Marmar Mesgarzadeh, Shubha Nanda

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Ad-Hoc Operative Calibration Committee

Department of Comprehensive Care

Non-Surgical Management of Dental Caries April 1, 2021

Introduction Treatment and management of Dental Caries, the most prevalent dental disease, is currently based upon evidence-based preventive and conservative dentistry. This approach is based on patient risk factors and risk indicators, early caries detection and assessment and efforts to reverse and/or arrest caries lesions. The overall aim is to preserve tooth structure and maintain health.1 To understand and implement this, the comprehensive care department is creating guidelines for the non-surgical treatment of dental caries. Rationale It is necessary for dental clinicians to understand that once the tooth enters a cycle of surgical intervention, it enters a pathway of costly recurring restorative treatments. The goal is to avoid unnecessary invasive restorative treatments and maintain the health of tooth structure as long as possible. Given today’s lower risk of lesion progression and an increased body of evidence supporting the efficacy of less invasive treatments, operative procedures for the sole purpose of caries management are best delayed unless non-operative preventative regimens such as fluoride treatments and sealants have demonstrated to be ineffective at arresting the lesion.2 (refer to guidelines on threshold of surgical intervention). Fluorides have been shown to reduce dental caries incidence consistently in both the primary and permanent dentitions, with the most current evidence strongly suggesting that most of fluoride’s cariostatic effect is topical, by affecting the demineralization-remineralization exchanges between the tooth and the biofilm.3 Sealants are considered one of the most cost-effective evidence-based strategies to prevent and arrest caries lesions in pits and fissures. The

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material penetrates the pits and fissures, and then hardens, acting as a physical barrier on these surfaces.4 Systematic reviews suggest that children and adolescents who received sealants on sound occlusal surfaces or non-cavitated pit and fissure lesions in their primary or permanent molars experienced 76 % reduction in the risk of developing carious lesions after a 2 year follow-up.5 Even after 7 years, teeth with sealants are at a much-reduced caries incidence than teeth that have never been sealed (29% versus 74%). A surface with a failed sealant is at no higher risk than a surface that has never been sealed.

In certain clinical situations, restorations may still be indicated for esthetics, structural integrity, or functional reasons.

Fluorides Fluoride was introduced into dentistry over 70 years ago, and it is now recognized as the main factor responsible for the dramatic decline in caries prevalence being observed worldwide.6 Mode of Action: When fluoride ions are present during remineralization, they become incorporated in the apatite structure, forming fluor-hydroxyapatite crystals, which are more resistant to future acid challenges. The formation of intra oral reservoirs capable of supplying ions for a prolonged period is crucial for the success of topical treatments. Fluoride, which is retained on the teeth after brief exposure to topical fluoride agents or toothpastes, is retained as calcium fluoride. Calcium fluoride is most likely the provider of free ions during cariogenic challenges. Calcium fluoride globules are protected from rapid dissolution by a phosphate-protein coating of salivary origin, which will open at low pH, when, incidentally, the fluoride is most needed. The fluoride present inside the solid enamel is most likely of lesser importance than fluoride in solution. In fact, this fluoride is not effective until exposed, due to crystallite dissolution. Upon post-eruption acidic challenge, “firmly“ bound fluoride would be released to the fluid phase, thus inhibiting demineralization and enhancing remineralization. Evidence from cohort studies also supports fluoride’s systemic mechanism of caries inhibition, especially in the pit and fissure surfaces of permanent first molars. 7

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Fluoride is delivered to the teeth systemically or topically to aid in the prevention of dental caries. Types: Systemic fluoride: Water fluoridation, fluoride tablets and drops are valuable sources of systemic fluorides. Fluorides from ingested sources ae found in blood serum and can be deposited only in developing teeth in children.8 However, ingested fluoride present in saliva and crevicular fluid, will have a topical effect as well. Topical Fluoride: A constant supply of topical fluoride, even low levels, has been shown to be most beneficial in preventing caries and can be delivered through dentifrices and mouth rinses via home care or through fluoride gels and foam, varnish or silver fluoride products via office care. HOME CARE: Topical fluorides are in the form of: Dentifrices with fluoride concentrations of 1000 ppm or above have been shown to reduce dental caries experience. For some formulations, for example, those with fluoride, calcium carbonate, and arginine, there is substantial clinical data demonstrating non-cavitated caries lesion arrest.36 Their use during toothbrushing is probably the most common and effective oral hygiene practice around the world. Dentifrices with high fluoride concentration (5000 ppm fluoride/1.1% NaF) available in the US by prescription only, are particularly effective in root surface carious lesion prevention and arrest. Since there is a dose-response effect of fluoride dentifrices, these high-concentration dentifrices are also commonly considered for patients at higher risk of coronal lesions. Mouthrinses : For higher-risk patients, over 6 years of age, fluoride mouth rinses are recommended. Sodium fluoride mouth rinse, formulated at 0.05 % (230 PPM fluoride) is recommended for daily use. Instructions: Swish 10 ml between the teeth and around the mouth for 1 minute daily and spit out. Sodium Fluoride mouth rinse, formulated at 0.2% (920 ppm fluoride) is recommended to be used once a week. Instructions: Swish 10 ml between the teeth and around the mouth for 1 minute once a week and spit out.9

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OFFICE CARE: Fluoride gel and foam These are frequently recommended for individuals at higher risk and are effective for caries prevention and arrest of non-cavitated caries. lesions in primary and permanent teeth. Acidulated Phosphate Fluoride or APF gel which contains 1.23 % NaF or 12,300ppm fluoride and NaF foam, which contains the same amount of fluoride must be used in a tray for 4 minutes. It is highly acidic and should not be used on patients with glass ionomer or porcelain restorations because the acid will etch and damage the restorations. Varnishes

Most fluoride varnishes contain 5% NaF (22,600ppm of fluoride) in a natural colophony base, which allows the varnish to adhere to the tooth surface even in the presence of saliva. Varnish is effective for caries prevention and arrest of non-cavitated lesions in primary and permanent teeth. 5% Fluoride varnish is approved in US for treating tooth sensitivity and used off label for caries management. Silver fluoride products (refer to specific guidelines) 38% silver diamine fluoride (44,800ppm fluoride) has also been shown to be effective at arresting cavitated lesions in coronal and root surfaces. vii Fluoride Toxicity: Even though the beneficial effects of fluoride on dental health are well-established, it is very crucial to regulate the amount of fluoride intake. Excess fluoride ingestion during tooth formation results in dental fluorosis. Enamel fluorosis refers to fluoride-related alterations in enamel, which occur during enamel development. These alterations become more severe with increasing fluoride intake, and time of exposure.10 Other effects of chronic fluoride toxicity include skeletal fluorosis, hypersensitivity reactions, dyspepsia, gastric irritation, renal insufficiency, numbness, muscular spasm and cancer. Therefore, fluoride consumption at elevated levels may lead to a range of detrimental effects. In addition to naturally or artificially fluoridated water, fluoride is available in a number of dental products and materials as mentioned earlier. As recommended by CDC, optimal level of fluoride in drinking water is 0.7 – 1.2 mg/l; Referring to a common salt of fluoride, sodium fluoride (NaF), the optimal dose of fluoride for children and adults is 0.05-0.07mgF/kg body

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weight and the toxic dose of fluoride for children and adults is 5 mg F/kg body weight and the lethal dose for most adult humans is estimated at 5 to 10 g (which is equivalent to 32 to 64 mg elemental fluoride/kg body weight) 11 At our school: Pulpdent Embrace Varnish (5% Sodium Fluoride with Calcium Phosphate and Xylitol) is used. EMBRACE™ Varnish PRODUCT DESCRIPTION AND INTENDED USE EMBRACE™ Varnish (from manufacturer) is a resin-based varnish that provides sustained, time-release of fluoride, calcium and phosphate ions over a period of 4 hours or longer. The calcium and phosphate salts are nano-coated with xylitol and are bioavailable. Exposure to saliva dissolves the xylitol and releases the calcium and phosphate ions, which continuously react with fluoride ions in the saliva to form protective fluorapatite on the teeth. EMBRACE™ Varnish contains 5% sodium fluoride, which is equivalent to 22,600 ppm fluoride (22.6 mg fluoride/mL). The material is tooth shade. It dries quickly forming a smooth thin film on the teeth. Indications: (As indicated in the chart) Manufacturer’s indications: EMBRACE™ Varnish treats hypersensitivity by releasing fluoride, calcium and phosphate ions that precipitate on and occlude dentinal tubules and fill superficial, non-carious enamel lesions. (It is used off-label for caries management) Contraindications: Fluorosis, ulcerative gingivitis and stomatitis, and allergy to any of the contents. Caution: Calculate total fluoride intake/application to prevent fluoride toxicity. Instructions for Use:

1) Dry the teeth with a gauze pad. It is best if teeth are at least minimally clean, but it is not necessary to do a prophy.

2) On a pad or mixing well, dispense 0.25mL varnish for children and 0.4 mL varnish for adults.

3) Using a brush, apply a thin coat of varnish on the desired tooth surfaces. It is not necessary to use all the varnish.

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4) It is best if patients refrain from eating hard foods or drinking hot liquids or alcohol for 3-4 hours after treatment. Eating soft foods for the rest of the day is advantageous. Instruct patients not to brush their teeth for at least 4 hours.

Embrace Varnish can be removed by brushing or flossing.

Sealants Types: There are different types of resin sealants filled and unfilled. Filled sealants are a combination of resins, chemicals, and fillers. The purpose of the filler is to increase bonding strength and resistance to abrasion and wear. Unfilled sealants have a higher ratio of resin to filler material, due to low viscosity they readily flow into the pits and fissures. There are 4 sealant materials under a classification proposed by Anusavice et al.12 1) Resin-based sealants are urethane dimethacrylate, “UDMA,” or bisphenol

A-glycidyl methacrylate (also known as “bis-GMA”) monomers polymerized by either a chemical activator and initiator or light of a specific wavelength and intensity. Resin-based sealants come as unfilled, colorless, or tinted transparent materials or as filled, opaque, tooth-colored, or white materials.

2) GI sealants are cements that were developed and are used for their fluoride-release properties, stemming from the acid-base reaction between a fluoroaluminosilicate glass powder and an aqueous-based polyacrylic acid solution.

3) Polyacid-modified resin sealants, also referred to as compomers, combine resin-based material found in traditional resin-based sealants with the fluoride-releasing and adhesive properties of GI sealants.

4) Resin-modified GI sealants are essentially GI sealants with resin components. This type of sealant has similar fluoride-release properties as GI, but it has a longer working time and less water sensitivity than do traditional resin sealants.

Indications (Resin sealants): Sealants are effective at:

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1. Arresting non-cavitated lesions (initial lesions) in occlusal and proximal coronal surfaces. They can be used alone or in combination with 5% NAF varnish

2. Arresting lesion progression when used in small, cavitated or micro-cavitated lesions (moderate lesions), although there is limited data supporting this.

3. Arresting non-cavitated proximal lesions. This requires 2 visits. Due to non-accessibility of the surface, wedging it is required for direct vision. Alternatively, resin infiltration (Icon, DMG) is recommended as an effective treatment for arresting proximal coronal non-cavitated caries lesions (initial lesions), either alone or in combination with a 5% NAF.

4. Preventing caries on occlusal surfaces of permanent molars in children and young adults. 13

Contraindications (Resin sealants): 1. Large cavitations (advanced caries and moderate active caries lesions

requiring restorative treatment). 2. Inability for proper isolation due to difficulty with patient’s behavior

management. 3. Allergy to methacrylate. How to Apply (Resin Sealants: Ultraseal plus by Ultradent) 1. Proper isolation is critical for a successful sealant. Rubber dam is advised

whenever possible, if not, cotton roll isolation is advised, especially if resin-based sealant are used.

2. Pumice the occlusal surface with a prophy cup, so it is free of biofilm and food debris. Rinse off.

3. Apply 35% phosphoric acid gel as acid etchant for 20 sec on occlusal surface pit and fissures for 30 sec. Rinse thoroughly with water for 30 sec.

4. Gently air dry until chalky appearance is seen. 5. Use ExciTE F beneath sealants (literature shows it can improve sealant

retention). Air dry excess. 6. Apply sealant material, just enough to seal the pits and fissures. Remove

excess and any trapped bubbles. 7. Light cure for 20 sec. 8. Check retention and marginal seal of sealant with an explorer with mild

pressure. 9. Check patient’s occlusion and adjust as necessary.

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Indications (Glass Ionomer sealants): All indications for resin sealants apply here. In addition, when moisture control is an issue or in a new partially erupted tooth, GI sealants are recommended due to their hydrophilic properties and closer coefficient of thermal expansion to tooth structure. GI sealants have fluoride release properties. It provides 24-month fluoride protection and the fluoride ions can get reactivated (recharged) by using fluoridated rinses. 14 GI sealants come in two different colors: Pink and white. The pink type has an advantage of setting time acceleration by a halogen light for pediatric patients. How to apply (GI sealant: GC Fuji LC) 1. Isolation can be done with Cotton rolls and Dri-angle to retract the tongue and enough moisture control. The GI sealants are hydrophilic materials; therefore, their moisture tolerance is higher in compare to resin sealants. 2. Pumice the occlusal surface to be free of biofilm and food debris. Rinse off with water. 3. Apply a drop of Cavity conditioner onto the occlusal surface with a microbrush for 10 sec. Gently dry the tooth with an air syringe. Do not leave the surface desiccated. 4. Tap the Capsule of GI on a hard surface and activate. Push the plunger, so it is flush with the main body. 5. Place the capsule in the applier and click the lever once. Then remove and triturate for 10 seconds. Then load it back into the applier and click twice. 6. Dispense the material onto the pits and fissures and manipulate it with microbrush. 7. Working time is under 2 minutes from the time of mixing. 8. Remove any excess with micro brush. 9. Once the material loses its gloss, place a thin coat of GC Fuji Coat LC with a microbrush and light cure for 20 sec. 10. Check occlusion and adjust as necessary. Contraindications (GI Sealant) : Allergy to Fluoride or any of the contents.

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Non- surgical Caries Management – Definition: For the purpose of these guidelines, non-surgical management (non-operative management) of caries lesions includes home care and clinical intervention with sealants, fluorides and chemotherapeutic agents.. Non-surgical Intervention are criteria based on:

1) Patient Level: Risk assessment15 2) Individual Tooth level-

i) Type of tooth surface:16 ii) Lesion Severity and activity17

Following are the suggested guidelines based on the CariesCare Practice Guide12 and the consensus of the faculty in this committee. Each case must be viewed as a distinct case and must be assessed accordingly. The management protocol should be based on the clinical judgement of the faculty/professional and meticulous detection and diagnosis of caries. In the absence of evidence that a caries lesion is inactive, particularly in the case of proximal lesions, the lesion shall be charted as active, based on the caries risk of the individual and local findings, like proximity to gingiva, papillary inflammation and bleeding, and surface roughness. Reviewing and comparing bitewings of the previous five years, if available, is highly recommended.

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CORONAL CARIES LESIONS

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CORONAL CARIES LESIONS (Cont.)

ROOT CARIES LESIONS

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References

1 Fontana M : Nonrestorative Management of Cavitated and Noncavitated Caries Lesions. Dent Clin North Am. 2019 Oct;63(4):695-703

2 Schwendicke F. Frencken JE, Bjørndal L, Maltz M, Manton DJ, Ricketts D, Van Landuyt K, Banerjee A, Campus G, Doméjean S, Fontana M, Leal S, Lo E, Machiulskiene V, Schulte A, Splieth C, Zandona AF, Innes NP. Managing Carious Lesions: Consensus Recommendations on Carious Tissue Removal. Advances in Dental Research 2016, Vol. 28(2) 58–67.

3 Margherita Fontana et al.: Evidence-Based Dentistry Caries Risk Assessment and Disease Management. Dental Clinics of North America January 2019, Pages 119-128

4 Wright JT, Tampi MP, Graham L, Estrich C, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V, Donly K, Hewlett ER, Quinonez RB, Chaffin J, Crespin M, Iafolla T, Siegal MD, Carrasco-Labra A. Sealants for Preventing and Arresting Pit-and-fissure Occlusal Caries in Primary and Permanent Molars. Pediatr Dent. 2016;38(4):282-308

5 Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV : Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database Syst Rev. 2017 Jul 31;7(7)

6 Ten Cate JM, Buzalaf MAR. Fluoride Mode of Action: Once There Was an Observant Dentist . . . J Dent Res. 2019 Jul;98(7):725-730.

7 Rošin-Grget K, Peroš K, Sutej I, Bašić K. The cariostatic mechanisms of fluoride. Acta Med Acad. 2013 Nov;42(2):179-88.

8 Carey C M et al. Focus on fluorides: update on the use of fluoride for the prevention of dental caries. J Evid Based Dent Pract. 2014 Jun;14 Suppl:95-102.

9 Lam Anty, Chu C.H.: Caries management wityh Fluoruide agents: New York State Dental Journal 2012, Nov.(11) 29-36. 10 DenBesten P, Li W. Chronic fluoride toxicity: dental fluorosis. Monogr Oral Sci. 2011;22:81-96.

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11 Ullah R, Zafar MS, Shahani N. Potential fluoride toxicity from oral medicaments: A review. Iran J Basic Med Sci. 2017 Aug;20(8):841-848.

12 Anusavice K.J. Shen C. Rawls H.R. Phillips: Science of Dental Materials. Elsevier/Saunders, St. Louis MO 02013

13 Pit and fissure sealants for preventing dental decay in permanent teeth: Anneli Ahovuo-Saloranta et al. Cochrane Database Syst Rev. 2017

14 Rochelle G. Lindemeyer: The use of Glass Ionomer Sealants On Newly Erupting Permanent Molars www.cda-adc.ca/cda. March 2007, Vol73, No.2 15 Martignon S, Pitts NB, Goffin G, Mazevet M, Douglas GVA, Newton JT, Twetman S, Deery C, Doméjean S, Jablonski-Momeni A, Banerjee A, Kolker J, Ricketts D, Santamaria RM: CariesCare Practice Guide: Consensus on Evidence into Practice. Br Dent J. 2019 Sep; 227(5):353-362.

16 Backer Dirks : Posteruptive changes in Dental Enamel. J Dental Research 45: 503-511.

17 Ferreira Zandona A., et al. : The Natural History of Dental Caries Lesions: A 4-year Observational Study. J Dent Res 2012, 91 (9) 841-846.