NON-INVASIVE/NON-RESTORATIVE

TREATMENT OF CARIES LESIONS

Fiona Collins BDS, MBA, MA, FPFA

2CE
CREDITS
Non-invasive/non-restorative treatment of caries lesions
Dental caries is a multifactorial, endemic disease and a significant global oral health burden with an estimated
60% to 90% of schoolchildren and the majority of adults impacted. 1 In the United States, the estimated caries
prevalence among adults 20 to 64 years-of-age is 90%. 2 For individuals 2 to 19 years-of-age an estimated caries
prevalence of 45.8% has been found. 3 With respect to untreated dental caries, an estimated prevalence of 10%,
16% and 21.3%, respectively, has been found for individuals aged 2–5 years, in the primary dentition for children
aged 6–8 years, and among adults. 3 , 4 These statistics highlight the ongoing need for effective caries
management.

The caries process

Figure 1. Early phase of the caries process

The caries process involves repeated cycles of demineralization and remineralization. Demineralization occurs
due to exposure to acid produced through the bacterial metabolism of fermentable carbohydrates. Therefore,
the presence of cariogenic bacteria and fermentable carbohydrates are prerequisites for dental caries. 5 The
initiation and progression of dental caries depends on the balance between risk factors and protective factors,
and occurs when loss of calcium and phosphate from the dental hard tissue (demineralization) outpaces
remineralization. 6 , 7 During the initial phase of lesion formation, the surface appears visibly intact while
subsurface demineralization is present. Remineralization occurs when calcium and phosphate enter the area, if
conditions are favorable. In the presence of fluoride this is accelerated, with fluoride adsorbing to the partially
demineralized surface and attracting calcium ions, which in turn attract phosphate. These then enter the tooth,
remineralizing it and the fluoride taken up results in the formation of fluorapatite. (Figure 1) In order to determine
the destructive and protective factors involved and caries risk level for an individual patient, a periodic caries risk
assessment should be performed. 8

Non-cavitated caries lesions are also referred to as initial caries lesions/incipient lesions/enamel lesions. ‘Enamel
lesion’ is, however, not synonymous with non-cavitated lesions since these are not all in/only in enamel. 9 Non-
cavitated caries lesions have incurred no loss of integrity of the tooth (visible breakdown). 10 Conversely, cavitated
caries lesions are advanced lesions and demonstrate loss of integrity of the tooth, i.e., cavitation. 10 Under the
International Caries Detection and Staging method (ICDAS) coronal caries lesions are categorized as initial,
moderate or extensive based on visual and radiographic evaluation. 11 Initial lesions are ICDAS 1 or 2, equivalent to
the ‘initial’ lesion described as visually non-cavitated under the American Dental Association Caries Classification
System. 12 ICDAS 3 and 4 are ‘moderate lesions’ and may or may not be cavitated. For approximal lesions, the
radiolucency on radiographs extends to the dentinoenamel junction or outer third of dentin for ICDAS 1 and 2
and into the middle-third of the dentin for ICDAS 3 and 4. 13 ICDAS 5 and 6 are extensive (advanced) caries lesions
with visible cavitation. 11 More information on ICDAS staging, visual signs and assessment, and protocols can be
found on the relevant websites. 11 , 13

Non-cavitated caries lesions have incurred no loss of

integrity of the tooth, while cavitated caries lesions
are advanced and demonstrate visible breakdown.

Caries management
Caries prevention and control measures recommended for individual patients include oral hygiene instructions
and thorough home care, as well as dietary and lifestyle advice. Other measures can include applications of in-
office topical fluorides and home use of OTC/Rx gels, toothpastes, and rinses; resin infiltration; sealants; and
other interventions. 14 Selection of management options is based on numerous factors and, among these, at the
lesion level it is necessary to evaluate the site, stage/progression and activity. 9 , 12 , 15 Guidelines on the non-
restorative (noninvasive/microinvasive) management of non-cavitated and cavitated caries lesions have been
published by the American Dental Association. 16 For the arrestment or reversal of non-cavitated lesions, the
guidelines are surface-specific.

Non-cavitated coronal lesions

Figure 2. Prioritized management options for non-cavitated coronal lesions

Occlusal – Application of sealants plus application every 3 to 6 months of 5% sodium fluoride (NaF) varnish is the
highest priority recommendation. Other options in descending order of priority include sealants, 5% NaF varnish,
and 1.23% APF gel. For the primary dentition, resin infiltration plus 5% NaF varnish is a further option. The lowest
priority is weekly use of 0.2% NaF rinse.

Approximal – the highest priority recommendation is application of 5% NaF varnish. Lower priority options
include resin infiltration, and sealants. For the primary dentition, resin infiltration plus 5% NaF varnish is a further
option.

Facial and lingual – application of 5% NaF varnish or 1.23% APF gel. (Figure 2)
Cavitated coronal lesions
For cavitated coronal lesions in primary and permanent teeth, 6-monthly application of 38% silver diamine
fluoride (SDF) is prioritized over 5% NaF varnish applications weekly for 3 weeks.

Non-cavitated and cavitated root caries lesions

The use of 5,000 ppm fluoride toothpaste/gel at least once daily is the highest priority recommendation for the
arrestment and reversal of root caries. Other options, in descending order of priority, include 5% NaF varnish
(every 3-6 months), a two-step annual application of 38% SDF followed by potassium iodide, 38% SDF annually,
and 1% chlorhexidine+1% thymol varnish (every 3-6 months).

Basis for the ADA Guidelines

Recommendations in the ADA guidelines are ranked based on data on efficacy, resource efficiency, patient values
and preferences, and feasibility. 16 , 17 A systematic review of 44 randomized controlled trials (RCT) conducted from
1984 to 2018, while published after publication of the guidelines, provided input for the guidelines. 17 (Table 1)

Non-cavitated caries lesions

Eight RCT were included on occlusal caries interventions, with 7 included in a network meta-analysis. Sealant
application plus use of 5% NaF varnish provided a more than three-fold likelihood of caries arrestment/reversal
(RR 3.35) compared to no treatment. 17 For other recommended interventions, the likelihood of
arrestment/reversal ranged from two- to three-fold. For approximal lesions, to compare interventions, a network
meta-analysis (NMA) was conducted on 6 of 13 related RCT in the review. Lesions were assessed as confined to
the enamel or in the outer-third of the dentin. In comparing use of resin infiltration plus 5% NaF varnish to 5% NaF
varnish alone, it was determined that the likelihood of lesion arrestment/reversal could be five-fold (1 study) and
two-fold (2 studies), respectively. However, ‘certainty’ was graded as very low. Resin infiltration or sealant use
resulted in a two-fold chance of reversal or arrestment, with low certainty. For facial and lingual lesions, a two- to
three-fold likelihood of arrestment/reversal was found for use of 5% NaF varnish or 1.23% APF gel.

Cavitated coronal lesions

Four RCT were included in the systematic review. At 2.5 years, twice-yearly application of 38% SDF was found to
be more effective than annual applications in arresting lesions. As noted in the review, the recommendation for
cavitated coronal lesions in the permanent dentition was based on extrapolation of results for the primary
dentition.

Root caries lesions

Seven of 11 RCT on various interventions were included in the meta-analysis. Based on 4 of the RCT, use of 5,000
ppm toothpaste or gel resulted in a three-fold likelihood of arresting/reversing non-cavitated and cavitated root
caries lesions compared to no treatment. Results for other interventions across RCT yielded a two- to three-fold
greater likelihood, however with very low certainty. 17
 Table 1. Priority interventions evaluated in a systematic review 17

Three-fold likelihood of caries arrestment/ reversal with sealant

Non-cavitated occlusal lesions
application plus use of 5% NaF varnish vs. no treatment.

Possibly five-fold likelihood of arrestment/reversal with resin

Non-cavitated approximal lesions infiltration plus 5% NaF varnish; possibly two-fold for 5% NaF varnish;
both very low certainty.

Two- to three-fold likelihood of arrestment/reversal with use of 5% NaF

Non-cavitated facial/ lingual lesions
varnish or 1.23% APF gel.

At 2.5 years, twice-yearly application of 38% SDF was found to be

Cavitated coronal lesions more effective than annual applications in arresting lesions in the
primary dentition.

Three-fold likelihood of arresting/reversing non-cavitated and

Root caries lesions cavitated lesions with use of 5,000 ppm toothpaste or gel compared to
no treatment.

Additional reviews and studies

A more recent systematic review assessed the results of thirty-five RCT conducted between mid-2017 and March
2022. 18 Overall, SDF demonstrated greater efficacy than 5% NaF varnish in arresting dentinal caries, while 5%
NaF varnish was an effective intervention for arresting lesions in enamel. The results also confirmed the efficacy
of fissure sealants on occlusal surfaces, with similar efficacy found for resin-based and glass ionomer sealants. In
addition, based on 10 RCT, resin infiltration was effective as an intervention for proximal lesions in dentin in both
the primary and permanent detention. Caries arrestment rates ranged from 37.5% to 64.1% at 12 months and
48% at 30 months. For white-spot lesions, 5% NaF varnish and resin infiltration were both effective (no significant
difference). 18

Resin infiltration is an effective intervention for

proximal lesions in dentin in the primary and
permanent detention, based on a recent systematic
review.

In an umbrella review of systematic reviews conducted between 1970 and 2018, 19 use of SDF was superior to
fluoride varnish, ART, and placebo in arresting caries lesions in the primary dentition. Caries arrestment ranged
from 65% to over 90% with use of SDF. Insufficient evidence was found to determine the effect of SDF on the
permanent dentition. In a second umbrella review, twice-yearly application of SDF was found to be between 53%
and 91% effective in primary teeth, depending on the included review. 20 The American Academy of Pediatric
Dentistry supports the use of SDF for caries arrestment. 21

An ORCA/EFCD consensus statement (2020) on proximal caries in the permanent dentition was published, based
on a systematic review and meta-analysis of reviews and RCT. 22 It stated that fluoride and biofilm management
reduced the likelihood of lesions progressing, and that proximal sealants or resin infiltration (which are both
micro-invasive) were more effective than no treatment or non-invasive treatment. In a study with 193 adolescents
and a follow-up of 4 to 5 years, almost half of more than 1100 permanent molars were identified with non-
cavitated inactive occlusal lesions at baseline. 23 Most lesions did not progress. At the subject level, approximately
70% of children had only sound surfaces/inactive lesions at follow-up (no extractions, restorations, or active
lesions).

Fluoride and biofilm management reduce the

likelihood of lesions progressing, and proximal
sealants or resin infiltration are more effective than no
treatment or non-invasive treatment. 22

Other considerations
As noted above, in addition to efficacy, the resource efficiency, patient values and preferences, and feasibility of
an intervention are considered. 16 , 17 Non-invasive interventions are the least resource intensive and, along with
micro-invasive interventions, are preferable given the preservation of tooth structure. Non-invasive/minimally
invasive options are also more desirable and comfortable for patients.

There has been debate over whether sealants should be placed over early caries lesions. In doing so, the lesion is
isolated from the oral cavity provided there is integrity of the sealant. In addition, any bacteria present would
also be sealed, isolating them from the fermentable carbohydrates they need to produce acid. Furthermore,
current evidence supports the efficacy of sealants on sound teeth and those with non-cavitated lesions. Sealant
integrity needs to be assessed at recalls and further care provided if the sealant no longer functions (chipped or
(partially) lost).

Current evidence supports the efficacy of sealants on

sound teeth and those with non-cavitated lesions.

SDF is used in children and to treat root caries in adults. Caries removal is not required prior to application, and
the application is relatively easy and painless. 24 This intervention is less traumatic for children than alternatives
and helps with patient cooperation. Patient preferences help to inform the prioritization of a two-step protocol
with annual application of 38% SDF followed by potassium iodide which results in minimal tooth stain, over a
one-step SDF application that is associated with grey/dark grey tooth stain. The acceptability of the discoloration
is higher for posterior than anterior teeth and additionally for parents when a child’s cooperation is lacking
during treatment, information was provided ahead of time, and where the alternative was general
anesthesia. 25 , 26 Patients/parents must be informed of staining associated with SDF and provide written informed
consent before treatment is provided. 27
 Non-invasive interventions are the least resource
intensive and, along with micro-invasive interventions,
are preferable given the preservation of tooth
structure.

Conclusions
Non-restorative interventions for non-cavitated and cavitated lesions avoid/minimize loss of tooth structure and
can remove a cycle of expanded restorative care from the equation. They are also supported by recent research.
Further research using robust designs with clear diagnostic criteria and objective evaluations would further
inform care. Recent research on diagnoses involving adjunctive use of AI has been promising.

It is essential that patients attend on an ongoing basis for evaluation and care, as well as for periodic caries risk
assessment since risk level is dynamic. The likelihood of patient compliance with home care as well as return
visits and recalls must also be considered when determining appropriate interventions for a given patient. It is
recommended that non-restorative (non-invasive/ minimally invasive) interventions be provided when
possible. 28 , 29 Consideration of individual patient factors, preferences and values are part of the clinical decision-
making and collaborative process in agreeing on appropriate interventions.
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