Early Carious Lesions - Treatment Considerations
restorative dental treatment has many shortcomings and has not been shown to be
an effective method for managing caries. In spite of this, many dentists
continue to be powered by an aggressive restorative approach which may result
in unnecessary treatment and which must now be seen as inappropriate. There is
a pressing need for a greater understanding as to the precise criteria that
dictate the need for both non-invasive (reversible) preventive measures and
invasive (irreversible) restorative treatment”1
dental caries has been managed simply by detecting cavities or precavitated lesions
followed by drilling and filling. In recent years, a better understanding of
the caries process has changed this operative treatment philosophy: preventive
strategies involving fluoride and re-mineralization are preferred, and
operative treatments are undesirable unless the carious lesion has reached
Using MEDLINE, articles were selected to
review possible treatment for early carious lesions. The papers fit AADC
criteria for sample size and duration to determine the need for, success of, or
failure in treatment of early carious lesions. The papers selected for review
in this literature each were aggregate studies evaluating large sample size
many pits show evidence of some slight softening in early youth, which is
stopped by the coming of immunity or some change of local conditions. These
become dark in color and so remain without further change. These should not be
interfered with, as they are just as safe without any filling whatever.”3
above was written in 1908 by G. V. Black.
are no established standards in the diagnosis of carious lesions. Early or
incipient lesions are particularly difficult to diagnose due to the subjective
nature of lesion determination. Further, there are no standards for the
treatment of early or incipient carious lesions. This creates a dilemma for
clinicians. There is a fear that if lesions are not treated early, progression can
lead to more tooth damage requiring more extensive treatment. However, studies
have demonstrated that early surgical intervention in comparison with
non-surgical techniques, including re-calcification, results in unnecessary
loss of tooth structure.
AADC Positions Committee has investigated evidence-based literature to
establish the position of the AADC regarding the restoration of early or
central focus of this AADC position paper is the efficacy of non-surgical
management of early carious lesions based on current best evidence. The position
committee wishes to make it clear that this position paper is not intended to
investigate or establish a position regarding the diagnosis of carious lesions.
While there is existing research that attempts to classify carious lesions
along a continuum from early enamel lesions to extensive cavitated lesions, the
committee is of the opinion that there is no current consensus on established
criteria for diagnosis or diagnostic codes and the use of diagnostic codes for
caries are not generally used in private practice settings. The diagnosis of
caries as well as the extent of a lesion remains subjective. As such, the
committee’s position regarding current best evidence for the nonsurgical management
of early carious lesions starts with an assumption that there is a consensus
that the lesions are early lesions.
management of carious lesions, even early lesions, has traditionally involved
the surgical model, ie, a restoration. The old theory of “extension for
prevention” actually encouraged the removal of healthy enamel and dentin,
replacing it with amalgam or composite. With increased knowledge of the cause
of caries, there has been increasing evidence in support of a “medical model”
that includes treating non-cavitated early lesions non-surgically, thus preserving
tooth structure. The new paradigm encourages treating the disease and not
merely the destruction caused by the disease. The position committee conducted
a literature search of the current best evidence to determine the efficacy of
non-surgical management of early carous lesions.
rationale for the AADC to take a position regarding the management of early
lesions is embodied in a recent New York Times article (November 28, 2011)
entitled “A Closer Look at Teeth May Mean More Fillings” by Ritchie S. King.
The article states as follows:
increasingly sophisticated detection technology, dentists are finding — and treating
— tooth abnormalities that may or may not develop into cavities. While some describe
their efforts as a proactive strategy to protect patients from harm, critics
procedures are unnecessary and painful, and are driving up the costs of care.”
article, Jim Bader, DDS, MPH,( research professor, Department of Operative Dentistry,
School of Dentistry, and a senior research fellow, Cecil G. Sheps Center for Health
Services Research, University of North Carolina, Chapel Hill), states: “Many experts
think it doesn’t make sense to operate in the early stages of decay. If you don’t have
any kind of demonstrable collapse of the enamel wall, then you shouldn’t put in
committee found it interesting that even a cursory search of the literature uncovered
no less than 15 peer reviewed articles on the subject. The vast majority of the
studies demonstrated the efficacy of re-mineralization of early carious lesions
using various methods, materials, and techniques. A synopsis of the research
of the most time honored and traditional methods of caries prevention is
fluoride. The dental profession has always embraced the ability of fluoride to
harden enamel making it less susceptible to destruction by acid producing
bacteria. Further, fluoride has also been shown to be effective in
re-mineralization of both enamel and dentin affected by bacteria producing
regimens on enamel re-mineralization “…indicated fluoridated rinse to have
significantly greater re-mineralization effects on adjacent caries than the other
groups…”. “The glass ionomer restorative material and fluoridated dentifrice
also had significantly greater re-mineralization effects on adjacent caries
than the control, yet significantly less than the fluoridated rinse…” 4
present case report shows that fluoride varnish may be a good addition to preventive
therapy for arresting caries in adult patients in general practice. Surgical
intervention may be avoided in patients whose risk has shifted to a lower
community-based study conducted in schools concluded
results suggest that biannual APF gel application is an effective preventive
measure in reversing incipient carious lesions.”
is Acidulated Phosphate Fluoride Gel)
compounds have also been shown to be as effective, if not more effective, than
fluoride. Research has demonstrated the use casein phosphopeptide, or CPP, to
remineralize tooth surfaces to be effective.
CPP [Casein phosphopeptide], by stabilizing calcium phosphate in solution, maintain
high-concentration gradients of calcium and phosphate ions and ion pairs into
the subsurface lesion and thus effect high rates of enamel remineralization.7
demonstrate that CPP’s are able to promote re-mineralization of early enamel
has also been demonstrated to be effective for deciduous teeth.
is concluded that it is possible to re-mineralize initial carious lesions in deciduous
enamel in a similar way as it has been described for enamel of permanent
of early interproximal lesions has been shown to be effective as well.
quantitative light-induced fluorescence showed a significant remineralizing effect
after the fluoride treatment…compared to the placebo treatment…”10
non-invasive method to treat early lesions as well as help prevent lesions is
the use of sealants. Sealants have been well recognized and accepted as a
preventive measure in children. Further, research has also demonstrated the
ability of sealants to treat early proximal enamel lesions.
results show the potential of sealants to act as a noninvasive treatment of early
proximal enamel lesions.”11
systematic review investigating emerging methodologies that might be used in
the prevention of and/or the repair of carious tissues (enamel and dentin) was
conducted at the University of Michigan School of Dentistry by Dr. Brian
Clarkson, Chair Department of Cariology, Restorative Sciences, and Endodontics
and Dr. Rafter, Associate Clinical Professor. The review included 33 research
articles that met inclusion criteria out of 200 articles. The reviewers
investigated four emerging methods: partitioned dentifrice, laser technology,
fluoride releasing restorative materials, and for deep lesions, bone morphogenic
protein (BMP). All four methods demonstrated encouraging results.
the authors opined that more clinical trials were necessary before these technologies
can be recommended for use in general practice.12
best evidence supports the ability of fluoride, sealants, and some non-fluoride
compounds to reverse through re-calcification the de-mineralization of tooth
surfaces. As such, re-mineralization techniques have been shown to be effective
in the treatment of early carious lesions. However, the traditional approach of
surgical intervention in the treatment of early lesions not only persists, but
is prevalent in the United States.
recently, surgical intervention was considered the essential cure for such
lesion, and the profession has been trained to undertake operative procedures
However, it has now been shown clearly that the disease
reasonably slowly in the early stages. In fact, it can be controlled or
eliminated before surface cavitation. A lesion is reversible and can be
up until there is a cavity deep enough to retain bacterial plaque.”
profession must become aware of the importance of identifying the early
of disease, rather than just seeking cavities. After all, it can take as
as 4 years for a carious lesion to penetrate the enamel and a further 4
to reach the depths of the dentine.” 13
recent study conducted by the Washington Dental Service was designed to see if
there was an economic advantage in finding a dental home by the age of one and
using interceptive methodology to prevent the necessity to have a first
restoration on first molar teeth prior to the age of thirteen. Members of WDS
were tracked from age five through age 12 for restorative history on first
molars. Restorative costs were tabulated. A second group was tracked from age
one through age seven to determine how many first molars were restored and what
the interceptive costs were.
the study was eventually abandoned early indications were that such a program would
be cost effective. With that in mind, AADC concludes that there may be
additional rationale for delaying initial restorations until more conservative
treatment has failed to arrest or reverse the initial lesion.
the preponderance of current best evidence, it is the position of the AADC that
non-surgical management of early carious lesions through the use of
re-calcification techniques has been shown to effectively stop or reverse the
caries disease process. Further, evidence supports that such non-surgical
treatment is more effective in the preservation of natural tooth tissue and is
more cost effective than placing restorations.
with restorative dentistry: when to intervene?”; Elderton RJ, International
Dental Journal; Feb. 1993; 43(1); 17-24.
Risk Assessment in an Educational Enviornment.”; Sophie Domejean-Orliaguet,
DDS, Stuart A Gansky, Dr.P.H., John D Featherstone, PhD; Journal of Dental
Education, Dec. 2006, Vol. 70 (12), p. 1346-54.
Black, G.V., Operative dentistry. Chicago, Medico-Dental Publishing Co., 1908,
lack, G.V., Operative dentistry. Chicago, Medico-Dental Publishing Co., 1908,
case report: arresting dental caries.”; Milgrom P, Rothen M, Spadafora A,
Skaret E; Journal of Dental Hygiene, Summer 2007; 75(3): 241-3.
of including APF gel application in a school oral health promotion program as a
caries-preventive agent: a community intervention trial.”; Agrawal N,
Pushpanjali K; Journal of Oral Science, 2011; 53(2): 158-91.
of enamel subsurface lesions by case in phosphopeptide-stabilized calcium
phosphate solutions.”; Reynolds EC; Journal of Dental Research; Sept.
1997; 76(9): 1587-95.
vivo remineralizing effect of GC tooth mousse on early dental enamel lesions:
SEM analysis.”; Ferrazzano GF, Amato I, Cantile T, Sangianantoni G, Ingenito A;
International Dental Journal, Aug. 2011;61(4):
of initial carious lesions in deciduous enamel after application of dentifrices
of different fluoride concentrations.”;; Hellwig E, Altenburger M, Attin T,
Lussi A, Buchalla W; Clinical Oral Investig.,
June 2010; 14(3): 265-9.
of artificial interproximal carious lesions using a fluoride mouthrinse.”; Altenburger
MJ, Schirrmeister JF, Wrbas KT, Hellwig E; American Journal of Dentistry,
Dec. 2007; 20(6): 385-9
2-year clinical evaluation of sealed noncavitated approximal posterior carious
lesions in adolescents.”; Gomez SS, Basili CP, Emilson CG; Clin. Oral
Investig, Dec. 2005; 9(4): 239-43.
Methods Used in the Prevention and Repair of Carious Tissues”; Brian H.
Clarkson, PhD; Mary E. Rafter, B. Dent.Sc., F.F.D., M.S. Journal of Dental
Education, Oct. 2001, Volume 65, No 10, pages 1114-1120.
Classifying, and Placing Incipient Caries Lesions in Perspective.”; Graham J.
Mount, AM, BDS, DDS; Dental Clinics of North America, 49, 2005: 701-723.
Michael Weisenfeld (Chair)
Clay Pesillo (Principal Author)
E FitzGerald (Co-Author)