The clinical management of dental caries has historically focused on the later stages of the disease, when the tooth displays visible cavitation. However, we know that dental caries begins long before cavitation occurs, and that demineralization from early caries lesions can be arrested or even reversed. By prioritizing early intervention, we can provide our patients with minimally invasive treatment options and better long-term outcomes.
Minimally invasive treatments for dental caries include the use of high-level fluoride toothpastes, sealants and varnishes. For patients, these options are much more desirable than other interventions.
Compared to restorations and extractions, minimally invasive treatments:
Involve significantly less discomfort and distress.
Are considerably less expensive.
Preserve tooth structure, function and appearance of the tooth.
Help to avoid repeated cycles of repair.
The American Dental Association (ADA) has developed a comprehensive method of classifying caries, incorporating up-to-date scientific knowledge on all stages of the disease. The four stages identified in the ADA Caries Classification System (ADA CSS) are:
Sound surface. The tooth is intact and healthy in appearance, with no clinically detectable caries lesions.
Initial caries lesion. Also known as an early or incipient caries lesion, the lesion is non-cavitated and limited to the enamel or cementum, or the outermost dentin layer. The lesion may appear as a white spot, or a slight discoloration, depending on its location.
Moderate caries lesion. The tooth is displaying visible signs of demineralization, and some micro-cavitation or shallow cavitation of the enamel may be apparent. Where dentin is involved, it may be visible through the enamel surface as a dark gray shadow or stain.
Advanced caries lesion. The lesion has broken the surface of the enamel. The tooth is fully cavitated and the dentin is exposed.
In 2018, the ADA published detailed guidelines on non-restorative treatment of caries lesions. To arrest or reverse non-cavitated lesions in the primary or permanent teeth, the ADA recommends that dentists prioritize the use of sealants plus 5% sodium fluoride varnish for occlusal surfaces, or sealants alone over any other option alone.
For approximal non-cavitated lesions, the recommendation is to prioritize 5% sodium fluoride varnish
5% sodium fluoride varnish or 1.23% acidulated fluorophosphate (APF) gel is recommended for facial or lingual non-cavitated lesions
The use of 5,000 ppm fluoride is prioritized for non-cavitated root caries.
5% Sodium Fluoride Varnish contains 22,600 ppm fluoride. When applied, it sets quickly to leave a thin film of protective fluoride over the teeth, promoting ultra-high, sustained fluoride uptake and the remineralization of lesioned enamel.
To arrest or reverse non-cavitated lesions on the root surfaces of permanent teeth, the ADA recommends prioritizing the use of high-level fluoride toothpaste or gel (1.1% sodium fluoride). Toothpaste that contains 5,000 ppm fluoride, and has been shown to help reverse white-spot lesions and to improve remineralization in just ten days.
A cavitated lesion would typically be treated with restoration or extraction, however minimally invasive interventions are possible:
The ADA recommends the biannual application of a 38% silver diamine fluoride (SDF) solution for cavitated lesions on the coronal surfaces of primary and permanent teeth, and for this to be prioritized over 5% sodium fluoride varnish. SDF is especially favorable in young children as it very effectively hardens the enamel and dentin of the primary teeth, avoiding the trauma of "drilling and filling."
To arrest cavitated root caries in the permanent teeth, the ADA recommends that clinicians prioritize the use of 5,000 ppm fluoride (1.1% NaF) toothpaste or gel at least once daily.
While minimally invasive treatment is available for the management of dental caries, we must place a strong emphasis on preventing it in the first place. We can do this by identifying and monitoring our at-risk patients, and by providing and recommending preventive care.
The ADA offers two caries risk assessment frameworks: one for patients up to six years of age, and another for patients over six years of age. Using these assessments at each appointment helps to not only identify at-risk patients and provide appropriate interventions, but also to monitor any changes to the patient’s risk level over time and assess the effectiveness of interventions.
For at-risk patients 6 years of age and older, an ADA Council on Scientific Affairs expert panel has recommended:
5% sodium fluoride varnish or 1.23% fluoride APF gel for in-office topical fluoride treatment.
Prescription-strength, home-use 5,000 ppm fluoride gel or paste.
0.09% fluoride mouth rinse.
For patients under six years of age, only 5% sodium fluoride varnish is recommended.
By adopting the use of minimally invasive therapies such as high-fluoride toothpastes, sealants and varnishes, we can provide minimally invasive care and help our patients to preserve their dentition. Ultimately, that helps to improve oral health and wellbeing outcomes for patients, and creates stronger patient relationships for us.