Oral Health and Preventive Dentistry, 06/2019

Purpose: To assess the current evidence regarding the early caries preventive effects of CPP-ACP compared with fluorides. Materials and Methods: An electronic search from PubMed, Cochrane Library, EMBASE, Web of Science and ScienceDirect database with a complementary gray literature search for randomised controlled human clinical trials were carried out. No language restrictions were applied. Results: A total of 395 participants in 10 studies of the 600 selected studies were carefully reviewed and selected for inclusion in this meta-analysis. The pooling data of the remineralisation scores in vivo showed a weighted mean difference (WMD) in favor of CPP-ACP as compared to fluorides (WMD: -2.47; 95% confidence interval [CI]: [-3.62, -1.32]; p < 0.0001). The DMFS/dmfs (decayed, missing, filled surfaces) index and the Enamel Decalcification Index (EDI) did not differ significantly between CPP-ACP and fluorides. No serious side effects associated with CPP-ACP and fluoride agents were found. Conclusion: CPP-ACP may offer a safe and efficient alternative to fluorides with less mineral content loss (laser fluorescence values) and more remineralisation of early caries lesions. In view of the inherent limitations of the included researches, high-quality, well-designed randomised controlled trials are still needed. CPP-ACP has potential utility in promoting enamel remineralisation of early caries lesions compared with fluoride. Keywords: early caries, casein phosphopeptide-amorphous calcium phosphate(CPP-ACP), fluoride, meta-analysis

Purpose: Matrix metalloproteinases (MMPs) are closely associated with the progression of oral cancer. This study is a meta-analysis of the published literature on MMPs and oral cancer prognosis. Materials and Methods: A comprehensive search of the literature on the prognosis of MMPs and oral cancer in PubMed, Embase, Web of science databases and the Cochrane Library was performed. All eligible studies were included in the final study and HR data were extracted. Pooled hazard ratio (HR) was analysed. Results: A total of 15 studies concerning 1266 patients were included for the meta-analysis. Pooled HR showed that overexpression of MMPs negatively influenced overall survival (OS) (HR = 2.18; 95% CI: 1.80-2.65; heterogeneity test, p = 0.080; I2 = 35.5%). In the subgroup analysis, the HR of MMP-2 was positive and the OS was poor (HR = 3.93; 95% CI: 2.19-7.07; weight 10.94%; heterogeneity test, p = 0.481; I2 = 0.0%). The HR of MMP-9 was positive and the OS was poor (HR = 1.96; 95% CI: 1.55-2.48; weight 68.12%; heterogeneity test, p = 0.115; I2 = 15.3%). A few articles showed that MMP-11 and -13 overexpression is associated with differences in OS. The combined HR showed that the overexpression of MMPs negatively afftected the disease-free time (DFS) (HR = 2.45; 95% CI: 1.49-4.05; heterogeneity test, p = 0.061; I2 = 50.2%). Overexpression of MMPs tends to worsen DFS. No publication bias was found in the current meta-analysis. Conclusion: MMP-9 and -2 overexpression was associated with poor prognostes in oral cancer patients. Therefore, early and accurate detection of MMP-9 and -2 levels can help improve the prognosis of MMP-9- and MMP-2-positive oral cancer patients. Keywords: meta-analysis, MMP family members, oral cancer, prognosis

Purpose: To evaluate the effect of sugar-free snacks on caries-related factors in 6- to 9-year-old schoolchildren. Materials and Methods: Two hundred seventy-one children at risk for caries as measured through the Cariogram were randomly assigned to three groups consuming twice-daily snacks containing Stevia, maltitol or sugar for 42 days. Parents filled out a standardised questionnaire regarding personal, medical and oral behavioural information. Bleeding on probing, plaque pH and salivary mutans streptococchi (MS) and lactobacilli (LB) were assessed at baseline (t0), 42 days of snack use (t1) and 120 days after the end of use (t2). The Cariogram calculation was repeated at t1. Treatment effects were estimated using linear mixed-effects regression models. Results: At t2, a decrease in cariogenic bacteria (MS X2 = 8.01, p < 0.01 and LB X2 = 4.60, p = 0.03) and an increase of the minimum pH (F = 4.48, p < 0.01), maximum pH (F = 2.88 p < 0.01) and pH drop (F = 2.95 p < 0.01) was recorded in the Stevia group compared to baseline. In the maltitol group, an improvement effect was noted: LB concentration decreased (p = 0.04) and maximum pH (F = 3.16 p < 0.01) increased. Subjects classified by the Cariogram as have a low probability of developing caries increased in the Stevia and maltitol groups (X2(4) = 25.44, p < 0.01, C*sV = 0.38 and X2(4) = 12.85, p = 0.01, C*sV = 0.27, respectively). Regression analysis underlines the effect of Stevia snacks on the cariogenic microflora, mainly on MS and plaque pH variations. Conclusion: The short-term administration of Stevia or maltitol snacks improves some important factors related to caries. This preventive strategy might be an additional means of combatting this common childhood disease. Keywords: caries, children, paediatric dentistry, snacks, stevia

Purpose: To compare students' knowledge, attitudes towards oral health, and plaque scores after oral health education sessions delivered by trained schoolteachers vs the control group. Materials and Methods: The participants, comprising third-grade students in Amphoe Meuang, Nakhonphanom province (N = 435), were randomly divided into an experimental group (n = 216) and a control group (n = 219). Baseline data of the students' oral health knowledge, attitudes, and plaque scores were collected at the beginning of the study. The experimental group was given oral health education sessions by trained schoolteachers using a specifically designed student handbook, while the control group did not receive extra oral health education other than the national curriculum. The immediate post-test knowledge was evaluated after each session, and plaque scores were determined after the brushing session. After the oral health education programme ended, the experimental and control groups performed a monthly toothbrushing activity for 2 months. Final assessment of the students' knowledge, attitudes, and plaque score was done at the 3-month follow-up. Results: The experimental group's oral health knowledge statistically significantly improved immediately after each session and was still statistically significant during the following three months. This improvement was also statistically significantly higher compared with the control group. The attitudes towards oral health care, foods related to caries, and dental visit improved. The plaque score of the experimental group was statistically significantly lower immediately post-brushing, but was not statistically significantly different at the 3-month follow-up compared with baseline. Conclusion: The children receiving oral health education provided by trained schoolteachers had statistically significantly greater oral health knowledge and more positive attitudes towards oral health than the children who had not received the programme. No statistically significant differences in plaque scores were found after 3 months. Keywords: attitude, knowledge, oral health education, primary schools, schoolteacher

Purpose: To compare adhesive flash-free (FF) and adhesive pre-coated (APC) brackets in terms of plaque retention and constituents, gingival biomarkers and enamel demineralisation. Materials and Methods: Fifty adolescents (mean age ± SD; 14.23 ± 0.15 years, age range: 13-18 years) were randomly distributed to receive FF or APC ceramic brackets in the maxillary right or left quadrant. Plaque and gingival indices, quantitative light-induced fluorescence (QLF) imaging, gingival crevicular fluid (GCF) and plaque sampling were performed at baseline and at 1, 2 and 3 months (T0, T1, T2, T3) after bracket placement. QLF was repeated following debonding. GCF samples were analysed for biomarkers by immunoassay and plaque by real-time PCR for bacterial content. Data were analysed using the Wilcoxon test on dependent samples and 2-tailed ANOVA. Results: Plaque index, gingival index and fluorescence changes were similar for the two adhesive-bracket systems. GCF volumes and interleukin (IL)-1ß levels increased compared to baseline (p < 0.05). IL-17A levels and RANKL:OPG ratios were similar in both groups. In dental plaque, Aggregatibacter actinomycetemcomitans numbers were higher in the APC group at T3. Fusobacterium nucleatum (Fn) counts statistically significantly decreased at T1 and T3 as compared to T0 in the FF group (p < 0.05 and p < 0.01, respectively), whereas Fn counts increased in the APC group at T3 (p < 0.01). Porphyromonas gingivalis, Streptococcus oralis and total bacterial counts were significantly higher in the APC group than in the FF group at T3 (p < 0.01). Conclusion: In orthodontic patients with good oral hygiene, the quantity of plaque on adhesive flash-free brackets and conventional brackets did not differ, but the constituents of plaque differed, with less pathogenic bacteria detected around adhesive flash-free brackets. Further studies also including a group of individuals with poor oral hygiene and longer follow-up periods may better clarify the issue. Keywords: adhesive flash, biomarkers, cytokines, demineralisation

Purpose: To determine the effectiveness of fluoride varnish (FV) in preventing caries lesions on the erupting first permanent molars (FPM) of high-risk children. Materials and Methods: A randomised parallel-blinded clinical trial was conducted with a sample of 180 children between 6 and 7 years of age with at least one sound erupting FPM attending a public school in the Dominican Republic. Children were randomly assigned to three groups, one control and two experimental groups, which received FV application every 3 or 6 months. All the children received fluoride toothpaste (1450 ppm), toothbrush, diet counseling, and oral health recommendations every three months. The development of caries lesions was assessed at twelve months using ICDAS. Results: A total of 157 children completed the study, of which 51.0% were female. At the end of the study, 53 participants comprised the control group, 54 were included in the every-3-months (3-month) FV group, and 50 belonged to the every-6-months (6-month) FV group. Adjusted ORs were calculated to compare lesion development between the groups. The results showed that the control group was more likely to develop caries lesions in comparison to the 3-month FV group, with an associated AOR of 1.46 (95% CI: 1.18 to 1.81, p = 0.001). Likewise, applying FV every six months as opposed to every three increased the odds of developing caries with a significant AOR of 1.29 (95% CI: 1.03 to 1.64, p = 0.029). Conclusion: FV application every three months can be recommended to prevent caries lesions on the erupting first permanent molars of high-risk populations. Keywords: dental caries, fluoride varnishes, prevention

Purpose: Dentin hypersensitivity (DH) is a prevalent painful condition of the teeth, the management of which lies in the obliteration of patent dentinal tubules. The purpose of this study was to compare the efficacy of 5% potassium nitrate (PN), low-level laser therapy (LLLT), and combination of low-level laser therapy and 5% potassium nitrate (LLLT+PN) in patients with fluorotic and non-fluorotic hypersensitive teeth. Materials and Methods: Ninety self reporting patients with DH completed the randomised, double-blind study. Patients were equally divided into fluorosis group (FG), with moderate to moderately severe fluorosis and the non-fluorosis group (NFG) and subdivided into 3 groups to receive PN, LLLT (810 nm, 1 W) alone and LLLT+PN. Each participant had at least one tooth eliciting a response of ≥ 3 on a visual analog scale (VAS) to evaporative, thermal and electric tactile stimulus (digital scratch-o-meter). The teeth were evaluated at baseline, 30 min post treatment, 1 week, 4 weeks and 12 weeks. The magnitude of pressure applied by the scratch-o-meter was also assessed for all three interventions. Results: Statistically, LLLT+PN was more effective in alleviating DH at all time intervals compared to baseline. However, statistically significant results (p ˂ 0.05) were seen with LLLT+PN at 12 weeks in FG. Magnitude of pressure applied showed statistically significant differences with LLLT+PN at 30 min post treatment. Conclusion: LLLT+PN alleviated DH at all time intervals, with a greater effect in the fluorotic group. However, LLLT+PN was more efficacious in reducing DH at 12 weeks post treatment in the fluorotic group. Keywords: dentin hypersensitivity, fluorosis, low-level laser, potassium nitrate, scratch-o-meter, visual analogue scale, thermal test

Purpose: Dental health is associated with the growth and development, physical or psychological, of children. Although numerous preventive measures are available, dental caries among primary schoolchildren remains a public health concern in China. Understanding the disparity of children's dental health between rural and urban areas in China could provide further insight into the prevention of caries. Methods: A cross-sectional study was conducted to examine the oral health of pupils aged 6-12 years in Pudong District (Shanghai) and Lichuan (Jiangxi Province) in China. A questionnaire survey was performed among children's guardians to identify the potential risk factors for childhood dental caries. Results: A total of 1922 primary schoolchildren were included in this study, with 815 from Pudong and 1107 from Lichuan. The mean age of children from Pudong was 8.57 (SD = 1.61), which was statistically significantly lower than their counterpart from Lichuan (9.36 ± 1.75). The prevalence of caries in Pudong and Lichuan was 63.4% and 75.0%, respectively. Statistically significant differences of demographical and behavioural features were observed between schoolchildren in Pudong and Lichuan. In general, Lichuan children had a higher caries risk compared with their Pudong counterparts (OR = 3.43, 95%CI 2.65-4.28). Moreover, the non-parental caregivers, low family income, low parental educational level, as well as bad dietary habits, were identified as risk factors for caries. Conclusions: Childhood caries in the rural area was far more severe than that in the urban area. This disparity was determined by several factors such as the high proportion of left-behind children in the rural area (e.g. children who remain in rural regions of China while their parents leave to work in urban areas). Our government should put the prevention of caries among rural children at a higher priority in the near future to narrow the gap between rural and urban areas. Keywords: children, China, dental caries, rural city, urban city

Purpose: The aim of this in-vitro study was to evaluate the effects of different remineralisation agents and adhesives on the remineralisation of white spot lesions (WSL) using quantitative light-induced fluorescence (QLF) and the shear bond strength (SBS) of brackets. Materials and Methods: One hundred fifty premolars were bonded with Transbond XT and resin-modified glass-ionomer cement (RMGIC). WSL were created using a demineralization solution and an APF gel, Tooth Mousse (TM) and Duraphat were applied for remineralisation. WSL were evaluated using QLF and SBS of brackets and tested using an Instron testing machine. Paired-samples t-test, independent-samples t-test and one-way ANOVA were used for comparisons of the ∆F, area and SBS. Post-hoc tests were performed using Tukey's test. Results: In the Transbond group, all remineralisation agents provided remineralisation, with Duraphat producing greater improvement. In terms of lesion area, the positive control and APF gel group values were close to each other, and a statistically significant improvement was observed in the TM and Duraphat groups' areas. In the RMGIC group, with TM application, the ΔF value was statistically significantly higher; area differences between the APF and TM groups were not statistically significant. The Transbond group showed greater SBS than did RMGIC, and in the Transbond group, Duraphat had the highest SBS value. Conclusions: In bonding with Transbond, the Duraphat group demonstrated greater improvement than other remineralisation agents. In the RMGIC group, the best remineralisation was obtained by TM. The Transbond XT and Duraphat combination provided the highest SBS values. Keywords: casein phosphopeptide-amorphous calcium phosphate, fluoride gel, fluoride varnish, remineralisation, shear bond strength, quantitative light-induced fluorescence, white spot lesions

Purpose: This study investigated the role of desensitising-only and desensitising/whitening versions of arginine and calcium carbonate-containing (ACC) and calcium sodium phosphosilicate-containing (CSPS) toothpastes on surface loss and permeability of root dentine. Materials and Methods: Slabs of human root dentine were embedded and exposed to citric acid solution to create a lesion resembling hypersensitive dentine. Sixty specimens were divided into six groups and exposed to slurries made with ACC (Colgate Sensitive Pro-Relief) and CSPS (Sensodyne Repair & Protect) toothpastes, in their desensitising or desensitising/whitening versions, an ordinary toothpaste (Crest Cavity Protection) or distilled water (DI). The other 60 specimens were brushed with either slurries or DI and assessed for surface loss. All specimens were analysed for dentine permeability. Data were subjected to analysis of variance (ANOVA) and Fisher's least statistically significant difference tests. Results: ANOVA (p = 0.018) showed that in the group brushed with DI surface loss was lower than in the groups brushed with toothpastes, but there was no statistically significant difference among the ordinary, desensitising-only and desensitising/whitening toothpastes. Dentine permeability was not influenced by brushing (p = 0.125). Toothpastes affected dentine permeability (p = 0.004), with the groups submitted to desensitising-only and desensitising/whitening toothpastes presenting significantly lower permeability than those submitted to DI, but no difference existed between the group treated with the ordinary toothpaste and DI. Conclusion: In comparison to desensitising-only, desensitising/whitening toothpastes neither accounted for increased surface loss nor impaired tubule occlusion of root dentine. Keywords: dentine abrasion, desensitising, permeability, toothpastes, whitening

Purpose: Comparison of viridans group Streptococcus (VGS) susceptibility to benzylpenicillin, ampicillin, clindamycin and vancomycin in order to determine resistance rates to assess whether guidelines for prophylactic or therapeutic antibiotic treatment include the present resistance patterns. Materials and Methods: A retrospective analysis of antimicrobial susceptibility testing (AST) over 4 consecutive years (2014-2017) and 4 months in 2018 for 779 VGS isolates (cumulative data). Isolates originated from pus from orofacial infections cases and tissue fragments from patients undergoing maxillofacial surgeries Results: The highest resistance rate was observed to clindamycin. The highest overall resistance rate was for Streptococcus parasanguinis 43% and S. constellatus 49%; the lowest was for S. anginosus 12%. All S. anginosus isolates were susceptible to ampicillin during tested period. All isolates of analysed species were susceptible to vancomycin through studied period. Conclusion: Due to high resistance levels, individual antibiotic susceptibility testing for strains should become mandatory. Keywords: Streptococcus viridians (VGS), susceptibility, clindamycin, resistance rate

Purpose: To investigate the temperature changes in pulp chamber of incisor and canine teeth during different stripping procedures with thermal imaging. Materials and Methods: Intact and freshly extracted human permanent 40 maxillary lateral incisor, 40 mandibular canine and 40 mandibular incisor teeth were selected for this study. Diamond bur, tungsten carbide bur and perforated diamond-coated disc were used for interdental stripping in high and low speed handpieces by air and water cooling. Temperature changes and cooling time of the tooth groups were recorded by a thermal imaging system. Paired t test and one-way analysis of variance (ANOVA) tests were performed for intragroup and intergroup comparisons of temperature changes and cooling time values. Results: Stripping procedures created a statistically significant temperature rise in all study groups (p < 0.05). For maxillary lateral incisors and mandibular incisors, the greatest temperature rise was calculated during stripping with tungsten bur and perforated disk under air cooling (p < 0.001), while no statistically significant difference was found between the temperature rise values of mandibular canine teeth during different stripping procedures (p = 0.053). The lowest temperature rise and cooling time values among all tooth groups were observed during stripping with diamond bur under water cooling and the longest cooling time values were detected during stripping with perforated disc under air cooling (maxillary incisor; p < 0.001, mandibular incisor; p < 0.05, mandibular canine; p < 0.05). Conclusion: For all tooth groups, stripping with diamond bur in a high speed handpiece under water cooling produced the lowest temperature rise in the pulp chamber and the shortest cooling time values among different stripping procedures. Keywords: interproximal stripping, pulp chamber, temperature rise, cooling time, thermal imaging