The objective of this article is to review evidence-based strategies available for the nonrestorative management of caries lesions, both cavitated and noncavitated. The goal is to help clinicians make appropriate decisions regarding nonrestorative management of caries lesions. In addition, in the decision-making process, clinicians must consider thresholds for restorative and nonrestorative care and strategies for nonrestorative management that are supported by best available evidence. It is important that this information be considered taking into account a provider’s clinical expertise and a patient’s treatment needs and preferences, in order to maintain health and preserve tooth structure.
Key points
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To manage the caries disease process, a patient with active caries lesions needs a combination of strategies directed at the level of the individual to reduce the risk of caries and prevent future caries lesions and then additionally requires tooth-level strategies specifically targeted to manage existing caries lesions.
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Clinicians should consider thresholds for restorative and nonrestorative interventions for dental caries lesion management in the context of the patient, dentist, and existing evidence. Clinicians should strive to provide personalized or specific interventions with the highest levels of supporting evidence whenever possible.
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For cavitated lesions, evidence-based nonrestorative effective alternatives are limited, for example, silver diamine fluoride.
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For noncavitated lesions, effective strategies vary by tooth surfaces.
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Caries lesions treated nonrestoratively should be monitored over time, to assess the efficacy of interventions.
Introduction
Dental caries, a multifactorial disease process, results from a dysbiosis in the oral biofilm, stimulated by frequent exposure to fermentable carbohydrates, which over time results in demineralization of dental hard tissues. Currently, caries management involves a conservative and preventive evidence-based philosophy, with person-centered risk-based disease management, early detection of caries lesions, and efforts to reverse and/or arrest caries lesions, with the aim to preserve tooth structure and maintain health. To facilitate implementation of this philosophy, guidelines have been developed to aid in clinical decision making between restorative and nonrestorative interventions for caries lesions. Guidelines also have been developed to identify what the best evidence-based strategies are for nonrestorative management of caries lesions of different severity in primary and permanent teeth and in different locations of the tooth structure.
Caries lesion characteristics that influence treatment decision making
The accurate detection and assessment of existing caries lesions, and their monitoring over time, are essential steps in the diagnostic process leading to a clinical decision about how to best manage, in a person-centered manner, both the disease and the resulting caries lesions.
If an active dental caries disease process develops in a tooth surface (ie, where acids derived from the metabolism of oral biofilms result in more demineralization than remineralization of tooth structure over a period of time), and this is allowed to continue unmanaged, over time the disease results in the development of detectable changes in the tooth structure, or caries lesions. In the beginning, these caries lesions are noncavitated (ie, macroscopically intact, sometimes referred to as white spot lesions) but eventually might progress to cavitation (ie, referred to as a cavity, where there is a break in the tooth surface, usually determined using visual or tactile means). Because the activity of the caries disease process can vary over time (eg, the risk for dental caries can change as individuals, for example, change their oral hygiene or dietary habits), caries lesions also can go through stages of progression and arrest throughout the life time. This can happen naturally (through exposure to saliva, self-cleaning, and so forth) or can be aided with products and/or interventions (nonrestorative as well as restorative). In general, it is more difficult to arrest caries lesions once they are cavitated, unless they are restored, because oral biofilms are infecting dental tissues and thus are difficult to access for control. Furthermore, caries lesions can be located in different tissues (ie, enamel vs dentin) and surfaces (eg, occlusal, proximal, and root), which allows for different clinical access and may require different interventions. Lesions also may be active or arrested, which also influences the need or not for intervention from a disease perspective.
A recent expert-based consensus report suggested that for best management, a caries lesion’s cavitation, cleansability, and activity need to be considered. The report also provided recommendations for thresholds between restorative and nonrestorative interventions. Thus, the following recommendations can help guide when use of nonrestorative strategies may be most appropriate :
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Arrested caries lesions do not need to be treated from a caries disease perspective (either restoratively or nonrestoratively [ Fig. 1 ]), except when the goal is to address issues associated with esthetics, function, or risk for pulpal death.
Fig. 1 Example of a noncavitated caries lesion in a mesial coronal surface of a primary incisor. Because the lesion is now cleansable and smooth, the lesion is considered arrested and not in need of caries intervention. - •
Noncavitated active caries lesions should be treated using evidence-based nonrestorative products or interventions.
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Some occlusal noncavitated lesions might extend radiographically deep into dentin. These lesions can be treated nonrestoratively (eg, using sealants), but it has been suggested that a trampoline effect (ie, in which the surface of the lesion may cavitate, because the body of the lesion is extensive and may undermine it) may result in the sealant failing, and thus treatment should be closely monitored.
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Cavitated caries lesions ( Fig. 2 ) generally are noncleansable and thus active; therefore, these lesions most commonly need to be restored. Selective removal of carious tissues is guided by the depth of the lesion, pulpal health, and choice of dental material. Restoration of the existing cavity allows for oral biofilms to be relocated to the surface of the tooth and amenable to better control of the local disease process. In addition, restoring the cavity allows for re-establishment of function and esthetics, which can be important patient-level outcomes.
Fig. 2 Example of an advanced cavitated caries lesion with dentin clinically exposed in the facial coronal surface of a primary canine. Because dentin is soft on gentle probing, the lesion is considered active and in need of intervention. - •
Some cavitated lesions that are not pulpally involved could be treated nonrestoratively (eg, with silver diamine fluoride [SDF]), either temporarily or permanently, if the primary goal is to arrest the caries disease process, with the understanding that function and esthetics remain compromised because of the loss of tooth structure. For some individuals, because of medical, social, behavioral, and/or financial factors, this compromise is the most appropriate person-centered approach to managing appropriate cavitated lesions.
Nonrestorative caries lesion treatment options
Clinicians should consider options for nonrestorative interventions for dental caries lesion management in the context of the patient, dentist, and, whenever possible, the highest levels of supporting evidence. Clinical decision making must take into consideration patient caries risk, readiness for change, and likelihood of compliance with the proposed interventions. Systematic reviews and evidence-based practice guidelines for nonrestorative treatment options were published recently by the American Dental Association (ADA) ( Figs. 3 and 4 ). Although this article does not discuss risk assessment and caries prevention, it is imperative to remember that to manage the caries disease process, a patient with active caries lesions needs a combination of strategies directed at the level of the individual to reduce the risk of caries and prevent future caries lesions and then additionally requires tooth-level strategies (some of them nonrestorative), specifically targeted to manage existing caries lesions. Evidence-based nonrestorative treatment alternatives are discussed.
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