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Practice Guideline: What should be recommended to arrest or reverse non-cavitated coronal carious lesions on primary or permanent teeth?

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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.

Question

To arrest or reverse noncavitated coronal carious lesions on primary or permanent teeth, should we recommend NaF, stannous fluoride, acidulated phosphate fluoride (APF), difluorsilane, ammonium fluoride, polyols, chlorhexidine, calcium phosphate, amorphous calcium phosphate (ACP), casein phosphopeptide (CPP)eACP, nano-hydroxyapatite, tricalcium phosphate, or prebiotics with or without 1.5% arginine, probiotics, SDF, silver nitrate, lasers, resin infiltration, sealants, sodium bicarbonate, calcium hydroxide, or carbamide peroxide?

Non-cavitated Lesions on Occlusal Surfaces

Recommendation

  • To arrest or reverse non-cavitated carious lesions on occlusal surfaces of primary teeth, the expert panel recommends clinicians prioritize the use of sealants plus 5% NaF varnish (application every 3-6 months) or sealants alone over 5% NaF varnish alone (application every 3-6 months), 1.23% APF gel (application every 3-6 months), resin infiltration plus 5% NaF varnish (application every 3-6 months), or 0.2% NaF mouthrinse (once per week). (Moderate-certainty evidence, strong recommendation.)
  • To arrest or reverse noncavitated carious lesions on occlusal surfaces of permanent teeth, the expert panel recommends clinicians prioritize the use of sealants plus 5% NaF varnish (application every 3-6 months) or sealants alone over 5% NaF varnish alone (application every 3-6 months), 1.23% APF gel (application every 3-6 months), or 0.2% NaF mouthrinse (once per week). (Moderate-certainty evidence, strong recommendation.)

Notes

  • The order of treatments included in this recommendation is a ranking of priority that the panel defined when accounting for their effectiveness, feasibility, patient values and preferences, and resource use.
  • The panel prioritized the use of sealants plus 5% NaF varnish or sealants alone over the use of all other treatments for occlusal non-cavitated lesions on both primary and permanent teeth. Although the studies in which the investigators examined the combination of sealants plus 5% NaF were conducted in primary teeth, the panel had no reason to believe these treatments would have a substantially different effect when applied to permanent teeth.
  • Investigators in the studies informing the recommendations for sealants included a mixture of resin-based, glass ionomer cement, and resin-modified glass ionomer sealants and reported a range in sealant retention from 41% through 89%. Maintaining a dry field and using proper technique are essential for sealant effectiveness and retention. If maintaining a dry field is not possible, a hydrophilic sealant material such as glass ionomer cement may be preferred over resin-based material. In settings in which the quality of sealant application cannot be guaranteed, the panel suggests that clinicians consider other treatments included in the recommendations. Notably, enamel removal is unnecessary before sealant application.
  • The study in which the investigators provided data about 0.2% NaF mouthrinse also included supervised toothbrushing as a co-intervention.
  • Although data from 1 study support the use of resin infiltration plus 5% NaF varnish on occlusal surfaces of primary teeth, resin infiltration has been developed and studied primarily for treating approximal surfaces. The panel advises clinicians to consider the relatively high costs associated with this intervention compared with the cost of sealants.
  • To mitigate the risk of experiencing accidental ingestion of high doses of fluoride, 0.2% NaF mouthrinses are not appropriate for uncooperative children who cannot control swallowing. In addition, in-office gels (for example, 1.23% APF gel) require suction to minimize swallowing, especially when used in children.

Non-cavitated Lesions on Approximal Surfaces

Recommendation

To arrest or reverse non-cavitated carious lesions on approximal surfaces of primary and permanent teeth, the expert panel suggests clinicians use 5% NaF varnish (application every 3-6 months), resin infiltration alone, resin infiltration plus 5% NaF varnish (application every 3-6 months), or sealants alone. (Low- to very-low-certainty evidence, conditional recommendation.)

Notes

  • The order of treatments included in this recommendation is a ranking of priority that the panel defined when accounting for their effectiveness, feasibility, patient values and preferences, and resource use.
  • After detecting an approximal lesion (and when it is not possible or feasible to separate the teeth for direct clinical observation), the clinician must rely on radiographic depth to diagnose the lesion as non-cavitated or cavitated. Study investigators included lesions with radiolucencies ranging from the enamel to lesions in the outer one-third of the dentin. The panel emphasizes that approximal lesions that appear limited to the enamel and outer one-third of the dentin on radiographs are most likely non-cavitated, and the clinician should prioritize the use of non-restorative interventions.
  • Investigators in the studies informing the use of resin infiltration alone conducted the studies in permanent teeth, whereas the study investigators examining the use of resin infiltration plus 5% NaF varnish conducted the study in primary teeth. Investigators in 1 study examined the effectiveness of resin infiltration in mixed dentition, and the results suggested that it was significantly more effective in arresting or reversing approximal non-cavitated lesions than was the control, described by the investigators as “mock treatment.” The panel suggested using these treatments in both primary and permanent teeth because they did not expect them to have a substantially different effect in the 2 types of dentition. Resin infiltration is technique sensitive and may not be appropriate for uncooperative children.
  • The evidence supporting the recommendation for sealants on approximal surfaces came from studies in which the investigators evaluated resin-based and glass ionomer cement sealants. In no included studies did the investigators report on sealant retention for approximal surfaces. In addition, the use of sealants on approximal surfaces requires temporary tooth separation (a few days) and is technique sensitive. The remarks associated with the use of sealants on occlusal surfaces also apply to the use of sealants on approximal surfaces.

Non-cavitated Lesions on Facial or Lingual Surfaces

Recommendation

  • To arrest or reverse non-cavitated 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). (Moderate- to low-certainty evidence, conditional recommendation.)

Notes

  • The order of treatments included in this recommendation is a ranking of priority that the panel defined when accounting for their effectiveness, feasibility, patient values and preferences, and resource use.
    In-office gels (for example, 1.23% APF gel) require suction to minimize swallowing, especially when used in uncooperative children.

Non-cavitated Lesions on Any Coronal Tooth Surface

To arrest or reverse non-cavitated carious lesions on coronal surfaces of primary and permanent teeth, the expert panel suggests clinicians do not use 10% CPP-ACP if other fluoride interventions, sealants, or resin infiltration is accessible. (Low-certainty evidence, conditional recommendation.)

Note

  • The panel emphasizes that 10% CPP-ACP should not be used as a substitute for fluoride products.
    We found no evidence on the effect of stannous fluoride, difluorsilane, ammonium fluoride, calcium phosphate, ACP, nano-hydroxyapatite, tricalcium phosphate, or prebiotics with or without 1.5% arginine, SDF, silver nitrate, lasers, sodium bicarbonate, calcium hydroxide, or carbamide peroxide for non-cavitated lesions on any coronal tooth surface.

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.

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