Caries one of the world’s commonest diseases and decisions to restore caries affected teeth depends on a number of factors. For vital primary and permanent teeth with moderate and advanced caries there are options in extent of carious tissue removal and type of direct restorative material used for restoration.
This clinical practice guideline was developed to assist clinicians in making restorative choices with their patients.
Scope and purpose
This clinical practice guideline forms part of a series on caries management. The purpose is to help clinicians select the most appropriate carious tissue removal (CTR) and direct restorative materials for the treatment of moderate and advanced caries lesions. Moderate caries lesions are defined as International Caries Detection and Assessment System (ICDAS) codes 3 and 4 and advanced lesions as ICDAS codes 5 and 6.
Methodology
Searches for systematic reviews were conducted in Medline, Embase, the Cochrane Database of Systematic Reviews, and Trip Medical Database and randomised controlled trials in Medline, Embase ,, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The Appraisal of Guidelines for Research and Evaluation Reporting Checklist II (AGREE) and Guidelines International Network-McMaster Guideline Development Checklist (GIN-McMaster guideline checklist )were followed. A number of virtual and in person meeting between the guideline panel members and methodologists with stakeholder and public engagement undertaken by methodologists. Recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.
Review and Updating
Updating of the guideline recommendations are planned to take place every 5 years or when new evidence is available and could change the direction and strength of recommendations.
Recommendations
- 16 recommendations and good practice statements were formulated,
- 4 on CTR approaches specific to lesion depth,
- 12 on direct restorative materials specific to tooth location and surfaces involved.
- A summary of the recommendations for primary and permanent teeth is shown in the tables below. All the recommendation are conditional and based on evidence of low certainty.
| Primary teeth | Recommendations |
| Carious Tissue Removal Approaches | To treat moderate caries lesions on vital primary teeth requiring a restoration, the guideline panel suggests the use of selective carious tissue removal, nonselective carious tissue removal, or no carious tissue removal (that is, sealing lesions with a preformed crown) |
| To treat advanced caries lesions on vital primary teeth requiring a restoration, the guideline panel suggests prioritizing the use of selective carious tissue removal or no carious tissue removal (that is, sealing with a preformed crown) over nonselective carious tissue removal or stepwise carious tissue removal. | |
| Direct Restorative Materials | For moderate and advanced caries lesions on vital anterior primary teeth requiring a Class III (approximal) restoration, the guideline panel suggests the use of either nanocomposite or hybrid resin composite (RC). |
| For moderate and advanced caries lesions on vital anterior primary teeth requiring a Class V (cervical third of facial or lingual) restoration, the guideline panel suggests the use of either conventional GIC, hybrid RC, or resin-modified GIC. | |
| For moderate and advanced caries lesions on vital posterior primary teeth requiring a Class I (pit and fissure) restoration, the guideline panel suggests prioritising the use of resin-modified GIC, RCs, conventional GIC, or preformed crowns over compomer or dental amalgam. | |
| For moderate and advanced caries lesions on vital posterior primary teeth requiring a Class II (approximal) restoration, the guideline panel suggests prioritising the use of resin-modified GIC, RCs, or preformed crowns over compomer, conventional GIC, or dental amalgam. | |
| For moderate and advanced caries lesions on vital posterior primary teeth requiring a Class V (cervical third of facial or lingual) restoration, the guideline panel suggests the use of either conventional GIC, hybrid RC, or resin-modified GIC. |
| Permanent teeth | Recommendations |
| Carious Tissue Removal Approaches | To treat moderate caries lesions on vital permanent teeth requiring a restoration, the guideline panel suggests prioritising the use of selective carious tissue removal over nonselective carious tissue removal. |
| To treat advanced caries lesions on vital permanent teeth requiring a restoration, the guideline panel suggests prioritising the use of selective carious tissue removal over stepwise carious tissue removal or nonselective carious tissue removal. | |
| Direct Restorative Materials | For moderate and advanced caries lesions on vital anterior permanent teeth requiring a Class I (lingual pit and fissure) restoration, the guideline panel suggests the use of either conventional GIC, hybrid RC, or resin-modified GIC . |
| For moderate and advanced caries lesions on vital anterior permanent teeth requiring a Class III (approximal) restoration, the guideline panel suggests the use of either nanocomposite or hybrid RC. | |
| For moderate and advanced caries lesions on vital posterior permanent teeth requiring a Class I (pit and fissure) restoration, the guideline panel suggests prioritizing the use of conventional GIC, dental amalgam, RC, or resin-modified GIC over compomer. | |
| For moderate and advanced caries lesions on vital posterior permanent teeth requiring a Class II (approximal) restoration, the guideline panel suggests prioritizing the use of dental amalgam, RC, or resin-modified GIC over conventional GIC. | |
| For moderate and advanced caries lesions on vital posterior permanent teeth requiring a Class V (cervical third of facial or lingual) restoration, the guideline panel suggests the use of either conventional GIC, hybrid RC, or resin-modified GIC. | |
| For moderate and advanced root caries lesions on vital anterior and posterior permanent teeth requiring a restoration, the guideline panel suggests the use of either resin-modified GIC or conventional GIC. |
- For primary and permanent teeth one good practice statement was also included in relation to the use of direct restorative materials.
| Good practice statement | The US Food and Drug Administration recommends not using dental amalgam in “children, especially those younger than six years of age; people with pre-existing neurological disease; people with impaired kidney function; [and] people with known heightened sensitivity (allergy) to mercury or other components (silver, copper, tin)” wherever possible. |
Conclusions
The authors concluded: –
To restore moderate and advanced caries lesions on vital, non-endodontically treated primary and permanent teeth, the panel suggests the use of more conservative, single-visit CTR approaches and various direct restorative materials. The panel acknowledges the importance of considering additional factors, such as patient and caregiver preferences and treatment costs, when developing a treatment plan
Comments
The guideline has been developed by a broad panel of dentists, cariologists and dental materials specialists following internationally recognised standards. It is reported in an extensive open access document online and interested readers can see full details of the questions addressed and detailed findings and recommendations. When considering the guideline, it should be borne in mind that the values and preferences taken into account when developing the recommendations will be those of the USA and may not directly transfer to other countries. However, the evidence-base on which the decisions are made will be. For this guideline only systematic reviews and randomised control trial evidence was included. One systematic review was specifically undertaken (Dental Elf – 27th Feb 2023) to complement a 2021 Cochrane review (Dental Elf – 21st Jul 2021). While the extensive documentation is worth a read the authors conclusion provides a helpful take home message.
Links
Primary Paper
Dhar V, Pilcher L, Fontana M, González-Cabezas C, Keels MA, Mascarenhas AK, Nascimento M, Platt JA, Sabino GJ, Slayton R, Tinanoff N, Young DA, Zero DT, Pahlke S, Urquhart O, O’Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association. J Am Dent Assoc. 2023 Jul;154(7):551-566.e51. doi: 10.1016/j.adaj.2023.04.011. PMID: 37380250.
Other references
Dental Elf – 27th Feb 2023
Direct restorative materials for treating cavitated carious lesions
Dental Elf – 25th Jan 2023
Dental Elf – 21st Jul 2021
