Behavioral Modification: Oral Hygiene and Diet
Patients, especially those at high risk of caries development, should be instructed to reduce the amount and frequency of carbohydrate consumption.14 Patients should limit sugary snacks between meals15 and eat a healthy diet that limits added sugars and high-acid foods that can affect mineralization of enamel.15 Encourage patients to chew sugar-free gum with xylitol, which can promote salivary flow, remineralization, and cannot be metabolized by cariogenic bacteria.16 All patients should be educated in optimal oral hygiene practices, including brushing with fluoride toothpaste twice a day and cleaning between teeth daily. Although some caries prevention recommendations5 include use of topical antimicrobials (e.g., chlorhexidine rinse) in patients 6 years of age and older who are at high risk of caries, a 2015 Cochrane systematic review found no trials for the use of antimicrobial chlorhexidine mouth rinses, sprays, gels, or chewing gums to prevent caries in children and adolescents.17
Topical Fluoride Application for Caries Prevention or Arrest
A 2013 systematic review18 from the ADA CSA Expert Panel on Topical Fluoride Caries Preventive Agents provided evidence-based clinical recommendations regarding professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention. Evidence was sought from clinical trials of professionally applied and prescription-strength topical fluoride agents—including mouthrinses, varnishes, gels, foams and pastes—reporting on caries increment outcomes. Clinical recommendations included the following for people at risk of developing dental caries:
The panel recommends the following for people at risk of developing dental caries: 2.26% fluoride varnish or 1.23% fluoride (acidulated phosphate fluoride) gel, or a prescription-strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients 6 years or older. Only 2.26% fluoride varnish is recommended for children younger than 6 years. The strengths of the recommendations for the recommended products varied from “in favor” to “expert opinion for.” As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.
Another form of topical fluoride application, Silver Diamine Fluoride 38% (Advantage Arrest™, Elevate Oral Care, L.L.C. or Riva Star, SDI, Inc.) has been cleared for marketing by the U.S. Food and Drug Administration for treating dentinal hypersensitivity in adults.19 A CDT code20 adopted in 2016 is D1354—interim caries arresting medicament application: “Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.” This new code allows for coding the off-label use of silver diamine fluoride for caries arrest.21
Anatomical grooves, or pits and fissures on occlusal surfaces of permanent molars can trap food particles and promote the presence of bacterial biofilm, increasing the risk of developing caries lesions. Effectively penetrating and sealing these surfaces with a dental material, e.g., pit-and-fissure sealants, can prevent lesions and is part of a comprehensive caries management approach.22 From a secondary prevention perspective, there is evidence that sealants also can inhibit the progression of non-cavitated caries lesions.23 The use of sealants to arrest or inhibit the progression of caries lesions is important to the clinician when determining the appropriate intervention for non-cavitated caries lesions.
Based on a systematic review, a 2016 guideline panel convened by the ADA CSA and the American Academy of Pediatric Dentistry (AAPD) came to the following evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.24, 25
- sealants are effective in preventing and arresting pit-and-fissure occlusal caries lesions of primary and permanent molars in children and adolescents compared to the non-use of sealants or use of fluoride varnishes; and
- sealants can minimize the progression of non-cavitated occlusal caries lesions (also referred to as initial lesions) that receive a sealant.
Based on available limited evidence, the panel was unable to provide specific recommendations on the relative merits of one type of sealant material over the others, so the choice of sealant type used depends on provider preference and experience. The report defined pit-and-fissure sealant materials as follows: 1) resin-based sealants, 2) glass ionomer cements or sealants, 3) polyacid-modified resin sealants, and 4) resin-modified glass ionomer sealants.22
2018 ADA Clinical Practice Guideline on Nonrestorative Treatments for Carious Lesions
In 2018, the ADA Center for Evidence-Based Dentistry conducted a systematic review and network meta-analysis26 informing a clinical practice guideline27 on nonrestorative treatments for carious lesions. The expert panel formulated 11 clinical recommendations, each specific to lesion type (i.e., cavitated, noncavitated), tooth surface (i.e., coronal, root surface [in adults]) and dentition (i.e., primary or permanent), each recommendation with an associated strength or certainty of the evidence (please refer to the clinical practice guideline for specific recommendations, strength of those recommendations, and the certainty of the evidence associated with them). The panel provided recommendations for the use of the most effective treatment options, including 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide–amorphous calcium phosphate. The chairside guides for primary; and permanent dentition are available for download, and clinicians may also consult the online tool for personalized clinical recommendations based on the clinical parameters of the lesion.
This guideline is the first in a series of four guidelines that will focus on caries management from the ADA Center for Evidence-Based Dentistry.28 The other guidelines are scheduled to be developed and published in the coming years and will focus on caries prevention, restorative treatments for carious lesions, and carious lesion detection and diagnosis.