PMC:7546139 / 11339-18596 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7546139","sourcedb":"PMC","sourceid":"7546139","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7546139","text":"Methods to control carious lesions\n\nPrevention\nPrimary preventive approaches (also known as non-invasive strategies for the management of caries) can reduce the risk of progressive dental tissue loss and avoid the need for treatments using rotary instruments. The main preventive approaches have to be through the community and home, with behavioural components such as sugar restriction, plaque removal and oral health education. Clinicians hold a pivotal role in supporting oral health behaviours.\nFor remineralisation, fluoride-based agents are accepted as the primary medicament. Although there is less supporting evidence, other remineralisation agents such as self-assembling peptide P11-428 might be considered.\nPreventive sealants cover plaque-retentive areas, occlusal fissures and pits, which are most vulnerable to caries.29,30 However, resin-based sealants involve a washing step to remove the acid etch thoroughly, generating some aerosol. Nevertheless, this risk can be avoided by using low-viscosity or high-viscosity glass-ionomer cement (LVGICS/HVGIC) and excess material can be removed with hand instruments. A Cochrane review found no difference in the preventive effect of resin, LVGIC or HVGIC sealants.30\n\nEarly detection\nThe purpose of treating dental caries is primarily to stop its progression within the tooth as well as restoring the lost dental hard tissues when needed. Early detection of carious lesions will reduce the need for aerosol-producing restorative care required for advanced lesions. In addition, patients with active dental caries need to have their disease risks addressed as part of the long-term disease management.31,32\n\nNon-restorative cavity control for dentinal lesions\n\nWhat it is and when to use it\nNRCC is a method of using 'cleaning' to prevent biofilm maturation and carious lesions progression. It can be used for dentinal carious lesions in the primary and permanent dentition, root carious lesions and cavitated coronal smooth surface lesions.\n\nHow it works and clinical effectiveness\nBy making the carious surface accessible and having plaque frequently and thoroughly removed, the carious process will arrest.\nIn primary teeth, the effectiveness of NRCC in medium and large cavities together with ART restorations in small cavities has been tested in comparison to amalgam and ART restorations.33 Tooth survival after 3.5 years was 89% and not significantly different from either amalgam (91%) or ART restorations (90%), and in a randomised control trial of occluso-proximal cavitated lesions, survival (of pulp and tooth) was 92% at 2.5 years compared to 98% for teeth treated with the HT.34 NRCC has a less robust evidence base than the other treatment options discussed in this paper, with most of the reports of success being related to particular situations and carried out by dentists who support this technique. The choice to use NRCC is less dependent on the shape or type of lesion than it is on the attitude of the patient towards prevention and the skill of the dentist in behaviour change.35\n\nNon-AGP use\nNRCC consists of three concurrent stages:Working with the patient to make plaque control more successful (improving oral hygiene procedure/habits). The patient has to be ready to change behaviours that led to development of the disease in the first place. Success depends on the clinician's ability to change the patient's (or in the case of a child, the parent's) behaviour towards taking responsibility. So, 'prevention' becomes very much more than simply providing instruction of what to do (knowledge) and how to do it (skills), but has to involve an aspect of refocusing the patient to feeling empowered to make a difference to their own oral health (attitude). Daily removal or disruption of the biofilm by brushing with a fluoridated toothpaste will slow down the carious process and can even halt it\nCreating a cavity shape where the carious biofilm/dentine is accessible to a toothbrush (lesion exposure). In some cases, overhanging enamel has to be removed. To avoid use of rotary instruments, hand instruments can be used to gain access to the lesion (see ART)\nTreatment with 38% SDF and/or a 5% NaF varnish therapy to reduce carious activity and promote remineralisation.33 These additional measures can support success of the NRCC approach if the carious lesion is active or there is increased risk that carious lesion activity will recur.\nIn the primary dentition, the goal is to avoid the lesion causing pain and/or infection until the tooth exfoliates. For the permanent dentition, with grossly broken down teeth, root carious lesions or coronal smooth surface lesions, the main goal is to avoid the lesions leading to pain and/or infection while also avoiding or delaying the need for restoration.\n\nSDF for dentine lesions\n\nWhat it is and when to use it\nSDF is a clear, colourless liquid that arrests active cavitated carious lesions and remineralises demineralised enamel and dentine.36 Some products have a blue tint, but these are not available in the UK. Although licensed to treat dentine sensitivity in the UK and some other countries, it is more usually used 'off-label' to arrest carious lesions. It turns active carious lesions black; therefore, consent to treatment must be obtained and it must be handled with care as it will temporarily stain skin, mucosa and most surfaces on contact.\nSDF is an effective way of treating active lesions for primary and permanent teeth (coronal dentine and root).37,38 It can be used opportunistically while the patient is in the dental chair by applying to other high-risk surfaces. SDF is effective in arresting early childhood caries39 and exposed root surfaces.40 It is more successful when used in cleansable lesions and accessible areas of the mouth.41 When caries is more severe or affects multiple teeth, repeated applications of SDF controls the disease (for example, applied after two weeks and six weeks, then six months as required).42\n\nHow it works and clinical effectiveness\nSDF penetrates infected dentine,43 making the lesion twice as hard as healthy dentine.44 It produces a dense superficial layer and fills in micro-cavities with solid metallic silver.45 It also acts directly on the plaque biofilm,46,47 inhibiting bacterial growth.48,49 Removing carious tissue before SDF application is not necessary as it does not improve caries arrest.50\nSDF has been shown to have some effect in preventing carious lesions in primary teeth, with one review showing that, by applying it at least once per year, 61% of new caries lesions might be prevented.51 SDF is clinically effective as well as cost-effective, and has the advantage of combined use with all other caries management techniques.51,52\n\nNon-AGP use\nCarious tissue is not removed at all. To minimise droplet and aerosol production, the surface is dried with cotton instead of compressed air, then SDF is applied using a micro brush. Arresting lesions using SDF can provide a solid foundation for restorations53,54 and can be combined with ART in primary or permanent teeth or the HT. There are currently no clinical trials of efficacy, so combinations may be thought of as a 'belt and braces' approach to synergise the benefits of both 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