20 November 2019

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Non-restorative Treatments for Caries: what to expect.

Lorenzo Breschi

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Dental caries is one the most prevalent chronic disease in the world. It affects 60% to 90% of children and a large part of the adult population (data of the World Health Organization 2018).
Carious lesions damage tooth structures and may produce cavity formation in the enamel, dentine and cementum. Cavitation in teeth results from a pathogenic process that occurred on the tooth surface for weeks or even years. Accumulation of dental plaque (biofilm) on the tooth is usually the first manifestation of the disease. Dental plaque is a biofilm formed on the tooth's surface and frequently contains caries‐producing bacteria. These micro‐organisms metabolise dietary sugars and produce acids on the tooth surfaces. The resulting decreasing pH leads to an altered mineral saturation within the biofilm and the dissolution of tooth minerals. Prolonged loss of mineral components will eventually lead to cavitation of the carious lesions, i.e. decay. Arresting cavitated lesions is more difficult, as loss of tooth structure creates niches for the biofilm that are not easily accessible.

Therefore, early detection, diagnosis and the use of effective nonrestorative treatments are crucial for the management of non-cavitated carious lesions and to minimize the loss of sound tooth structure.

A systematic review and network meta-analysis from Urquhart et al. summarized the available evidence on non-restorative treatments focusing on  the outcomes:
1) arrest or reversal of non-cavitated and cavitated carious lesions on primary and permanent teeth;
2) adverse events.

The authors followed the guidance from the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) Checklist to report the systematic review and included in the study parallel or split-mouth randomized controlled trials, with follow-up of any length. The research focused on adults and children with non-cavitated or cavitated carious lesions on primary or permanent teeth diagnosed with the following criteria:
-  Lesions diagnosed with radiographs or visual/tactile assessment.
-  Caries classification methods or lesion assessment criteria (DIAGNOdent and quantitative light-induced fluorescence were not included)
-  Lesions without demineralized tissue removal (beyond acid etching for bonding) before application of the intervention.

Interventions on the lesions included professionally applied or prescribed products available in the United States in which an active intervention was compared with another active intervention or no intervention/placebo. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing non-cavitated or cavitated carious lesions.

The results obtained by the authors suggest that:
1) the combination of sealants and 5% NaF varnish was the most effective for non-cavitated carious lesions on occlusal surfaces in primary and permanent teeth (moderate certainty),
 2) the combination of resin infiltration and 5% NaF varnish may be the most effective for noncavitated carious lesions on approximal surfaces in primary and permanent teeth (low certainty).
Similarly, 5,000-ppm F (1.1% NaF) toothpaste or gel may be the most effective for non-cavitated and cavitated carious lesions on root surfaces in permanent teeth (low certainty). Furthermore, the research data showed that when compared with no intervention, 5% NaF varnish could be the most effective treatment for arresting or reversing non-cavitated facial/lingual lesions on primary and permanent teeth (low to moderate certainty).   The authors conclude that the certainty in the evidence ranged from very low to high for the outcome of arrest or reversal across all surfaces, types of lesions and dentition, but a downgrading in the certainty was necessary  due to serious issues of risk of bias and imprecision.

For that reason, Urquhart et al. suggest that it may be useful if experts could establish a core set of outcomes informing benefits and harms of non-restorative treatments for caries management and a definitions of these outcomes in order to increase the overall quality of researches and provide a more detailed report of their methods, thus reducing risk of bias through the implementation of acceptable methods for allocation concealment and randomization.  

For additional informations: Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis.