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Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 167-173

The effect of atraumatic restorative treatment on adhesive restorations for dental caries in deciduous molars

1 Department of Pediatric Dentistry, Federal University of Paraíba, João Pessoa, Paraíba, Brazil
2 Department of Dentistry, State University of Paraíba, Campina Grande, Brazil
3 Department of Pediatric Dentistry, University of Pernambuco, Recife, Pernambuco, Brazil

Date of Web Publication10-May-2017

Correspondence Address:
Ana Flávia Granville-Garcia
State University of Paraíba, Street Juvêncio Arruda s/n, Bodoncogó, Campina Grande, PB
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_98_16

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Background: Minimal invasive approaches to managing caries, such as partial caries removal techniques and atraumatic restorative treatment (ART), are showing increasing evidence of improved outcomes over the conventional complete caries removal. Objective: To evaluate clinically and radiographically the effect of ART on restorations using restorative cement and glass ionomer cement (GIC) for dental caries in the deciduous molars of children aged between 4 and 8 years. Settings and Design: The study design was a split-mouth, randomized, blind clinical trial. Materials and Methods: Eighty-six patients had 108 restorations placed with GIC (Ketac Molar Easy Mix – 3M ESPE) and 108 restorations placed with composite resin (CR) (Filtek Z250 – 3M ESPE). The restorations were assessed by means of images obtained with a digital camera and periapical radiographs at baseline and after 12 months of follow-up. Statistical Analysis: The Student's t-test, Pearson Chi-squared test, and Bonferroni paired comparison test were used to evaluate the differences in proportions and correlations between the variables. Results: After 12 months of follow-up, the restorations were considered clinically successful in 89.3% of cases and radiographically successful in 80.5% of cases. There was statistical difference neither between the two restorative materials used nor between the numbers of restored surfaces. Conclusions: GIC and CR can be used successfully for restorations of one or two dental surfaces after ART.

Keywords: Atraumatic restorative treatment, composite resin, deciduous teeth, glass ionomer cement, randomized clinical trial

How to cite this article:
de Medeiros Serpa EB, Clementino MA, Granville-Garcia AF, Rosenblatt A. The effect of atraumatic restorative treatment on adhesive restorations for dental caries in deciduous molars. J Indian Soc Pedod Prev Dent 2017;35:167-73

How to cite this URL:
de Medeiros Serpa EB, Clementino MA, Granville-Garcia AF, Rosenblatt A. The effect of atraumatic restorative treatment on adhesive restorations for dental caries in deciduous molars. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2021 Dec 6];35:167-73. Available from: https://www.jisppd.com/text.asp?2017/35/2/167/206043

   Introduction Top

Tooth decay is one of the most globally prevalent chronic childhood diseases and is a major problem both from a public health perspective and for individual families who have to deal with a young child suffering from dental pain. This condition often goes untreated in young children. Carious lesions are among the major oral health problems of preschool children even though children lose the first set of teeth in this age group.[1],[2],[3],[4]

Minimal invasive approaches to managing caries, such as partial caries removal techniques and atraumatic restorative treatment (ART), are showing increasing evidence of improved outcomes over the conventional complete caries removal. There is also increasing interest in techniques where no caries is removed.[5] These techniques were based on scientific findings of partial caries removal with minimally invasive dentistry: the removal of demineralized dentin using hand tools and rotary equipment, without the need for local anesthesia; disinfection of the cavity; and tooth restoration.[6],[7]

It has therefore become possible to apply more conservative dentistry, preserving more dental tissues than in the past.[8] ART has great benefits as an effective restorative technique; a set preserves more dental tissue than conventional dental treatment. In addition, it avoids the use of rotary equipment and dental anesthesia, which are known to contribute to anxiety during dental treatment.[9],[10]

Since this technique is potentially, particularly useful with small children, further research is required to evaluate the quality of such restorations, especially when placed in tooth cavities on two surfaces.[11],[12] The purpose of the present study was to evaluate the effect of ART on restorations using different materials (restorative cement and glass ionomer cement [GIC]) for dental caries in the deciduous molars through a clinical trial.

   Materials and Methods Top

Sample characteristics

The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Declaration of Helsinki, 1975, as revised in 2000. Ethical approval was obtained from the Ethics Committee of the University of Pernambuco, Recife, Brazil. Written informed consent was obtained from the parents of each child. This study was conducted within the consort templates for clinical trial.

This was a clinical, randomized, controlled trial. The evaluations were performed after a12-month interval.

The sample consisted of 216 primary carious molars in dentin, affecting 86 patients aged 4 to 8 years of both genders. The sample consisted of children who were attended at the clinic for dental examinations; therefore, they are characterized as convenience samples.[13]

We selected children with bilateral pairs of the deciduous molars with carious dentin lesion. These caries lesions should be deep. Thus, at least one restoration was performed with GIC from one hemi-arch and a restoration of composite resin (CR) was performed with equal surface number on the other hemi-arch in each child. This type of study, called a split-mouth study, is more effective in minimizing selection bias than forming parallel groups.[14]

Eligibility criteria

The inclusion criteria were (1) age 4–8 years of age, (2) free of any systemic disease, (3) free of any current use of medications, (4) any history of spontaneous toothache, and (5) at least two teeth with carious lesions in dentin.

The tooth selected for the treatment must not have any physiological or pathological mobility, and its antagonist should be present. No dropouts/losses of patients were found at the 12-month recall evaluation.

Loss of the sample was considered as children who did not present the consent form signed by parents or guardians and children who were not found after 12 months.

Clinical intervention

The groups were established according to the tooth surface to be treated and the type of restorative material used and were selected by random.

The selection of patients consisted of a convenient sample of children who attended the clinic for dental checkups. The split-mouth approach was employed for the allocation of the two restorative materials. Intraoral assignment of the material to the teeth was chosen by coin toss.[15] The number and combinations of GIC and CR restorations per child were determined as defined for the intervention groups as follows:

  1. Group 1 - Cavity placed on one surface and restored with Ketac™ Molar Easy Mix GIC (3M ESPE AG, D-82229 Seefeld, Germany, Lot 199786), 68 teeth, control group
  2. Group 2 - Cavity placed on one surface and restored with Filtek™ Z250 CR (3M ESPE, Dental Products, St. Paul, MN, USA, Lot 4NC), 68 teeth, experimental group
  3. Group 3 - Cavity placed on two surfaces and restored with Ketac™ Molar Easy Mix GIC, 40 teeth, control group
  4. Group 4 - Cavity placed on two surfaces and restored with Filtek™ Z250 CR, 40 teeth, experimental group.

All the procedures were performed by the same dentist with the help of a dental assistant, and the materials were manipulated according to the manufacturer's instructions, in a fully equipped dental clinic.

The technique ART was performed without local anesthesia, and the field was kept dry by a saliva ejector and cotton rolls. Sharp excavators were used to remove the soft decayed tissue. To avoid pulpal exposure in deep cavities, the remaining dentin was left untouched. Color and texture were verified to differentiate contaminated and sclerotic dentin. In the molar teeth with deeper carries, the color and texture of the dentin were observed with the naked eye. The softened dentin was removed. Rigid and darkened dentin was considered sclerotic.

The teeth were conditioned using polyacrylic acid and then washed and dried. In case of restorations involving two tooth surfaces, a previously cut-out and slightly curved 0.5 mm steel matrix was used, adapted to the proximal surface of the tooth, and held in place with a wooden wedge. The GIC was hand-mixed and inserted into the cavity by pressing with a petroleum jelly-coated gloved finger to prevent the formation of bubbles and to improve the adaptation of the cement to the cavity walls.

Excess material was removed with a Hollenback carver. The occlusion was checked with articulating paper, and the restorations were subsequently protected from moisture and dehydration with a protection varnish.[16],[17] The patient was advised not to chew solids for 1 h after the placing of the restoration.

The removal of caries in the experimental group was performed according to the previously described method.

The cavity preparation was etched with 10% phosphoric acid (Bisco, Inc., Itasca, IL, USA), and the adhesive resin system Prime & Bond (Dentsply, Milford DE DE, USA) was applied to the entire cavity in accordance with the manufacturer's instructions. All teeth were restored with Z250 CR using the incremental technique, and each increment was polymerized for 40 s. The Dentsply adhesive system was used. Studies show the quality of the Dentsply system.[18],[19] The adhesive system of Dentsply has tertiary butanol as the solvent, while other adhesives researched in the literature show solvent based on water, alcohol, and/or acetone. The function of the solvents facilitates the wetting of the dental surface by the resinous monomers.[20] According to the manufacturer Dentsply, tertiary butanol has some advantages when compared to ethanol, such as greater stability and compatibility.[21]

In case of deep dentinal lesions, a 1–1.5 mm thick layer of calcium hydroxide liner (Dycal, Dentsply, Milford, DE, USA) was applied for pulp protection.

The occlusion of the restorations was adjusted when necessary.

Photographs (digital camera Sony Cybershot) and periapical radiographs (Kodak Insite) were taken for each restored tooth at three intervals: 1 – diagnosis, 2 – immediately after completion of the restoration (baseline), 3 – after 12 months. Each restored tooth also received a specific code only known to the dentist.

The clinical and radiographic criteria used were self-formulated. The images were obtained with the aid of mirrors for intraoral photographs and oral retractors of the restoration. Digital images were saved on compact disks and identified with the restore code. No alteration of the images was carried out that could jeopardize the posterior evaluation. For each restoration, a PowerPoint ® file was organized with its code, containing the sequence of photographs, of the three moments described above. Care was taken to maintain the same frame, same light, and same distance for each photograph.

Clinical data collection

Patient data were collected in two moments: the first part on the day of consent request by interview to the child's parents or guardians about the child's personal data (name, gender, date of birth of the child, name of the address, telephone number, monthly income, maternal education, anamnesis of the general state of the child).

In the second part, the filling of the odontogram was performed. For each tooth that received the intervention, the type of cavity (one or two surfaces), type of dentin (sclerotic or contaminated), restored tooth and the material used (GIC or CR) were recorded. This was identified by a number. After 12 months, a new clinical record with a new odontogram was completed, where the changes observed were noted in relation to recurrence of caries, new carious lesions, and pulp complications.

A 12-month evaluation was carried out. One calibrated evaluator (PhD in Pediatric Dentistry), who played no part in the intervention trial, examined the quality of the photographs at a magnification of ×16. The periapical radiographs were also examined, with an interval of 15 days between the first and the second examinations, using a PowerPoint file containing 26 teeth to establish intraexaminer reliability. The kappa value was 0.90. The evaluator was blind to the type of material used as she/he received precoded photographs and radiographs.

The restorations were considered satisfactory when they scored 0 or 1 by clinical criteria and scored 7 by radiographic criteria. The clinical criteria used for assessing the quality of the restorations were as follows:

  • 0 - Restorations satisfactory: In place, without clinically visible alterations
  • 1 - Restorations satisfactory: In place, little wear, gap without exposure of dentin, not needing repair
  • 2 - Restoration unsatisfactory: In place, waste or rift with dentin exposure, needing repair
  • 3 - Restoration unsatisfactory: Missing; total loss of the restoration
  • 4 - Restoration unsatisfactory: The restoration was replaced
  • 5 - Missing: The tooth was permanently replaced
  • 6 - Dropout: Child not found.

The absence of (1) fistula, edema, and abnormal mobility and (2) pain or sensitivity to pressure was also considered successful outcomes.

The radiographic criteria for assessing the quality of restorations were as follows:

  • 0 - Restoration satisfactory: In place, no progression of radiolucency
  • 1 - Restoration unsatisfactory: In place, presence of radiolucency suggesting secondary caries
  • 2 - Restoration unsatisfactory: In place, presence of radiolucency in the interradicular or periapical regions
  • 3 - Restoration unsatisfactory: Missing; total loss of the restoration
  • 4 - Restoration unsatisfactory: The restoration was replaced
  • 5 - Missing: The tooth was permanently replaced
  • 6 - Dropout: Child not found.

Statistical analysis

For data analysis, EPI Info version 6.04d (CDC, USA) and IBM SPSS Statistics (version 21.0; IBM Corp., Armonk, NY, USA) were used. The effects with respect to the quality of the restorations for the two treatment groups were tested using the Student's t- test, Pearson Chi-square test, and one-way ANOVA test. Paired evaluations were assessed by the Bonferroni paired comparison test. The 95% confidence intervals for success were established based on the binomial distribution. The statistical significance of the data was determined at P ≤ 5%.

The restorations of children not found at the 12-month evaluation (sample loss) and exfoliated teeth were not analyzed.

   Results Top

The study sample consisted of 86 children aged between 4 and 8 years (6.14 median age), of whom 47 (54.7%) were male and 39 (45.3%) were female. The 216 teeth were randomly divided into four groups. The total loss of the sample was 47 teeth (21.75%), and of these, 23 teeth were exfoliated [Figure 1].
Figure 1: Diagram of recruitment, allocation, and tracking and analysis of the clinical study

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The majority of children (76.9%) had one pair of molars treated [Table 1]. There were reports of postoperative pain indicative of irreversible pulp pathology in two cases and the presence of fistula in other two teeth, both from Group 3. The majority of teeth had sclerotic dentin (52.8%) as opposed to contaminated dentin (47.2%).
Table 1: Number and percentile distribution of the molars of the children treated at the initial evaluation

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The GIC restorations presented more wear than the CRs, with the main failure of the CR restorations being total loss. There was no statistically significant difference in unsatisfactory evaluations between the treatment groups for all the restorations [Table 2] and [Table 3].
Table 2: Clinical evaluation after 12 months according to treatment groups

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Table 3: Clinical evaluation after 12 months according to treatment groups categorized

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The 12-month clinical success rate of all restorations was 89.9%. [Table 3] shows that there was no statistically significant difference in the successes of restorations using CR and those using glass ionomer and the number of restored surfaces (P = 0.63).

Both radiographic evaluations indicated that there was no statistical difference between the results according to the type of material and the number of restored surfaces. In relation to the radiographic evaluation, the teeth restored with GIC showed more radiolucency, suggesting secondary caries, than those restored with CR [Table 4] and [Table 5].
Table 4: Radiographic evaluation after 12 months according to treatment groups

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Table 5: Radiographic evaluation after 12 months according to treatment groups categorized

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   Discussion Top

The results showed an acceptable survival rate, and no operator effect over the period investigated (12 months). The dropout rate (2175%) was similar to those reported in literature.[22],[23],[24] The limits of the present study include its small sample size, short evaluation period, and lack of a control group for comparison.

At the 12-month follow-up, the restorations were considered clinically successful in 89.3% and radiographically successful in 80.5% of cases. However, the CR restorations showed better clinical development than the GIC restorations. The viscous consistency of the GIC makes the manipulation and insertion of this material a little complex. This is an important factor in the failure of GIC/ART. These characteristics may lead to incorrect adaptation to the tooth surface, resulting in gaps at the restoration-tooth interface and the loss and replacement of the restoration.[24],[25] In addition, the biomimetic characteristics of GIC are often hampered by their poor mechanical properties.[26],[27],[28]

After 1 year, the treatment with CR was more positive than treatment with GIC. Other studies confirm that these findings as resins are known to have a lower wear resistance, reduced polymerization shrinkage, increased surface hardness, and a higher fracture toughness than those of GIV.[29],[30],[31],[32],[33]

Holmgren and Frencken [34] report that the size of the cavity can also affect the of survival restorations: the larger the cavity, the lower the survival rate of the restoration. This relationship was not found in this study. Restorations placed on a surface or two surfaces with both materials (resin composite [RC] or GIC) responded well. This result may be due to the fact that both materials showed good physical properties, and restorations were placed by the same experienced dentist in a dental clinic environment. This impressive result rate may be due to the absence of fractures, overcontoured marginal integrity, and restored surface texture.[35]

Recurrent caries was not observed in the treated teeth. This can be explained by the protection of the dentin-pulp complex after, or because the use of adhesive RC could have induced better marginal sealing of the restorations, or by the release of fluoride by GIC.[10],[28],[36],[37],[38]

Radiographic evaluation did not reveal a statistically significant difference between the satisfactory results and the type of material used or the number of restored surfaces. The lesion progressed under the restoration in 4.9% of the cases. None of these children had any major complaint regarding the affected teeth. The progression of the lesion in restorations can be attributed to marginal leakage arising from hollow material, poor bonding, cracks in the enamel due to restoration setting stress, or fracture of the tooth substance at the restoration–cavity interface, probably due to unsupported enamel overhangs and moisture contamination.[39],[40] In addition, inadequate cavity conditioning, poor mixing of the restorative material, and inadequate adhesion of the material to the cavity walls can also lead to gaps and consequently to marginal leakages. The presence of restoration-gaps weakens the restoration and makes it susceptible to early failure.[41],[42] Although the operator was adequately prepared and had gained some experience in the technique after training, it is possible that the above-mentioned factors occurred.

The results underline the potential of the ART approach for providing people with restorative care. It is suggested that the ART approach should be largely adopted for restoring dentin lesions on one or two surfaces. Closing bacterial niches is a simple and effective approach for public health program, especially in those countries where the access to traditional treatment is expensive and difficult to obtain for the major part of their population.

   Conclusions Top

The 1-year follow-up evaluation of primary molars subjected to partial caries removal, restored both with GIC and RC, presented excellent outcomes. The results were satisfactory when placed in restorations of one or two dental surfaces after partial caries removal.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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