Evidence-based Clinical Practice Guidelines on Nonrestorative Treatments for Carious Lesions – Science Sunday

Evidence-based Clinical Practice Guidelines on Nonrestorative Treatments for Carious Lesions

Dental caries is one of the most common noncommunicable diseases worldwide. It affects people of all ages and demographics. Caries prevention should be the goal, however once the disease is evident, determining the best treatment to stop the process can be challenging. An expert panel convened to do a systematic review and formulate evidence-based guidelines for the arrest or reversal of non-cavitated and cavitated carious lesions using nonrestorative treatments. The results were published October 2018 in The Journal of the American Dental Association.1

Recommendations for Advanced Cavitated Lesions on any Coronal Tooth Surface

Four studies, totaling 2,115 participants with a 30 month follow up showed 38% silver diamine fluoride (SDF) applied bi-annually has a “1.13 times greater chance of arresting advanced cavitated lesions on primary teeth” compared to annual application.  Additionally, 30% SDF applied annually resulted in 1.45 times greater chance of arresting advanced cavitated lesions when compared to 30% SDF applied once per week for 3 weeks and a 1.41 times greater chance of arresting advanced cavitated lesions when compared with 5% sodium fluoride varnish applied once per week for 3 weeks. There was no evidence to support silver nitrate or sealants for advanced cavitated lesions. 

These results led to the panel issuing the following recommendations:

• To arrest advanced cavitated carious lesions on any coronal surface of primary teeth, the expert panel recommends clinicians prioritize the use of 38% SDF solution (biannual application) over 5% NaF varnish.
• To arrest advanced cavitated carious lesions on any coronal surface of permanent teeth, the expert panel suggest clinicians prioritize the use of 38% SDF solution (biannual application) over 5% NaF varnish

Noncavitated Lesions on Occlusal Surfaces

Eight studies with a total of 726 participants were evaluated to determine the recommendations made by the expert panel regarding noncavitated occlusal lesions. Review of these studies included comparing sealants plus 5% NaF varnish, sealants alone, 5% NaF varnish alone, 1.23% APF gel, resin infiltration plus 5% NaF varnish, or 0.2% NaF mouth rinse plus supervised brushing. The evidence showed the combination of sealants and 5% NaF varnish was most effective.

According to these findings the expert panel issued the following recommendations:

• To arrest or reverse noncavitated carious lesions on occlusal surfaces of primary teeth , clinicians should prioritize the use of sealants plus 5% NaF varnish (application every 3-6 months) or sealants alone over 5% NaF varnish alone, 1.23% APF gel, resin infiltration plus 5% NaF varnish  or 0.2% NaF mouth rinse.
• To arrest or reverse noncavitated carious lesions on occlusal surfaces of permanent teeth , clinicians should prioritize the use of sealants plus 5% NaF varnish (application every 3-6 months) or sealants alone over 5% NaF varnish alone, 1.23% APF gel, resin infiltration plus 5% NaF varnish  or 0.2% NaF mouth rinse.

Noncavitated Lesions on Approximal Surfaces

Thirteen studies with a cumulative of 2,516 participants were evaluated to determine the recommendations regarding noncavitated lesions on approximal surfaces. The results showed a 5 times greater chance of reversal or arrest of noncavitated approximal lesions with the combination of resin infiltration plus 5% NaF varnish, a 2 times greater chance of reversal or arrest when resin infiltration or sealants were used alone when compared with no treatment. Lastly, 5% NaF varnish alone showed a 2 times greater chance of reversal or arrest, however, the results were not significant. 

These findings led the expert panel to recommend the following: 

• To arrest or reverse noncavitated carious lesions on approximal surfaces of primary and permanent teeth the expert panel suggests clinicians use 5% NaF varnish (application 3-6 months), resin infiltration alone, resin infiltration plus 5% NaF varnish (application every 3-6 months), or sealants alone.

Noncavitated Lesions on Facial or Lingual Surfaces

Five studies with a total of 584 participants were evaluated for guidance from the expert panel regarding noncavitated lesions on facial or lingual surfaces. These studies showed lesions treated with NaF varnish and 1.23% APF gel had a 2 times greater chance of arresting or reversing noncavitated carious lesions on facial or lingual surfaces when compared to no treatment. 

The expert panel made the following recommendations after evaluating these studies:

• To arrest or reverse noncavitated carious lesions on facial or lingual surfaces of primary and permanent teeth, the expert panel suggests clinicians use 1.23% APF gel (application every 3-6 months) or 5% NaF varnish (application every 3-6 months).

Noncavitated and Cavitated Lesions on Root Surfaces

Eight studies with 584 participants were reviewed to determine the recommendation on best nonrestorative treatment options for noncavitated and cavitated carious lesions on root surfaces. Studies showed 5,000 parts per million fluoride (1.1% NaF) toothpaste had a 3 times greater chance of arresting or reversing lesions when compared with no treatment. Additionally, the use of 1% chlorhexidine and thymol varnish, 38% SDF solution (applied annually), 38% SDF plus potassium iodide (applied annually), or 5% NaF varnish had a 2-3 times greater chance of reversing or arresting lesions. No evidence supported the use of stannous fluoride, APF, ammonium fluoride, polyols, calcium phosphate, AP, CPP-ACP, nano-hydroxyapatite, tricalcium phosphate, or prebiotics with or without 1.5% arginine, probiotics, silver nitrate, lasers, resin infiltration, sealants, sodium bicarbonate, calcium hydroxide, or carbamide peroxide for cavitated or noncavitated lesions on root surfaces. 

The expert panel made the following recommendations based on these studies:

• To arrest or reverse noncavitated and cavitated carious lesions on root surfaces of permanent teeth, the expert panel suggests clinicians prioritize the use of 5,000 ppm fluoride (1.1% NaF) toothpaste or gel (at least once per day) over 5% NaF varnish (application every 3-6 months), 38% SDF plus potassium iodide solution (annual application), 38% SDF (annual application), or 1% chlorhexidine plus 1% thymol varnish (application every 3-6 months).

The expert panel stresses the importance of monitoring all noncavitated and cavitated lesions while treating with nonrestorative treatments to ensure success and evaluate for other treatment options if they become necessary. The panel also suggests diet counseling as an intervention, though it isn’t included in this article, it is being considered for future articles. 

The authors conclude by stating, “To arrest or reverse noncavitated carious lesions in both primary and permanent teeth, the expert panel suggests clinicians prioritize the use of sealants plus 5% NaF varnish on occlusal surfaces, 5% NaF varnish on approximal surfaces, and 1.23% APF gel or 5% NaF varnish alone on facial or lingual surfaces. The expert panel also suggests clinician prioritize the use of 5,000 ppm fluoride (1.1% NaF) toothpaste or gel to arrest or reverse noncavitated and cavitated lesions on root surfaces of permanent teeth. To arrest advanced cavitated carious lesions on coronal surfaces of primary teeth, the expert panel recommends clinicians prioritize the use of 38% SDF solution biannually. The expert panel extrapolated these results to suggest that clinicians could use 38% SDF solution biannually to arrest advanced cavitated lesions on coronal surfaces of permanent teeth as well. The biannual application of 38% solution SDF for advanced cavitated lesions may be relevant if access to care is limited, for uncooperative patients, or for patients when general anesthetic is not considered safe.”

What protocol does your office use in regard to nonrestorative treatments? Do these results and recommendations make you consider implementing new nonrestorative treatments? Do these findings encourage change in your current protocol?

1. Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM, Nový BB, Tinanoff N, Weyant RJ, Wolff MS, Young DA, Zero DT, Tampi MP, Pilcher L, Banfield L, Carrasco-Labra A. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc. 2018 Oct;149(10):837-849.e19. doi: 10.1016/j.adaj.2018.07.002. PMID: 30261951.