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| Year : 2023 | Volume
: 26
| Issue : 3 | Page : 249-257 |
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| The revolutionary evolution in carious lesion management |
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Nebu Philip1, Bharat Suneja2
1 Paediatric Dentistry, College of Dental Medicine, QU Health, Qatar University, Doha, Qatar
2 The Dental Care Centre, Ludhiana, Punjab, India
Click here for correspondence address and email
| Date of Submission | 19-Jan-2023 |
| Date of Decision | 23-Feb-2023 |
| Date of Acceptance | 19-Apr-2023 |
| Date of Web Publication | 16-May-2023 |
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 Abstract | | |
Contemporary paradigms of dental caries management focus on the biological approaches to treating the disease and its principal symptom, the carious lesion. This narrative review traces the evolution of carious lesion management from the operative and invasive approaches of G. V. Black's era to the current period of minimally invasive biological approaches. The paper explains the rationale for adopting biological approaches to dental caries management and lists the five core principles of this management approach. The paper also details the aims, features, and the most recent evidence base for the different biological carious lesion management approaches. Based on current practice guidelines, collated clinical pathways for lesion management are also presented in the paper to aid clinicians in their decision-making. It is hoped that the biological rationale and evidence summarized in this paper will bolster the shift to modern biological carious lesion management approaches among dental practitioners.
Keywords: Biological management; carious lesion; dental caries
How to cite this article:
Philip N, Suneja B. The revolutionary evolution in carious lesion management. J Conserv Dent 2023;26:249-57 |
| Introduction | |  |
The necessity of treating teeth affected by dental caries was recognized even in prehistoric times. Primitive forms of carious lesion treatment using bow drills and beeswax dental fillings were evidenced as early as the Neolithic period.[1] In more recent times, the establishment of dentistry as a surgical specialty in the 19th century seems to have set the course for a generation of dental professionals to adopt a predominantly operative approach toward managing carious lesions.[2] G. V Black's seminal statement, “Generally when the cavity has been cut to form no carious dentine should remain,” influenced how dentists treated carious lesions for more than 100 years.[3] This historical approach to carious lesion management gave little consideration to its effects on pulp vitality or the loss of healthy tooth structure. Rather, carious tissue was treated like gangrenous tissue with its complete surgical excision considered the gold standard. However, even in that era of dentistry, there were opposing views on how much carious tissue should be removed. Sir John Tomes, writing in 1859, suggested that “it is better that a layer of discolored dentine should be allowed to remain for the protection of the pulp rather than run the risk of sacrificing the tooth.”[4] However, Black's guidelines encompassing non-selective caries removal and “extension for prevention” remained the bedrock of carious lesion management, taught religiously at dental schools, and practiced faithfully by dentists worldwide.
The first philosophical evolution in lesion management principles occurred in the late 1960s and early 1970s based on concurrent research by Fusayama and Massler.[5],[6],[7] They described two distinct layers of carious dentine, an outer bacterially contaminated or “infected” zone, and an inner demineralized or “affected” zone. It was suggested that only the bacterially contaminated outer zone needed to be excavated during cavity preparation, leaving behind the inner zone that had remineralization potential. This advice was the genesis of selective carious tissue removal and the first departure from Black's guidelines. The earlier convention of completely removing even demineralized dentine assumed that such dentine would not support restorations as well as sound dentine.[8] However, it is now well-established that remineralization and restitution of the mechanical properties of demineralized dentine are possible.[9] Nevertheless, in advanced carious lesions, extending to the inner third of the dentine, both the non-selective caries removal suggested by Black and the selective caries removal of only “infected” dentine suggested by Fusayama and Massler, risk exposing the pulp.[10]
The other major development in the 1970s was two studies that showed dramatic reductions in viable bacteria numbers when sealed under restorations.[11],[12] Later studies replicated these early results, demonstrating that the microbiological load in “infected” dentine is progressively reduced when it is sealed off from the oral environment.[13],[14],[15] A corollary of these microbial studies was that remnants of bacterially contaminated “infected” dentine entombed below sealed restorations need not have detrimental effects on pulp, as clearly evidenced from multiple clinical trials.[16],[17],[18],[19] These include the feted studies of the Mertz-Fairhurst group, that showed that sealed restorations placed over frank cavitations arrested lesion progress even 10 years after their placement.[19] Systematic reviews and meta-analyses provided further confirmation on the effectiveness of sealed restorations in arresting the progression of carious lesions and reducing viable bacteria numbers.[20],[21]
Early this century, classic review papers by Pitts[22] and Kidd[23] urged dentists to move from operative to nonoperative management of carious lesions, emphasizing that there was “no clear evidence that it is deleterious to leave infected dentine, even if it is soft and wet, before sealing the cavity.”[23] Contemporary carious lesion management approaches focus on controlling the lesions' activity while preserving tooth tissue and pulp vitality. Even cavitated dentinal lesions can be managed by changing the biological conditions causing the demineralization-remineralization imbalance or simply by sealing over the lesion with leak-proof restorations. Rather than just fixing the symptoms of dental caries (lesions), biological caries management approaches also address the causes of the disease, potentially avoiding the vicious restorative cycle often seen with the traditional treatment of carious lesions. Systematic reviews have found robust evidence asserting the effectiveness of these less invasive biological approaches to carious lesion management.[24],[25],[26],[27],[28],[29]
| Biological Dental Caries Management: Rationale | | |
Historically, dental caries was perceived to be an “infectious” disease caused by specific bacteria inducing acid dissolution of the tooth tissues.[30] This resulted in dentists adopting a predominantly operative approach toward dental caries, with carious lesion management being synonymous with excising “infected” dental tissue.[2] It was assumed that surgically removing contaminated demineralized tissue would “cure” the disease of dental caries. Furthermore, the conventional drill-and-fill model was based on the erroneous concept that once a lesion was established, its further progress was inevitable unless lesion microbiota were eradicated from the “infected” tooth tissue. The futility of traditional operative approaches in managing carious lesions is now widely recognized as dental caries, rather than being a classical infectious disease, belongs to a group of multifactorial lifestyle diseases (such as cancer or diabetes) in which genetic, environmental, and behavioral risk factors interact and play a role in lesion initiation and progression.[31]
Dental caries is today acknowledged to be dynamic, polymicrobial, biofilm-mediated disease triggered by local environmental stresses that cause a deleterious shift in the microbial composition of the dental plaque biofilm.[32] The local environmental perturbations (e.g., sugar-rich diet and salivary dysfunction) that drive the plaque microbial dysbiosis, trigger an imbalance in the physiologic equilibrium between tooth mineral and biofilm fluid, resulting in mineral loss and carious lesions.[33] However, the caries process is not simply a continual cumulative loss of tooth minerals leading to cavitation, but rather a dynamic process characterized by alternating periods of demineralization and remineralization.[34] Lesion progression or reversal depends on the equilibrium between demineralization-favoring pathological factors (cariogenic bacteria, fermentable carbohydrates, and salivary dysfunction) and the remineralization-favoring protective factors (antibacterial agents, sufficient saliva, and remineralizing ions).[35]
The implication of accepting the ecological plaque hypothesis as the basis for caries pathophysiology is that symptoms of the disease can be reversed or arrested by manipulating the ecological and metabolic balance within the plaque biofilm.[33] As it is the biofilm that drives the caries process, obsessing over how “clean” a cavity must be before restoration becomes irrelevant.[23] Rather than tissue removal, the focus of dental caries management should be to beneficially shift the plaque biofilm environment from a cariogenic to a noncariogenic state.
| Biological Dental Caries Management: Principles | | |
Innes and Manton[3] summarized the five core principles for minimally invasive biological management of dental caries as follows:
Recognition
This includes an in-depth patient assessment to obtain information on dietary sugar exposures, brushing habits and relevant social/dental/medical history. Recognition also incorporates the detection of disease (whether a lesion is present or not), determining lesion activity (active or arrested), cleanability (non-cavitated or cavitated), and depth (initial/moderate/advanced).
Re-orientation
This involves improving or altering disease-contributing risk factors such as reducing the frequency of dietary sugar intake, improving oral hygiene practices, and encouraging regular visits to the dentist.
Remineralization
Aims to arrest or reverse mineral loss in carious lesions at all disease stages, both precavitation and postcavitation. Besides the professional application of topical fluorides, encouraging twice-daily brushing with appropriately fluoridated dentifrices and reducing dietary sugar exposures are the best tools available to tip the balance back in favor of remineralization.
Repair
For existing active cavitated and noncavitated lesions, the repair approaches include both nonoperative interventions and operative interventions [Figure 1]. The aims, specific clinical interventions, features, and the evidence base for the different repair options are discussed below.
Review
To ensure a healthy oral and lifestyle environment is maintained.
| Biological Carious Lesion Management: Aims and Clinical Interventions | | |
For existing carious lesions, lesion activity, cleansability, and depth are the primary factors that determine which biological approach to adopt in specific clinical situations. While different lesion stages and activities might require different repair strategies, they all aim to inactivate the disease process, preserve dental hard tissue, avoid the repeat restoration cycle, and retain the affected tooth for as long as possible.[36] Depending on whether or not the intervention involves carious tissue removal, there are two broad clinical approaches to repairing existing active carious lesions: (i) Nonoperative interventions (noninvasive and microinvasive approaches with no carious tissue removal); and (ii) Operative interventions (minimally invasive approaches with conservative carious tissue removal). The specific clinical approaches under each of these interventions are presented in [Figure 1].
| Biological Carious Lesion Management Approaches: Features And Evidence-Base | | |
Noninvasive approaches: Lesion remineralization and hall crowns
The noninvasive approaches include lesion remineralization and the Hall crown restoration. For both approaches, there is neither any carious tissue excision nor any tooth tissue removal. The lesion remineralization approach is indicated for noncavitated and cavitated lesions in both primary and permanent teeth, while the Hall crown technique is indicated for moderate or advanced cavitated lesions in primary teeth. The evidence base for these noninvasive approaches is detailed below.
Lesion remineralization
Fluoride products, whether professionally applied (5% NaF varnish, 1.23% APF gel, or 38% SDF solution) or self-applied (5000 ppm fluoride dentifrices), have the most robust evidence supporting their use to reverse or arrest cavitated and noncavitated lesions. Evidence from two systematic reviews, a network meta-analysis, and an umbrella review found 38% SDF solution to be the most effective in arresting cavitated dentinal lesions on coronal surfaces of primary and permanent teeth (moderate-to-high-certainty evidence), consistently outperforming comparators such as fluoride varnish, atraumatic restorative treatment (ART), or placebo.[37],[38],[39],[40] For reversing noncavitated lesions on smooth surfaces of primary and permanent teeth, 1.23% APF gel was found to be the most effective (moderate-to-low-certainty evidence).[39],[41] However, for reversing noncavitated lesions on the caries susceptible occlusal surfaces, data from systematic reviews suggest that sealants alone or in combination with 5% NaF varnish may be more effective than the NaF varnish alone (moderate-certainty evidence).[39],[41],[42] There is low-to-very low-certainty evidence for the use of 5% NaF varnish in arresting noncavitated lesions on proximal surfaces of primary and permanent teeth, with the other options for managing noncavitated proximal lesions (sealants and resin infiltration) also having the same level of evidence.[39],[43] To arrest cavitated or noncavitated lesions on root surfaces of permanent teeth, at least once daily use of 5000 ppm fluoride dentifrice is recommended over 5% NaF varnish or 38% SDF solution (low certainty evidence).[39],[44]
Hall crowns
The Hall crown technique is a noninvasive approach that involves the placement of a preformed metal crown (PMC) overactive cavitated dentinal lesions in primary molars without any carious tissue removal or tooth preparation. The Hall technique (HT) is indicated in primary molars where there is a clear band of dentine between the carious lesion and the pulp. The biological rationale of sealing the carious lesion with the PMC is to isolate the lesion biofilm from the cariogenic oral environment and thereby inactivate it. There is now robust evidence from several randomized controlled trials (RCTs) proving that the HT is significantly superior to conventional restorations, the ART approach, or the nonrestorative cavity control (NRCC) approach with regards to survival rates, clinical efficacy, patient acceptance, and cost-effectiveness.[45],[46],[47],[48],[49],[50],[51] The most recent systematic reviews and meta-analyses reconfirmed the superiority of the HT compared to conventional restorations in managing active cavitated dentinal lesions in primary molars.[28],[52] Given this evidence base, clinicians still reluctant to offer this treatment option need to examine why they are treating a child more invasively when a less invasive option is available.
Microinvasive approaches: Sealants and resin infiltration
The microinvasive approaches (sealants and resin infiltration) are indicated to arrest or reverse non-cavitated lesions in primary and permanent teeth. No carious tissue removal is attempted in these micro-invasive approaches. However, unlike the noninvasive approaches, they do involve micrometer level removal of dental hard tissues during the acid etching step, before placing adhesive restorations directly over the lesion. The evidence base for these microinvasive approaches is detailed below.
Sealants
There is now compelling evidence from multiple RCTs showing that sealing noncavitated lesions on occlusal or proximal surfaces, even if the lesion extends partly into the dentine, is an effective treatment approach to arrest the lesion.[53],[54],[55],[56] Systematic reviews found sealants to be effective in arresting noncavitated occlusal carious lesions of primary and permanent molars compared to nonuse of sealants (moderate-certainty evidence) or the use of fluoride varnishes (low-certainty evidence).[57],[58] Although sealing noncavitated lesions on proximal surfaces is a more challenging procedure, it was still found to be an effective method for arresting lesion progression.[29],[39],[59] Regarding the depth of noncavitated lesions that can be sealed, a systematic review concluded that sealants are likely to effectively manage shallow or moderately deep lesions (low-to-very low-certainty evidence), but the evidence was lacking to make any sealant recommendations for deeper lesions.[60] It does appear that the mechanical properties of dental sealants will preclude their suitability for sealing deep dentinal lesions even when there is very little cavitation visible clinically.[61] Therefore, pending further evidence, the use of sealants for managing existing lesions should be limited to noncavitated occlusal/proximal lesions confined to the radiographic outer third of the dentine.[62]
Resin infiltration
Resin infiltration is a relatively newer technique in which a very low-viscosity resin infiltrate is introduced into the micro-porosities of noncavitated lesions, filling them through capillary diffusion and arresting their progress. The diffusion action results from surface and sub-surface dehydration conditions created by hydrochloric acid etching followed by surface drying with ethanol and air. Resin infiltration was developed and studied primarily for treating noncavitated proximal lesions, with some clinical trials showing them to be highly efficacious in arresting these lesions.[63],[64],[65] Conclusions from systematic reviews are however more equivocal, with two reviews suggesting that there is no strong evidence to support this technique,[66],[67] while other reviewers concluded that that resin infiltration is indeed an effective microinvasive treatment for noncavitated proximal lesions.[29],[68] With evidence showing that conventional sealants or 5% NaF varnish can also arrest noncavitated proximal lesions, clinicians need to also consider the relatively higher cost associated with the resin infiltration technique before adopting this technique.[43]
| Operative Interventions: Minimally Invasive Approaches | | |
Operative restorative interventions to repair active cavitated lesions involve minimally invasive carious tissue removal. They aim to: (i) Aid plaque control at the affected tooth location; (ii) protect the pulp-dentine complex; (iii) arrest the lesion by sealing it; and (iv) restore form, function, and aesthetics of the affected tooth.[36] The most important priority when removing carious tissue is to maintain pulpal health by preserving residual dentine over the pulp (thereby avoiding unnecessary pulpal insult) and preventing pulp exposure (even if it involves leaving soft-infected dentine in the pulpal aspects of deep cavities).[10] Preserving residual dentin over the pulp has been shown to have a favorable impact on the long-term prognosis and future treatment costs of the restored tooth.[16],[69]
Besides maintaining pulpal health, another critical priority during carious tissue removal is to achieve a hermitic seal by ensuring that the peripheral restoration can be placed onto hard or firm enamel/dentine.[36] A leak-proof marginal seal will entomb the biofilm under the restoration and lead to the inactivation of any remnant bacteria.[21] A tight seal may not be achievable in pulpal aspects of the cavity if soft dentine has been left over it to preserve pulp health. However, the lack of an optimal seal in areas proximate to the pulp does not seem problematic if the peripheral marginal seal of the cavity is satisfactory.[70] It should be underlined that the only purpose of leaving behind soft dentine in the cavity is to maintain pulp health, and there is no reason why caries should not be completely removed in areas where there is no risk to pulp.[71] The evidence base for three minimally invasive operative interventions-indirect pulp capping (IPC), ART, and NRCC-is detailed below.
Indirect pulp capping
IPC is an established minimally invasive approach suggested for managing deep carious lesions that extend to the inner third or quarter of dentine. IPC with either the one-step or the step-wise selective caries removal approach (leaving soft dentine over pulpal aspects of the cavity) significantly reduces the risk of pulp exposure. RCTs in primary and permanent teeth have shown that deep lesions treated with the step-wise IPC approach had a significantly higher proportion of healthy pulps compared to those treated with the nonselective caries removal approach.[16],[72],[73],[74],[75],[76] In fact, there is now growing evidence to suggest that the one-step IPC approach may be superior to the step-wise IPC approach when treating deep carious lesions in permanent teeth.[77],[78],[79],[80] There is a recommendation that the step-wise IPC approach be limited to permanent teeth with very deep lesions (i.e., those in the inner quarter of the dentine), while deep lesions in the inner third of the dentin can be successfully managed with the one-step IPC approach.[81]
Atraumatic restorative treatment
ART was initially developed as minimally invasive approach to manage carious lesions in underserved dental communities of economically less-developed countries. However, it is now recognized as a valid treatment option for many clinical situations in economically prosperous countries too.[82] A 2018 systematic review and meta-analysis with survival rates as the outcome measure found high survival rates for single-surface ART restorations in primary and permanent posterior teeth over 5 years, medium survival rates for multi-surface ART restorations in primary molars over 2 years, and insufficient data on survival of multi-surface ART restorations in posterior permanent teeth.[82] A more recent systematic review and meta-analysis on ART also concluded that ART using high-viscosity glass ionomer cement restorations can be considered as a replacement for traditional restorations in single- and multiple-surface cavities in primary molars, and for single-surface cavities in posterior permanent teeth.[83] However, other systematic/umbrella reviews suggest that there is only weak evidence supporting the use of ART for the management of multi-surface carious lesions affecting primary teeth.[84],[85] Recent evidence-based guideline recommendations also suggest that the ART approach should be limited to single-surface lesions even in primary teeth.[86]
Nonrestorative cavity control
Unlike other operative interventions, the NRCC approach does not involve the placement of a restoration. Instead, NRCC entails using hand or rotary instruments to remove overhanging, biofilm-trapping enamel or dentine to open up the cavitated lesion for self-cleansing. This is followed by treating the carious lesion with 38% SDF solution or 5% NaF varnish to promote lesion arrest and remineralization. The third step in the NRCC approach is patient-dependent and includes improving oral hygiene measures (twice-daily brushing with appropriate F dentifrice) and lifestyle changes (reducing dietary sugar exposures). Ideally, all three steps should be implemented concurrently to achieve successful lesion arrest. The success of the NRCC approach is highly reliant on patient compliance and the clinician regularly monitoring the lesion progress. NRCC is typically indicated in primary teeth where the purpose is to preserve the tooth without pain or infection until its natural exfoliation. NRCC is considered a child-friendly treatment as no extensive drilling or anesthesia is required. In permanent teeth, NRCC could be indicated for root lesions and coronal smooth surface lesions, where the main goal is to avoid the repeat restorative cycle.[87]
RCTs comparing traditional amalgam restorations with the ART and NRCC approaches in primary teeth found no significant differences between the three treatment approaches in survival percentages or quality of life indicators.[88],[89] A RCT in primary teeth compared conventional compomer restorations, Hall crowns, and the NRCC approach concluded that while the HT was superior, there were no significant differences between the conventional and NRCC approach.[50] The same investigators also observed that children treated with the biological approaches (HT and NRCC) exhibited better behavior and reported lower pain intensity that those treated with the conventional restorative approach.[49] NRCC has a less robust evidence base compared to the other biological approaches discussed in this paper, especially with regards to studies in permanent teeth. Moreover, because treatment success is almost completely dependent on excellent patient compliance, the use of NRCC cannot be unanimously recommended for the management of all types of carious lesions even in primary teeth.[90] Nevertheless, NRCC has a sound biological rationale and clinicians with excellent health education qualities should consider offering it to cooperative patients likely to comply with the stringent preventive and recall requirements of this approach.[87]
| Biological Carious Lesion Management Approaches: Clinical Pathways | | |
The evidence base for biological carious lesion management approaches has now translated into clinical practice guideline recommendations from several organizations. Policy guidelines from the International Caries Consensus Collaboration (2016)[36] for managing cavitated carious lesions in primary and permanent teeth; the American Dental Association (2018)[43] for the non-restorative treatment of cavitated and noncavitated carious lesions in primary and permanent teeth; and the European Academy of Pediatric Dentistry (2022)[86] for the management of deep carious lesions in primary teeth are now publicly available. To help clinicians in their decision-making, collated clinical pathways based on these guideline recommendations are presented in [Figure 2] (for primary teeth) and [Figure 3] (for permanent teeth). | Figure 2: Clinical pathway for the management of active carious lesions in primary teeth based on evidence-based guideline summaries from the ICCC for operative interventions in cavitated lesions;[36] the ADA for nonrestorative interventions in cavitated and non-cavitated lesions;[43] and the EAPD for management of advanced lesions.[86] ICCC: International Caries consensus collaboration, ADA: American dental association, EAPD: European academy of paediatric dentistry
Click here to view |
 | Figure 3: Clinical pathway for the management of active carious lesions in permanent teeth based on evidence-based guideline summaries from the ICCC for operative interventions in cavitated lesions[36] and the ADA for nonrestorative interventions in cavitated and non-cavitated lesions.[43] ICCC: International caries consensus collaboration, ADA: American dental association
Click here to view |
| Biological Carious Lesion Management: Future Challenges | | |
Biological approaches to carious lesion management need to be an established part of contemporary clinical practice. Dentists need to evolve from being mechanistic, cavity-oriented surgeons of the 19th century to becoming dental physicians of the 21st century. While biological lesion management approaches still have evidence gaps that need to be closed, the more pressing challenge is to implement already available research evidence into day-to-day clinical practice.[91] Efforts to collate further high-certainty clinical evidence are currently underway and among the most awaited are results from the Selective Caries Removal in Permanent Teeth trial, that is investigating the most clinically effective and cost-beneficial approach to managing deep dentinal lesions in permanent posterior teeth.[92]
Almost 20 years after first advising clinicians to move from operative to nonoperative treatment of dental caries, Pitts recently indicated that there is still a stubborn disconnect between international consensus evidence on how best to manage caries and mainstream practice.[93] There is thus a need to further educate and disseminate these evidence-based guidelines among dental practitioners who “don't know,” “can't do,” or “won't change.”[94] Moreover, there is a need to advocate for policy shifts and incentivizing remuneration schemes that would encourage clinicians to adopt these modern biological approaches to lesion management. G. V Black had predicted in a lecture to his students that “the day is surely coming and perhaps within the lifetime of you young men when we will be engaged in practicing preventive rather than reparative dentistry.” That day is well and truly here, and it is up to clinicians, researchers, and policymakers to align the last pieces of the caries puzzle and accelerate toward the goal of “making cavities history.”[93]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Dr. Nebu Philip
P. O. Box 2713, Qatar University, Doha
Qatar
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcd.jcd_54_23
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