prediction of clinical outcome of a restoration based on...

Prediction of Clinical Outcome of a Restoration Based on Marginal Quality EvaluationBased on Marginal Quality Evaluation

David C Sarrett D M D M SDavid C. Sarrett, D.M.D., M.S.March 9, 2006

Outline of presentationp

• Focus mainly on posterior composite restorations and reasons for interventionrestorations and reasons for intervention

• Clinical evaluation criteria and challenges with assessing marginal integritywith assessing marginal integrity

• Secondary caries– DevelopmentDevelopment– Risk and diagnosis– Association with marginal defectsg

• Polymerization shrinkage• Summary/Conclusions

Slide 2

y

From the beginningg g

• Posterior use – 30 years experienceM t i l bl• Materials problems– Rapid loss of material at margins– Marginal staining & bulk discolorationg g

• Dentist difficulties– No light-curing

S t i 2 3 i t h d t k i t it i kl– Set in 2-3 minutes – had to pack into cavity quickly– No specially designed matrix systems

• Patient complaintsp– Teeth sensitive– Discolored restorations

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Rates and causes of restoration failure

• Manhart J & others (2004), Hickel R, Manhart J (2001)J (2001)– 2.2% per year in clinical trials

• Mjör I (2005) and other publications from• Mjör I (2005) and other publications from practice-based studies– Median age of failure 6-8 yrs– Higher failure rates

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Secondary (recurrent) caries andSecondary (recurrent) caries and restoration replacements

• Mjör IA (2005) J Am Dent Assoc 136:1426-1433• Practice-based surveys of restoration replacement• 50% of replacements with diagnosis of secondary

caries• For composite the combination of secondary caries• For composite the combination of secondary caries

and discoloration is higher than 50%• Replacement rates in general practice due to

secondary caries much higher than in controlled clinical trials which is 2-3%/year

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Class II restoration survival probabilityp y• Studies in 70’s and 80’s

– Composite i l b

0.9

1

restorations last about half as long as amalgam restorations

• Recent data indicated 0 6

0.7

0.8

rviv

al

Recent data indicated the difference is minimal

• Bogacki et al. 2002 0.4

0.5

0.6

Prob

abili

ty o

f Su

– Insurance claims data to compare survival of composite and amalgam restorations 0.1

0.2

0.3P

g• Changing dentist

results in lower survival probability

00 12 24 36 48 60 72 84

Length of Observation (Months)

Different Dentist - Amalgam Same Dentist - Amalgam

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g gDifferent Dentist - Composite Same Dentist - Composite

Posterior composite restoration failuresp

• Brunthaler et al. (2003)Bulk fracture most common reason for failure for– Bulk fracture most common reason for failure for periods up to 5 years

1 to 14% -most below 5%14% S lit i14% was Solitaire

– Secondary caries most common reason for failure periods beyond 5 years

3 to 16%Higher percentage for longer observation periods

– Failures due to painpMost 2 to 8%One was 15% due to biting painOnly 5 of 24 studies reported failures due to pain

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Only 5 of 24 studies reported failures due to pain

Does initial marginal quality have anythingDoes initial marginal quality have anything to do with clinical longevity?

O ti f i l lit d i f• Our notions of marginal quality derive from traditional operative dentistry criteria.O t it i f li i l l ti d i• Outcome criteria for clinical evaluation derive from these traditional notions of quality dentistrydentistry.

• Why would we expect criteria used to grade restoration placement performance arerestoration placement performance are correct for evaluation of clinical performance?

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Does initial marginal quality have anything to do with clinical longevity?

G t i l hi /f t• Gaps, excess material, or chips/fractures can only be viewed or detected by explorer (or microscopy) at the junction linemicroscopy) at the junction line.

• This represents only a small percentage of the restoration contact with tooth structurethe restoration contact with tooth structure.

• Marginal quality evaluation does not include monitoring of bacteriamonitoring of bacteria.

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Does initial marginal quality have anything to do with clinical longevity?

Cli i l l ti ll b i• Clinical evaluation process usually begins after the restoration is placed.Wh t b t i f ti th t ti• What about information on the restoration process?

• What about the data matrix that guided the• What about the data matrix that guided the decision to restore the tooth in the first place?– Patient’s caries riskPatient s caries risk– Tooth information– Dentist experience and ability

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p y

How have we evaluated clinical outcomes?

• Gunnar Ryge – United States Public Health Service Criteria or Ryge CriteriaService Criteria or Ryge Criteria

• USPHS/CDA Quality Evaluation System• Two step evaluation process• Two step evaluation process

Meets all criteria (Romeo or Alpha)• Clinically Satisfactory

Cli i ll

Meets all criteria (Romeo or Alpha)

One or more features deviates from ideal (Sierra or Bravo)

• Clinically Unsatisfactory Future damage likely to occur (Tango or Charlie)

Damage is occurring (Victor or Delta)

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Damage is occurring (Victor or Delta)

Clinical performance evaluation of a packable posterior composite in bulk-cured restorations.

• Sarrett DC, Brooks CN, Rose JT (2006) J Am Dent ( )Assoc 137:71-80.

• Our contribution to the confusion

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Clinical Evaluation Using Modified USPHSClinical Evaluation Using Modified USPHS Criteria

• Surface

• Color

• Marginal Integrity– Visual

• Anatomical Form– Occlusal Contours

– Tactile

– Discoloration

– Proximal Contact

– Retention

– Caries

• First Week Sensitivity (Y/N)(Y/N)

• Sensitivity to Air Blast (0 10) at Recall

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(0-10) at Recall

Scoring Marginal Integrity• R – No evidence of ditching along

margin and no discoloration; No excess materialexcess material

• S – Evidence of ditching not extending to DEJ and/or discoloration between the restoration and the tooth structure; Excess material

• T – Ditching along the margin g g gextending to DEJ and/or penetration of discoloration toward pulpal direction; Excess materialcess a e a

• V – Restoration is mobile or fractured, tooth is fractured, or caries presentcontiguous with margin of restoration;

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contiguous with margin of restoration; Overhanging material

Challenges with scoring marginal integrityg g g g y

• Is it only a gap?• Is it only stained?y• Gap plus stain tends to

be scored as secondary caries

• Tendency for bias toward declaring secondary caries

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Sensitivity and specificity of secondary i di i icaries diagnosis is poor

• Söderholm KJ, Antonson DE, Fischlschweiger W (1989)• Visual and explorer examination of restorations in extracted• Visual and explorer examination of restorations in extracted

teeth• Restorations removed to assess for true secondary caries

True Caries Over TxCaries Not Tx

Caries Dx C t DCaries Dx Correct Dx

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Secondary caries processy p

• Kidd EAM (1990) Adv Dent Res 4:10-13 and (1981) Dental Update 8:253-260(1981) Dental Update 8:253-260

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Prediction of secondary cariesy

• Kidd EAM, Beighton D (1996) J Dent Res75 1942 194675:1942-1946

• Compared margins of tooth-colored restorationsrestorations– Staining and stained dentin visible through enamel– ditching and frank secondary cariesditching and frank secondary caries

• Bacterial composition– plaque at the marginplaque at the margin– underlying dentin at the DEJ

• Dentin at the DEJ

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e t at t e J– Hard or Soft


• 79.5% of soft dentin areas were below stained margins

• But, 55.5% of hard dentin areas were also b l t i d ibelow stained margins

• Except for the presence of a frank carious lesion none of the clinical indicatorslesion, none of the clinical indicators evaluated could predict the presence of soft dentindentin

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• Significant associations were found between th i l l b t i d b t i ithe marginal plaque bacteria and bacteria in underlying dentin

• More bacteria were present in the marginal• More bacteria were present in the marginal plaque of frank secondary caries compared with sites with no outer lesionwith sites with no outer lesion

• More bacteria present in marginal plaque over sites with soft dentin compared with hard pdentin.

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Marginal gaps and secondary cariesg g p y

• Goldberg J et al. (1981) J Am Dent Assoc 102 635 641102:635-641

• Increasing likelihood of secondary caries with i i i f i lincreasing size of marginal gap

• Oral hygiene also a significant factor in likelihood for secondary carieslikelihood for secondary caries

• For some sites, oral hygiene effect was more pronouncedpronounced

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• Hamilton JC et al. (1983) J Prosthet Dent 50 200 20250:200-202

• Marginal deterioration not associated with t ti l t trestoration replacement rates

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Marginal gaps and secondary caries g g p y

• Söderholm KJ, Antonson DE, Fischlschweiger W (1989)(1989)

• No statistical difference in gap size for secondary caries free sites vs. true caries sites

Slide 23


• Kidd EAM, Beighton D (1996) J Dent Res 75:1942-19461946– Only gaps > 4 mm resulted in increased bacteria in the

underlying dentin– Frank carious lesions had similar levels of bacteria to wide

gaps, however the s. mutans levels were greater

• Gaengler P et al. (2004) J Oral Rehab 31:991-1000g ( )– Concluded that imperfections in marginal integrity do not

contribute to increased secondary caries risk

• Hayashi M Wilson NH (2003) Eur J Oral Sci• Hayashi M, Wilson NH (2003) Eur J Oral Sci 111:155-162– Early marginal deterioration and discoloration associated

ith hi h f il t

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with higher failure rates

Polymerization Shrinkage – Important buty g p

• Much studied “problem”– 609 publications in PubMed on May 31, 2004– 704 on February 22, 2006

[d t l AND ( it OR i ) AND ( h i k*– [dental AND (composite OR resin) AND (shrink* OR contract*)]

• “Problems” blamed onProblems blamed on polymerization shrinkage– Secondary cariesy– Pain– Fractured teeth

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Polymerization Shrinkagey g

• The simple model on secondary caries– Shrinkage > loss of adhesion > marginal and interfacial gaps

> bacteria being allowed in > secondary caries• Eliminate shrinkage and you eliminate secondary g y y

caries – simple right?

Slide 26

Polymerization Shrinkagey g

• Why things are not this simpley g p– Modern understanding of caries risk points to the

patient as the main factor in secondary cariesBacteria strengthBacteria strengthDiet – carbsFluoride exposure

D l i it ith ti i i• Developing composites with anticariogenic activity will be more effective in decreasing secondary caries than will developing non-seco da y ca es t a de e op g oshrinking composites– Imazoto S and others (2001 & 2003)

Slide 27

Tooth sensitivityy• Polymerization shrinkage was once thought to be a

source of pain due to gaps and microleakage or cuspal deflection– Opdam and others (1998)– No evidence of relationship between marginalNo evidence of relationship between marginal

gaps, microleakage, and sensitivity• Failure of dentin bonding system to create hybridized

dentin and block dentinal tubules appears to be truedentin and block dentinal tubules appears to be true cause

• Sarrett DC, Brooks CN, Rose JT (2006) J Am Dent AAssoc– No increase in post-operative sensitivity or need to

replace restorations that were bulk-cured

Slide 28

p


N t id di t th• No strong evidence you can predict the clinical outcome of a restoration based on traditional margin quality evaluationstraditional margin quality evaluations– Limited evidence margin quality promotes

secondary cariesy– No evidence margin quality affects post-operative

sensitivity

Slide 29


Th i id th t f il d t• There is evidence that failures due to secondary caries are strongly related to bacterial counts oral hygienebacterial counts, oral hygiene

• There is evidence that we as dentist have poor diagnostic tools to assess the need topoor diagnostic tools to assess the need to replace/repair restorations except in the case of frank carious lesions at the marging

Slide 30


P ti t h h d ti t h hi h• Patients who change dentist have a higher restoration failure rate and likely a higher rate of secondary caries diagnosisof secondary caries diagnosis

• Current clinical evaluation criteria for marginal integrity lack the ability to predict future riskintegrity lack the ability to predict future risk for the need for intervention– Replacementp– Repair

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Thank you for your support of thisThank you for your support of this symposium.

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