air abrasion.

Assessment of the Article: My first issue with this article was the small sample size used. Only fourty teeth were used for these experiments and were then divided into four groups. Thus only ten samples were used in each of the four categories. In addition I found confusing the preparation of the enamel surfaces with a silicon carbide paper to produce a flat enamel surface. I thought the purpose of sealants were to seal pit and fissure anatomy? Lastly the preparations, thermocycling and emersion of these samples into dyes and potions did not impress me nor do they represent the oral environment. The small sample size and little difference in the numbers and characteristics of the four groups excluding the control group makes this experiment interesting yet not convincing.

Natural History of Treatment Outcomes of Permanent First Molars

Resident: Swan

Article Title: Natural History of treatment outcomes of permanent first molars: A study of Sealant Effectiveness

Journal: JADA

Volume (Number): Vol. 136

Major Topic: Sealant Effectiveness

Type of Article: Retrospective Cohort Study

Main Purpose: Use insurance claims data to retrospectively assess the natural history and treatment outcomes of sealed and non-sealed teeth. Assist public health planners, dentists, and patients in clinical decision making and program planning.

Overview of method of research: Data was collected from eligibility and dental claims for children enrolled in the Iowa Medicaid program from ’96-2000. Children were enrolled in the study if they were six years old, enrolled continuously in Medicaid from ’96-2000, and were routine utilizers of dental services during this time (on preventive visit in 1996, one in 2000, and one other). 308 children met these criteria. The natural history (subsequent treatment history) of all first molars was evaluated by constructing Treatment Outcome Trees (TOT) to display all services provided over a four year period. First treatment node on TOT=whether tooth received sealant before any other treatment. Second node=whether teeth received further “restorative tx,” ie restorations, crowns, RCT, EXTs.

Findings: Sealed molars were less likely to receive further restorative treatment than were non-sealed (13% versus 29%). For teeth with sealants, about 87% of first molars did not receive restorative treatment during study period. Of teeth without sealants, about 70% of firsts did not receive further treatment. Few teeth in both groups received extensive treatment (crowns, endo, ext). 4% of the sealed teeth received another sealant. Of all teeth that received restorations, median time to restorative treatment was greater for sealed than non-sealed teeth.

Key Points/Summary: In this study sample of kids aged 6-10, permanent first molars with sealants were less likely to receive subsequent restorative treatment than were those without sealants. These results are consistent with different studies that have used different methodologies.

Assessment of Article: Good study, solid design. The preventive effect in this study (16%) may be exaggerated because the study started follow up based on age (six years) as opposed to after sealant placement, which has been done in other studies. The study period was 4 years--it would be nice to see the outcomes after a longer period, maybe 8-10 years.

The atraumatic restorative treatment (ART) approach for primary teeth: review of literature.

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence


Article title: The atraumatic restorative treatment (ART) approach for primary teeth: review of literature.


Author(s): Smales, RJ and Yip, HK.


Journal: American Academy of Pediatric Dentistry


Year. Volume (number). Page #’s: 2000. 22(4). 294-297.


Major topic: ART approach and its effectiveness


Overview of method of research: Literature Review


Findings:
-Older Glass Ionomer Cements (GIC) w/ larger particle sizes had higher failure rates than newer, more esthetic GIC made specifically for ART. These newer GIC have only been researched in short term studies.
-Class I & V: highest survival rates (80-90% after 12 mo.)
-Class II: moderate survival rates (55-75%)
-Class III & IV: lowest survival rates (35-55%)
-Premature loss of restoration due to shallow or non-retentive preps, bulk fracture of multi-surface restorations and restoration wear.
-Although resin modified GIC offer more fracture resistance and adhesion, they also have higher wear rates.
-Recurrent caries not been shown as a problem at this time.


Key points/Summary:
-ART gaining interest & acceptance in treating primary dentition.
-ART involves removal of caries w/ hand instruments & sometimes slow speed. Not necessary or desired to remove all caries as intended to be pain-free procedure. Conditioner and GIC are then placed to seal preparation and adjacent pits and fissures. Excess material pressed into preparation w/ lubricated gloved finger.
-GICs release fluoride, have high pulpal biocompatibility and provide chemical adhesion to tooth structure.
-Most important factor in preparation is providing mechanical retention (most common cause of failure) as well as moisture control. Avoiding premature occlusal contacts is also especially important in GIC restorations due to their low fracture resistance.
-Need further research on long term clinical studies of cost-effectiveness of ART.
-ART is saving many teeth around the WORLD!


Assessment of Article: Unfortunately based on 10 studies done over 10 years ago, but we get the gist of it. Good summary article.

Bond Strength of 4 Sealants Using Conventional Etch and a Self-etching Primer

Resident: Roberts
Date: 8/20/10
Article title: Bond Strength of 4 Sealants Using Conventional Etch and a Self-etching Primer
Author: Sarheed, Maha
Journal: Journal of Dentistry for Children
Volume: 73:1 Pages: 37-41
Year: 2006
The purpose of this study was to determine and compare the shear bond strength of 4 fissure sealant systems (Dyract Seal, Concise, Visio-Seal, Helioseal) to enamel using conventional etch and self-etching primer (Prompt L Pop).
56 newly extracted noncarious 1st permanent molars were used and embedded in a Teflon mold. Mesial surfaces were exposed to a flattened area of enamel and then dried and washed. The teeth were divided into 8 groups, each consisting of 7 specimens stored in 37 C distilled water for 24 hours. Then specimens were tested in a shear mode at a crosshead speed of .5mm/minute. The mean and standard deviations were subjected to an analysis of variance.
Results: The average bond strengths using the L pop were 1. Dyract Seal 20.61 Mpa, 2. Concise 23.42 MPa 3. Visio- Seal 2.94 MpA and 4. Helioseal 1.83Mpa These values were higher than and statistically different from those of Dryract Seal 10.18 Mpa and Concise 9.14Mpa when the conventional etch system was used.
Conclusion: The bond strengths of L pop in conjunction with Dyract Seal and Concise fissure sealant materials, exceeded those of convention.

Xylitol, Sweeteners, and Dental Caries
Author(s): Ly, et al.
Resident: Cho
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. 28. 154-263.
Major topic: Xylitol, Dental Caries
Minor topic: Sweeteners
Type of Article: Conference Paper/Report
Main Purpose: The main purpose of this article was to provide an overview of xylitol and other sweeteners and how they affect the risk of dental caries.
Findings:
Xylitol, sorbitol, mannitol, and maltitol are all part of the sugar alcohol (polyol) family. These products are widely used in chewing gums, candies, and toothpastes and advertised as “sugar-free” products. Sugar alcohols are shown to be noncariogenic. In addition, xylitol has shown to reduce tooth decay by reducing the levels of Streptococcus mutans in plaque and saliva and by reducing the level of lactic acid produced by these bacteria. The main side effect associated with these products is osmotic diarrhea, which occurs when it is consumed large quantities (4 to 5 times greater than the amount to prevent dental caries).
- Participants in groups consuming 100% xylitol had greater reductions in caries or S. Mutans levels that those that consumed a combination of xylitol and sorbitol. Those that consumed xylitol and sorbitol had a greater reduction of caries that those who consumed 100% sorbitol.
- At a University of Washington, Seattle study, participants were put in 4 groups and given 12 pellets of xylitol gums to be divided evenly into four doses per day with varying levels of xylitol. MS levels were reduced with increasing doses of xylitol, with the effect leveling off between 6.88g/day and 10.32g/day.
- In an intensive xylitol chewing gum study, it was found that chewing a maximum of 14g/day of xylitol was not significantly different from chewing 10g/day upon analysis of DMFS scores.
- Two retrospective studies showed that xylitol use is associated with greater reduction in caries and suggested that a frequency of less than 3 times per day may not be effective.
- Study of 3 to 6 year olds comparing xylitol chewing gum and tooth-brushing using fluoridated toothpaste was conducted. Children brushed once after lunch or chewed xylitol gum 3 times each day during daycare hours. The children brushed as they normally would at home. The xylitol gum group had a better oral health status than the group that brushed after lunch.
- In Finland, a study was conducted with a group of mothers who had high S. Mutans levels. They were treated with either chlorhexidine varnish, fluoride varnish, or 100% xylitol gum. The children of mothers treated with xylitol had the lowest levels of S. Mutans.
Key points/Summary:
1. Xylitol content in products should be labeled so that consumers can make informed decisions to use these products for the prevention of tooth decay.
2. Recommendations of efficacious dose and frequency of xylitol use should be more clearly stated.
3. The effective daily dose of xylitol is 6 to 10g.
4. The effective frequency of consumption of xylitol is 3 to 5 times per day.
5. The effectiveness of xylitol is greater the higher the frequency and the higher the dose of xylitol.
6. There is a ceiling effect for the dose of xylitol, which is 10g per day.
Assessment of Article:
This article was informative. I was surprised by the amount of xylitol that needed to be consumed in order to have an effect on dental caries. Perhaps xylitol-containing products should be promoted to wean children off sugary snacks.

Effect of Preparation Technique, Fissure Morphology, and Material Characteristics on the In Vitro Margin Permeability of Pit and Fissure Sealants

Resident: Adam J. Bottrill
Date: 20AUG10
Region: Providence
Article title: Effect of Preparation Technique, Fissure Morphology, and Material Characteristics on the In Vitro Margin Permeability of Pit and Fissure Sealants
Author(s): Selecman, James et al
Journal: Pediatric Dentistry
Page #s: 308-314
Year: V29/No4 Jul/Aug 2007
Major topic: Pit and Fissure Sealants
Minor topic(s): NA
Type of Article: Comparative Study
Main Purpose: To evaluate the effect of material characteristics, preparation techniques and fissure morphology on the microleakage and penetrability of pit and fissure sealants.

Key points in the article discussion:

I General:

A. Pit and fissure caries comprise >80% of all childhood carious lesions.
B. Definition of Sealant: material that is introduced into the occlusal pits and fissures of caries-susceptible teeth forming a micro-mechanically bonded, protective layer, cutting access of caries-producing bacteria from their source of nutrients.


II. Methods:

A. Sealants used:
1. Aegis, Conseal, Admira Seal, Triage, Delton Opaque.
B. 100 extracted permanent molars randomly assigned to 10 groups and sealed.
1. Pumice prophy and air abrasion
C. Following sealant placement:
1. Thermal cycling
2. Dye immersion
3. Invested in Acrylic
4. Sectioned
5. Assessed for dye penetration

II. Results:

A. Aegis showed significantly less leakage than other brands
B. Delton and Triage showed superior sealant penetration.
C. Fissure morphology not significant WRT microleakage but DID effect penetrability (U-type = most penetrable)
D. No correlation between microleakage and sealant penetrability.

III. Conclusions!

A. Material characteristics and fissure morphology were significant factors regarding sealant success while surface preparation did not play a significant role in sealant microleakage or penetrability.


Assessment of article: Shenanigans... seems to me there are huge holes in this study. More than one practitioner placed the sealants and they were not done in the mouth. I'm not sold on the results.

The Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8-15 Months Old

Meghan Sullivan Walsh August 19, 2010

Literature Review - LMC/ Providence Pediatric Dentistry

The Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8-15 Months Old

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center - Providence

Article Title: The Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8-15 Months Old

Authors: Anna Galgany Almeida, DDS, DScD; Melissa C. Quelroz, DDS; Alvaro Jorge M. Leite, MD

Journal: Pediatric Dentistry

Volume Number, Month, Year, Pages ; Volume 29/Number 4, July/August Issue 2007, Pages 337-341

Major Topic: Infant tooth wipes, Spiffies, efficacy in plaque removal as well as the baby and parent’s satisfaction of this product.

Overview of Method od Research: Dental plaque index scores as well questionnaires were used to collect data.

Findings: 35 high-caries risk babies ages 8-15 months were identified and selected from a hospital in Fortaleza, Brazil. These infants selected went to bed routinely with a bottle containing milk and had at least two anterior teeth. None of the babies had visited a dentist, had their teeth cleaned, nor had their parents receive any oral hygiene instruction. A Pediatric Dentist would perform a lap to lap intra-oral exam and extra-oral exam and place disclosing solution on the children’s teeth. A photo was taken of the children at this time. The parents were then randomly assigned into the control group of tooth brushing or into the ‘Spiffies Baby Tooth Wipes’ group. (Spiffies are fiber towelletes saturated with xylitol and sorbitol.) Little instruction was given to the parents on how to brush their children’s teeth. After performing the parental cleaning another digital photograph was taken. The parents were instructed to brush their children’s teeth once on the night of day one right before bed and cease tooth cleaning afterwards for the next 48-72 hours. They were also instructed to resume their regular night time feeding. The babies and their parents then returned for a second visit and the same procedures were performed however each parent used the alternative method, (Spiffies or toothbrushing.) Dental plaque index scores were utilized in both cases from the intra-oral photos.

Afterwards the parents were handed a questionnaire asking their satisfaction and perceived acceptance of their child to either cleaning method.

Results: In both the tooth brushing and Spiffies group plaque index scores were significantly reduced with no significant difference between the two groups. Overall, however, the parents and their babies were more satisfied with Spiffies for nighttime tooth cleaning rather than tooth brushing. During the day there was no preferences for the parent or child towards tooth brushing or Spiffies.

Key Points: Spiffies or dental wipes are a preferred method of cleaning for infants and their parents for nighttime tooth cleaning. Both Spiffies and tooth brushing provide adequate plaque removal on smooth surface teeth for infants ages 8-15 months.

Assessment of the Article: It should be noted that the author does agree that tooth wipes are not a sufficient means for cleansing teeth with pits and fissures. Thus, once a child shows eruption of a molar it should be insisted that parents move to tooth brushing. Because tooth wipes appear to be an appropriate cleansing method and parents seem content and satisfied with this product, this would be a great addition for a Pediatric Dental practice. Especially for infant/toddler exams and early introduction to the dental office, tooth wipes would be a great beginning for infants and their caregivers into forming a healthy opinion of the dentist as well as reducing a child’s caries risk.

Compomer as a Pit and Fissure Sealant: Effectiveness and Retention after 24 Months

Resident: J. Hencler
Date: 08/20/2010

Article title: Compomer as a Pit and Fissure Sealant: Effectiveness and Retention after 24 Months

Author(s): Puppin-Rontani et al.

Journal: Journal of Dentistry for Children-73: 1, 2006

Major topic: Sealants

Type of Article: Clinical Study

Main Purpose:
To verify the retention and effectiveness of caries prevention in the occlusal surfaces after the use of 2 fluoride-containing materials: 1) FluroShield, a resin-based sealant and 2) Compoglass, a polyacid-modified, resin based composite.

Overview of method of research:
A convenience sample from 57 children aged 7-9 years were selected from an elementary school from a community with a fluoridated water supply. 228 sound permanent molars were chosen from the sample. The 228 teeth were divided into 2 grps. Group 1: #14 and 30 were sealed using a resin-based sealant, FluroShield and Group 2: #3 and 19 were sealed using a compomer, Compoglass. The teeth were cleaned using a child-sized toothbrush and water before applying sealants under relative isolation (cotton rolls and portable saliva ejector). The retention was assessed at 6, 12, 24 months. The incidence of caries was also reported at 12 and 24 months.

Findings:
There was a significant difference between lower and upper teeth for both materials concerning total retention. (See tables for specific values)

Key points in the article discussion:
Sealed pits and fissures have reduced the incidence of dental caries in occlusal surfaces. Compomers combine the best properties of composites and glass ionomers. Characteristics include better adhesion to enamel and dentin, lower water solubility, low dehydration susceptibility, and fluoride release at the tooth sealant interface. The total retention rate for FluroShield, the resin-based sealant used in this study, was similar to that found for Compoglass, a polyacid-modified, resin-based composite. Although the total retention rates could be considered low, an increase in dental caries was not observed during the study period. This could be due to sealant remaining in the microporosities, even after it had been considered clinically lost. In these situations, the resin tags embedded in the etched enamel may still offer bacterial invasion protection to the pits and fissures. Considering the overall low retention rates in this study, the authors report that the tooth-color appearance of the sealant material tested may have made clinical detection of the sealant at follow up more difficult and led to an under estimation of the sealant retention. In addition the authors also report that due to the isolation technique chosen in this study, the upper arch presented a greater moisture control problem compared to the lower arch. This study was poorly designed. Read on for amazing conclusions.

Summary of conclusions:
When evaluated at 24 months, total sealant retention was significantly different b/t FluroShield and Compoglass concerning upper and lower teeth. FluroShield showed significantly higher total retention rates when applied in lower teeth and Compoglass showed significantly higher total retention rates when applied in upper teeth. During the follow-up period, both materials effectively prevented caries in occlusal surfaces, although both showed low retention rates.

Assessment of article:
One of many major flaws in this study is that a rubber dam was not used during sealant application. How can these authors draw any solid conclusions about sealant retention when they were not applied under RDI? Double shenanigans!

Resident: Adam J. Bottrill
Date: 13AUG10
Region: Providence
Article title: The Efficiency of Semiannual Silane Fluoride Varnish Applications: A Two-year Clinical Study in Preschool Children
Author(s): Petersson, Lars et al
Journal: Journal of Public Health Dentistry
Page #s: 57-60
Year: Winter 1998
Major topic: Fluoride Varnish Application
Minor topic(s): NA
Type of Article: Community Demonstration Trial
Main Purpose: To study the caries inhibitory effects of semiannual applications of fluoride varnish in preschool children.

Key points in the article discussion:

I General:

A. In Sweden all children under 20yo are guaranteed free dental care. Yet... by age 6yo >50% have clinical caries.
B. Fluoride varnish has been accepted as effective for permanent dentition, but the effects have not been described as in depth for primary dentition.

I. Methods:

A. 24 Public health clinics in Sweden
1. Pts: 5137 pre-school children between 4 and 5 yo.
2. Children split into two groups
a. fluoride varnish group treated every 6mo with topical silane fluoride varnish.
b. reference group treated with no fluoride varnish.
3. Both groups received regular preventive visits and were followed for 2 years.
a. annual, dietary counseling, OHI
b. exams performed with mirror and explorer
4. Data collected WRT caries level

II. Results:

A. Caries prevalence not different at baseline.
B. No statistical significance in the difference of overall carious lesions after 2 yrs, although the fluoride group's number was lower.
C. Difference in the levels of interproximal carious lesions WAS statistically significant. (more in the NON-fluoride group)
D. Children with DFS score of >1 showed statistically significant reduction of interproximal caries when compared to reference group.

III. Conclusions!

A. Preschool children 4-5 yo with clinical caries who receive semiannual topical application of fluoride varnish (.1% F) experience a reduced incidence of approximal caries over two years.

Assessment of article: I guess this was something I was HOPING someone proved at some point but had never actually seen an article explaining the benefit. We were all taught the scientific explanation for topical F but it's good to see some actual clinical application.

This is EITHER:
1. The article to end all articles...
OR
2. An irrefutable breakthrough that will shock the world...
OR
3. An article describing stuff we sort of already knew...

....YOU DECIDE

Evidence-Based Use of Fluoride in Contemporary Pediatric Dental Practice

Resident: Swan

Article Title:

Evidence-Based Use of Fluoride in Contemporary Pediatric Dental Practice

Author: Steven M. Adair

Journal: Pediatric Dentistry 2006 28:2 pgs 133-140

Major Topic: Science-based recommendations for dentists regarding fluoride use in contemporary practice.

Article Type: Conference Paper--mainly reviews of meta-analyses and systematic reviews

Findings: The traditional view of fluoride's systemic effect is waning considerably, and there's really no direct evidence of fluoride having a pre-eruptive effect on teeth. The paradigm of fluoride's effect has shifted from systemic to topical effects on enamel, along with the biological effects fluoride has on cariogenic bacteria. With this change in mind, systemic fluoride supplements should be given following these recommendations:

1. Give supplements only to those children who live in fluoride deficient communities and are high risk for caries
2. Delay supplement use until after eruption of first permanent molars-fluorosis risk is highest from age 3-6.
3. Supplements should be chewed and swished in mouth to enhance topical effect.

Guidelines for use of:

Fluoride toothpaste:

1. Advise use in children 2 and older, due to fluorosis risk (although data are scarce to support the actual risk).
2. Brushing needs to be supervised by an adult to be effective. Use pea-sized dabs.
3. Twice daily brushing. 2x daily is more effective than 1, benefit from brushing more than 2x not well established.

Fluoride Mouthrinses:

1. Advise daily use of .05% NaF mouthrinse in moderate to high-risk children, including kids undergoing orthodontic tx and those with reduced salivary flow
2. Swish and spit rinses are as effective as those that are swallowed
3. Use with low risk kids shows little benefit.
4. Alcohol free rinses preferred

Fluoride gels/foams:

1. Consider prescribing self-applied gels for high risk kids in fluoride deficient areas (5,000 ppm)
2. Apply based on caries assessment.
3. Professionally, apply following prophy (12,300). This replaces the surface fluoride layer that is removed.
4. Use properly fitting trays, filled only enough to cover teeth, for max of 4 minutes
5. Pt can spit after application. No eating/drinking for 30 minutes

Professionally applied fluoride varnish:

1. Apply at 6 months intervals, for kids living in fluoridated and non-fluoridated areas.
2. No eating/drinking for 30 min, no brushing until next morning.
3. Apply frequently to open carious lesions in very young children (used with ART)
4. Varnish may be more effective than gels and foams

Summary/Assessment: Good article that gives the current guidelines for use of all fluoride modalities. Ironically, all the studies mentioned in this article showed fluoride’s positive effect in the permanent teeth--there’s virtually no evidence to support fluoride’s use for primary teeth, but we logically assume the same benefits exist.

Policy on Use of Fluoride/ Guideline on Fluoride Therapy

Department of Pediatric Dentistry
Resident’s Name: Jessica Wilson
Program: Lutheran Medical Center - Providence

Article title: Policy on Use of Fluoride/ Guideline on Fluoride Therapy

Author(s): AAPD, Council on Clinical Affairs

Journal: Reference Manual/Clinical Guidelines

Year. Volume (number). Page #’s: 2007-2008. 29(7). 34.
Clinical Guidelines. 2007. 111-113.

Major topic: Fluoride Recommendations

Overview of method of research:
A systematic literature review as well as expert opinions and best current practices were used to establish this policy/guideline.

Findings:
1. AAPD encourages optimal water supply fluoridation.
2. If water supply not optimal (<0.6ppm) including other dietary ingestion of fluoride, supplements should be administered according to AAPD Guidelines (see TABLE 1. of Guidelines).
3. Dentist should educate other medical professionals about the possible effects of excess fluoride ingestion prior to enamel maturation.
4. Further research to be carried out on causes of fluorosis.
5. Prenatal fluoride supplements not advised.

Key points/Summary:
Fluoridation of community water is the cheapest and most effective way to prevent caries (55-60%).
If supplements indicated, children should chew or suck on fluoride tablets in order to optimize topical exposure.
Professionally applied topical fluoride should be administered to mod-high risk children every 3-6mo. accordingly.
Fluoridated toothpaste recommended twice daily under supervision of parent/guardian. Additional at-home therapy may be advised for high risk children (rinse or gels).
Severity of fluorosis dependant on dose, duration and timing of intake.

Assessment of Article:
Good simplification of recommendations and reminders of importance of systemic intake of fluoride. Perhaps we should be taking a closer look at our patient population and educating parents about their children’s dental development needs!

Risk of Fluorosis Associated With Infant Formulas Prepared With Bottled Water

Resident: Roberts

Date: 5/13/10

Article title: Risk of Fluorosis Associated With Infant Formulas Prepared With Bottled Water

Author: Buzalef Marilia et al.

Journal: Journal of Dentistry for Children

Volume #: 71 number: 2

Pages: 110-113

Year: 2004

Purpose:

The purpose of this study was to evaluate the daily consumption of fluoride in the diet of an infant using infant formula with fluoridated and non-fluoridated water.

Methods:

Four infant formulas(Enfanmil Lacto-free, Soy infant formula; Enfamil Prosobee, Prosobee RTF) were prepared according to manufacturer instructions using deionized water and 5 brands of bottled water(Danon, Crystal Geyeser, Pure American, Ice Mountain, Nursery Water). Possible fluoride ingestion per kg body mass was estimated, based on suggested volumes of formula consumption, for infants 1 and 12 months.

Results/Discussion:

Fluoride concentrations ranged from .076 to .214 ppm and .092 to 1.053 ppm for formulas prepared with deionized and bottled water. When prepared with deionized water, none of the formulas provided a Fl intake above the suggested threshold for fluorosis. When prepared with some brands containing .623 and .893 ppm, all of them did prove to provide sufficient fluoride intake to cause fluorosis.

Conclusion:

The threshold for fluorosis is .07 mg/kg/day of Fl. Some brands of bottled water provide in excess when combined with infant formula the necessary fluoride daily intake. As health care providers we should be conscious of these dietary effects on teeth and make recommendation to parents based on this knowledge.