Evidence-based Strategies for the Minimally Invasive Treatment of Carious Lesions: Review of the Literature – Science Sunday

Evidence-based Strategies for the Minimally Invasive Treatment of Carious Lesions: Review of the Literature

Treatment of carious lesions is currently solely restorative. Other minimally invasive treatments are great alternatives for managing carious lesions. A recent review published in 2018 published in the journal Advances in Clinical and Experimental Medicine aimed to “examine the scientific evidence behind some of the most common minimally invasive alternatives for caries lesion management used today, including sealants, infiltration, ART and selective and/or stepwise removal for the management of deep carious lesions.”1

When considering minimally invasive treatments for non-cavitated lesions (ICDAS codes 1 and 2) it is imperative to select a treatment option that will arrest progression and prevent cavitation. Maintaining the integrity of the tooth while remineralizing to stop the progression is the goal for these lesions. Compelling evidence indicates sealants are a great option for non-cavitated carious lesions. Non-cavitated carious lesions treated with a sealant show an annual progression rate of 2.6% compared to 12.6% in untreated non-cavitated carious lesions. Robust evidence shows that carious lesions do not progress under well placed and retained sealants. Sealants eliminate a source of nutrition for the bacteria which arrests the lesion. 

Non-cavitated proximal lesions can be treated via infiltration using low-viscosity light-curing resin. In a clinical study proximal surfaces treated with infiltration show a progression rate of 7% compared to proximal lesions not treated which have a progression rate of 37%. In another randomized controlled trial showed a progression rate of 4% when the infiltration method was used compared to 42% in non-treated teeth with a three year follow up. Overall, there is strong and consistent evidence to support the use of sealants in non-cavitated carious lesions. 

Atraumatic restorative treatment (ART) is a minimally invasive technique used to arrest caries progression by partially removing involved tissues with hand instruments and restoring with high-viscosity glass ionomer. Multiple studies suggest ART has a comparable success rate to tradition restorative techniques. A meta-analysis found ART survival rates in primary teeth to be 93% for one surface after 2 years. In permanent teeth ART was successful for one surface lesions at 85% up to 3 years and 80% at 5 years. 

Stepwise technique is another minimally invasive technique that performed in two steps. First, removal of partial carious tissue, leaving carious tissue on the pulpal floor then placing a temporary restoration for 12 months. Second, removal of the temporary restoration and removal of carious tissue to firm dentine, followed by a permanent restoration. This technique aims to elicit the formation of dentinal sclerosis and tertiary dentine. A meta-analysis found this procedure reduced the risk of pulp exposure by 56%. The main concern with the stepwise technique is the need for two appointments and re-entry into the tooth poses a risk of pulpal exposure. 

 Selective removal of soft dentine or partial caries removal is like the stepwise technique. The difference is the second step is omitted and the final restoration is placed after excavation with hand instruments and rotary instruments. The goal is to selectively remove carious tissue until firm dentine is reached on the lateral walls and only removing the outer most layer of soft dentine from the pulp wall before placing a permanent restoration. Study that followed a cohort found 12 out of 13 teeth that used this technique for restoration remained unchanged for 10 years. The selective removal technique has a 91% success rate while the stepwise technique only has a 69% success rate. 

The authors conclude by stating, “Minimally invasive treatment of both cavitated and non-cavitated carious lesions constitutes a rational strategy for the management of dental caries and should be encouraged at the public, private, and educational level at universities. Despite the obvious advantages of these techniques compared with the more traditional approaches, there is a natural resistance to change in many professionals. It is, therefore, necessary to confront the clinicians with the available evidence to engage them into a more minimally invasive treatment philosophy.”

How do you feel about placing sealants on non-cavitated carious lesions? Do you see the benefit in this procedure? Would you be willing to have the ART technique, or the selective removal technique used on you or your family members? Why or why not?

 

1. Giacaman, Rodrigo A et al. “Evidence-based strategies for the minimally invasive treatment of carious lesions: Review of the literature.” Advances in clinical and experimental medicine : official organ Wroclaw Medical Universityvol. 27,7 (2018): 1009-1016. doi:10.17219/acem/77022