Caries is a chronic noncommunicable disease that is all too common globally. While caries is a preventable disease and prevention should be the primary goal of caries management programmes the costs of treating established disease are significant. In the early stages of the carious process tooth surfaces appear macroscopically intact (incipient, initial, early or white spot lesions) and these non-cavititated lesions can be arrest or be arrested with treatment while cavitated lesions usually require intervention.

The aim of this clinical practice guideline is to help clinicians decide which types of non-restorative treatments or interventions could be used to arrest or reverse existing non-cavitated and cavitated carious lesions in adults and children.

Methods

An expert panel was convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-based Dentistry  to develop this clinical practice guideline.  The guidelines was developed following the AGREE (Appraisal of Guidelines for Research and Evaluation) reporting checklist  and the Guidelines International Network McMaster Guidelines Denvelopment checklist . The process involved a number of face to face meetings, preparation of a systematic review and network meta-analysis  (Urquhart et al) supported by wider consultation.

Recommendations

A number of clinical recommendations were made and the need to use clinical judgements to identify situations when the applications of the recommendations might not be appropriate

A summary of the brief recommendations is provided below however the full details are available on the ADA website (see links).

Question	Primary teeth	Permanent teeth
To arrest cavitated coronal carious lesions on primary or permanent teeth, should we recommend silver diamine fluoride, silver nitrate, or sealants?	Prioritise the use of 38% SDF solution (biannual application) over 5% NaF varnish (application once per week for 3 weeks). (Moderate-certainty evidence, strong recommendation.)	Prioritise the use of 38% SDF solution (biannual application) over 5% NaF varnish (application once per week for 3 weeks). (Low-certainty evidence, conditional recommendation
To arrest or reverse non-cavitated coronal carious lesions on primary or permanent teeth, should we recommend NaF, stannous fluoride, acidulated phosphate fluoride (APF), difluorsilane, ammonium fluoride, polyols, chlorhexidine, calcium phosphate, amorphous calcium phosphate (ACP), casein phosphopeptide (CPP)eACP, nano-hydroxyapatite, tricalcium phosphate, or prebiotics with or without 1.5% arginine, probiotics, SDF, silver nitrate, lasers, resin infiltration, sealants, sodium bicarbonate, calcium hydroxide, or carbamide peroxide?	Non-cavitated Lesions on Occlusal Surfaces
	Prioritise the use of sealants plus 5% NaF varnish (application every 3-6 months) or sealants alone over 5% NaF varnish alone (application every 3-6 months), 1.23% APF gel (application every 3-6 months), resin infiltration plus 5% NaF varnish (application every 3-6 months), or 0.2% NaF mouthrinse (once per week). (Moderate-certainty evidence, strong recommendation.)	Prioritise the use of sealants plus 5% NaF varnish (appli- cation every 3-6 months) or sealants alone over 5% NaF varnish alone (application every 3-6 months), 1.23% APF gel (application every 3-6 months), or 0.2% NaF mouthrinse (once per week). (Moderate-certainty evidence, strong recommendation.)
	Non-cavitated Lesions on Approximal Surfaces
	Use 5% NaF varnish (application every 3-6 months), resin infiltration alone, resin infiltration plus 5% NaF varnish (application every 3-6 months), or sealants alone. (Low- to very-low-certainty evidence, conditional recommendation.)	Use 5% NaF varnish (application every 3-6 months), resin infiltration alone, resin infiltration plus 5% NaF varnish (application every 3-6 months), or sealants alone. (Low- to very-low-certainty evidence, conditional recommendation.)
	Non-cavitated Lesions on Facial or Lingual Surfaces
	Use 1.23% APF gel (application every 3-6 months) or 5% NaF varnish (application every 3-6 months). (Moderate- to low-certainty evidence, conditional recommendation.)	Use 1.23% APF gel (application every 3-6 months) or 5% NaF varnish (application every 3-6 months). (Moderate- to low-certainty evidence, conditional recommendation.)
	Non-cavitated Lesions on Any Coronal Tooth Surface
	Do not use 10% CPP-ACP if other fluoride interventions, sealants, or resin infiltration is accessible. (Low-certainty evidence, conditional recommendation
	Non-cavitated and Cavitated Lesions on Root Surfaces
To arrest cavitated root carious lesions or arrest or reverse non-cavitated root carious lesions on permanent teeth, should we recommend NaF, stannous fluoride, APF, difluorsilane, ammonium fluoride, polyols, chlorhexidine, calcium phosphate, ACP, CPP-ACP, nano-hydroxyapatite, tricalcium phosphate, or prebiotics with or without 1.5% arginine, probiotics, SDF, silver nitrate, lasers, resin infiltration, sealants, sodium bicarbonate, calcium hydroxide, or carbamide peroxide?	N/A	Prioritize the use of 5,000 ppm fluoride (1.1% NaF) toothpaste or gel (at least once per day) over 5% NaF varnish (application every 3-6 months), 38% SDF plus potassium iodide solution (annual application), 38% SDF solution (annual application), or 1% chlorhexidine plus 1% thymol varnish (application every 3-6 months). (Low-certainty evidence, conditional recommendation.)

In addition to the main recommendations the primary paper provides a number of additional helpful remarks  related to the  recommendations.

Research recommendations

The guidelines call for more high quality randomised controlled trials as many of the recommendations are supported by low certainty evidence. They also highlight the need to develop a minimum set of patient-important outcomes to improve decision making.

Comments

This clinical practice has followed a robust process and full article is open source and provides ample details about the process with the supporting systematic review and meta-analysis being published in the  journal of Dental Research (Urquhart et al).   The discussion section of the guideline indicates that while diet counselling was not included as an intervention the panel did emphasis that non-restorative treatments should be accompanied by a diet low in sugar.

Links

Primary Paper

Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento  MM, Nový BB, Tinanoff N, Weyant RJ, Wolff MS, Young DA, Zero DT, Tampi MP,Pilcher L, Banfield L, Carrasco-Labra A. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc. 2018 Oct;149(10):837-849.e19. doi: 10.1016/j.adaj.2018.07.002. PubMed PMID: 30261951

Other references

Urquhart O, Tampi MP, Pilcher L, Slayton RL, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM, Nový BB, Tinanoff N, Weyant RJ, Wolff MS, Young DA, Zero DT, Brignardello-Petersen R, Banfield L, Parikh A, Joshi G, Carrasco-Labra A. Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis. J Dent Res. 2018 Oct 5:22034518800014. doi: 10.1177/0022034518800014. [Epub ahead of print] PubMed PMID: 30290130.