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This is an excerpt of the article Evidence-based clinical practice guideline on non-restorative treatments for carious lesions. A report from the American Dental Association, published in JADA, October 2018
An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using non-restorative treatments in children and adults.
Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.
Recommendation
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 (application once per week for 3 weeks). (Moderate-certainty evidence, strong recommendation.)
To arrest advanced cavitated carious lesions on any coronal surface of permanent teeth, the expert panel suggests clinicians prioritize the use of 38% SDF solution (biannual application) over 5% NaF varnish (application once per week for 3 weeks). (Low-certainty evidence, conditional recommendation.)
Notes
- Although investigators in all included studies assessed the effectiveness of SDF in children with primary teeth, the expert panel did not expect SDF to have a substantially different effect when applied on coronal surfaces of permanent teeth. For this reason, the panel provided a strong recommendation for the use of 38% SDF solution in primary teeth and a conditional recommendation for its use on coronal surfaces of permanent teeth given that there is no direct evidence available informing the effectiveness of any concentration of SDF in permanent teeth (serious issues of indirectness).
- Although SDF has been used in other countries for decades, it was just introduced into the United States in 2014, when the US Food and Drug Administration approved the use of SDF to treat hypersensitivity in adults. At the time of publication, 38% SDF solution is the only concentration available in the United States.
- SDF could be used for a broad range of situations, including, but not limited to, when local or general anesthesia is not preferred, when a patient is not able to cooperate with treatment, or when it is necessary to offer a less costly or less invasive alternative.
- Data suggest that SDF may be more effective on anterior teeth than on posterior teeth. Hypotheses to explain this include, but are not limited to, anterior teeth being easier to keep clean and technique-related challenges for posterior teeth (for example, it is easier to maintain a dry field in the anterior teeth).
- One study informed the effect of SDF on International Caries Detection and Assessment System (ICDAS) 3 and 4 lesions, which involved using visual evaluation (with no radiographic assessment) to measure the progression of these lesions to ICDAS 5 and 6.
- Although the investigators reported results for approximal, occlusal, and facial or lingual surfaces combined, the panel remains uncertain about the effect of SDF on ICDAS 3 and 4 lesions on each of these surfaces separately. We suggest investigators in future studies use a combination of diagnostic strategies (for example, radiographic assessment and visual evaluation) for this type of lesion.
- Hardness of tooth surfaces on probing is an indication that a lesion is arrested. In contrast, the color of the lesion (that is, black) is not an acceptable method to judge arrest of a lesion.
- An adverse effect associated with SDF is black staining of the lesion, which may not be acceptable to some patients, parents, or caregivers.
- In keeping with the concept of informed consent, clinicians should offer or explain all nonsurgical and restorative treatment options and their potential adverse effects (such as blackened tooth surfaces treated with SDF) to all patients.
Clinical Implications
- Clinicians can use a variety of treatments to arrest or reverse carious lesions. The panel approached decision making by considering the type of lesion (non-cavitated or cavitated), dentition (primary or permanent), and tooth surface (for example, occlusal). The certainty in the evidence informing the panel recommendations ranged from very low to high because of issues of risk of bias, imprecision, indirectness, and inconsistency.
- The expert panel emphasizes the importance of actively monitoring non-cavitated and cavitated lesions during the course of non-restorative treatment to ensure the success of the management plan. Clinicians should observe signs of hardness on gentle probing or radiographic evidence of arrest or reversal over time and, if they do not see these signs, should implement additional or alternative treatment options. The panel suggests applying all treatments according to the dosage and technique provided within manufacturers’ instructions.
- Although the panel did not include diet counseling as an intervention in this guideline, the panel emphasizes that non-restorative treatments should be accompanied by a diet low in sugar. The panel will consider dietary modifications as an intervention for the next article on caries prevention.
Resource
International Caries Detection and Assessment System (ICDAS): A New Concept
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CDA Oasis Team
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