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Schwendicke2019_Article_WhenToInterveneInTheCariesProc

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When to Intervene in the Caries Process? An Expert Delphi Consensus Statement1

Publication Information

  • Journal: Clinical Oral Investigations
  • Date: August 2019
  • DOI: 10.1007/s00784-019-03058-w

Authors and Contributors

This consensus statement was developed by 19 authors, including:

  • Falk Schwendicke (Charité Universitätsmedizin Berlin)
  • Sebastian Paris (Charité Universitätsmedizin Berlin)
  • Avijit Banerjee (King’s College London)
  • Michael F. Burrow (The University of Hong Kong)

Authors of this publication are involved in ongoing research regarding:

  • Volatile Organic Compounds
  • Dental root caries

Document Metadata

  • Content Source: Uploaded by Falk Schwendicke on 27 August 2019.
  • Status: The user has requested enhancement of the downloaded file.

Introduction2

Abstract

Objectives To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions.

Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.

Results Carious lesion activity, cavitation and cleansability determine intervention thresholds.

  • General Principles: Inactive lesions do not require treatment (unless for form, function, or aesthetics); active lesions do. Non-cavitated and cleansable cavitated lesions should be managed non- or micro-invasively. Non-cleansable cavitated lesions usually require invasive/restorative management.
  • Occlusal Surfaces: Exceptions include enamel-confined cavitated lesions and non-cavitated lesions extending deep into dentine (D2/3).
  • Proximal Surfaces: Radiographic depth is used as a proxy for cavitation. Lesions in the middle/inner dentine (D2/3) are likely cavitated; enamel lesions (E1/2) are not. Outer dentine lesions (D1) are unlikely to be cavitated and should be managed non-invasively unless indicated otherwise.

Conclusions

Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions.

Clinical Relevance3

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.

Building an Expert Delphi Consensus

There is an increasing number of strategies to manage the caries process, ranging from early signs to extended cavitated lesions. Decisions should be based on:

  • Available evidence.
  • Patient characteristics, needs, and wishes.
  • Features of the tooth or lesion.
  • Operator experience.

This consensus aims to assist decision-making on when to intervene, utilizing a structured Delphi process involving over 20 international experts from ORCA, EFCD, and other global institutions.

Contemporary Understanding of Dental Caries

Dental caries is a prevalent non-communicable disease. Current understanding is based on the extended ecological plaque hypothesis:

  • Biofilm presence alone is insufficient; interaction between host, substrate, and microbiota is required.
  • Diet (free sugars), oral hygiene, and salivary factors drive dysbiosis.
  • Organic acids from microbial metabolism cause pH drops, leading to tooth mineral dissolution.

Caries Process and Pathophysiology4

Caries is characterized by demineralization caused by free sugar exposure to the dental biofilm, shifting the balance toward cariogenic dysbiosis. In dentine and root caries, mineral loss is followed by collagen cleavage by enzymes.

Evolution of Caries Management

Former management viewed caries as a purely infectious disease requiring invasive removal of all “contaminated” tissue. Modern evidence shows:

  1. The caries process can be controlled by modifying patient risk and behavior.
  2. Dysbiosis can be rebalanced without total microorganism removal.
  3. Active lesions can be inactivated.
  4. The spectrum of lesions is shifting toward more non-cavitated cases.
  5. Remuneration systems often lag behind this contemporary understanding.

The Restorative Death Spiral

Invasive interventions represent a late stage in management, intended to repair gross damage and restore function. Over-reliance on restorations leads to the “restorative death spiral,” where repeated interventions are necessary. Modern strategies prioritize controlling the caries process and lesion activity before resorting to surgery.

Intervention Strategies

Intervention strategies are classified by the degree of tissue removal:

  1. Non-invasive: No dental hard tissue removal (e.g., fluorides, biofilm control).
  2. Micro-invasive: Removal at the micrometre level, usually via etching (e.g., sealing, infiltration).
  3. Invasive: Removal of gross dental hard tissue, typically associated with restorations.
  4. Mixed: Strategies like Non-Restorative Caries Control or the Hall Technique.

Non-Invasive Strategies5

Dietary Control

Sugar restriction (mainly free sugars) or replacement is biologically plausible for lesion arrest, though primarily tested for prevention.

Biofilm Control

Restoring biofilm balance through mechanical hygiene, antimicrobials, or probiotics. Toothbrushing with fluoride is specifically effective for arresting active lesions.

Mineralization Control

Topical fluoride is highly effective. Options include:

  • Dentifrices (>1000 ppm or 5000 ppm).
  • Fluoride rinses, gels, and varnishes.
  • Silver diammine fluoride.
  • Calcium-based products (casein derivatives, calcium sodium phosphosilicate) and self-assembling peptides.

Micro-Invasive Strategies

Infiltration

Involves penetrating enamel lesions with low-viscosity resins after hydrochloric acid etching and ethanol drying. This creates a diffusion barrier to inactivate the lesion. Evidence supports its use for non-cavitated proximal lesions.

Sealing6

Sealing creates a diffusion barrier on the tooth surface. It is well-assessed for non-cavitated lesions on proximal, occlusal, and smooth surfaces. Sealing cavitated surfaces carries a higher risk of sealant failure (fracture or loss of retention).

Mixed Strategies

  • Non-restorative cavity control (NRCC): Reinstating cleansability by removing overhanging tissue so the patient can clean the area and apply fluoride. Used primarily in primary teeth or root lesions.
  • Hall Technique: Sealing cavitated lesions in primary teeth using preformed metal crowns without tooth preparation.

Invasive Strategies

Involves selective carious tissue removal and restoration. Modern adhesive materials allow for conservative preparations that preserve remineralisable tissue and pulpal health.

Clinical Assessment of Caries Lesions

Core Factors

Three primary factors determine intervention thresholds:

  1. Activity: Is the lesion progressing?
  2. Cavitation: Is there a surface breach?
  3. Cleansability: Can the biofilm be removed by the patient?

Lesion Activity Assessment7

Inactive (arrested) lesions do not require treatment unless for aesthetics or function. Active lesions require management. Clinical signs of activity include:

  • Presence of biofilm covering the lesion.
  • Localized gingivitis.
  • Texture and appearance: Active lesions are often rough and chalky; inactive lesions are smooth, shiny, or dark.
  • Longitudinal data (radiographs or clinical photos).

Cavitation Assessment

Cavitated lesions protect biofilms from cleaning and accelerate acid diffusion.

  • Smooth surfaces: Assessed visually/tactilely.
  • Occlusal surfaces: Deep radiographic lesions (D2/3) are usually contaminated and demineralized even if cavitation is hard to see.
  • Proximal surfaces: Cavitation is difficult to detect visually. Radiographic depth is used as a proxy:
    • E1/E2 (Enamel): Seldom cavitated.
    • D1 (Outer dentine): Cavitation status is uncertain.
    • D2/D3 (Middle/Inner dentine): Usually cavitated.

Cleansability Assessment

Even some cavitated lesions (e.g., open smooth surfaces in primary teeth or root lesions) can be cleansable, which may allow for non-invasive management.

Caries Risk and Susceptibility Assessment8

Caries risk assessment identifies the likelihood of new lesions or progression. Key indicators include:

  • Past Caries Experience: The most robust predictor.
  • Pathogenesis Factors: Diet, hygiene, and fluoride intake.
  • Root Caries: Number of exposed root surfaces.

Age and Patient Factors

  • Children and Seniors: Management is influenced by the behavior of carers and the patient’s own cooperation. Sedation or general anesthesia may necessitate lower intervention thresholds.
  • Primary vs. Permanent Dentition: Primary teeth have thinner enamel and larger pulps. Decisions must consider the time remaining until exfoliation and the higher risk of pulpal complications during invasive procedures.

Consensus Recommendations

  1. Activity: Inactive lesions are “scars” and only need monitoring. Active lesions need management (Agreement: 9.4).
  2. Cavitation: Increases progression risk; can be validly assessed on accessible surfaces (Agreement: 9.2).
  3. General Principles:
    • Inactive lesions (cavitated or not) do not require treatment (Agreement: 8.8).
    • Active non-cavitated lesions should be managed non- or micro-invasively (Agreement: 9.1).
    • Active cleansable cavitated lesions can be managed non- or micro-invasively (Agreement: 8.8).

Intervention Thresholds

Specific Intervention Thresholds

  • Non-cleansable Active Cavitated Lesions: Should be managed using invasive/restorative strategies (Agreement: 9.1).
  • Occlusal Surfaces:
    • Micro-cavitated enamel lesions: Manage with micro-invasive or mixed interventions (Agreement: 8.8).
    • Deep radiographic dentine lesions (D2/3): Usually require invasive/restorative management due to biofilm invasion and poor sealant stability (Agreement: 9.1).

Factors Determining Intervention Thresholds9

Proximal Surface Management

Radiographic depth serves as a proxy for cavitation:

  • E1/E2: Usually not cavitated; manage non-invasively.
  • D2/D3: Likely cavitated; manage accordingly.
  • D1: Decision problem; prefer non- or micro-invasive management as they are likely non-cavitated (Agreement: 8.9).

Risk and Behavioral Factors

Patient-specific risk factors should be managed and re-evaluated. Failure to modify risk may lower interventional thresholds (Agreement: 9.0).

Proximal Lesion Management10

Special Considerations

  • Sedation/General Anesthesia: Thresholds may be lowered for patients requiring these services (Agreement: 9.2).
  • Therapeutic Aims: In permanent teeth, the goal is long-term retention. In primary teeth, the goals are space maintenance and avoiding pain/sepsis (Agreement: 9.0).

Summary of Consensus

Intervention thresholds are determined by activity, cavitation, and cleansability.

  • Non-invasive/Micro-invasive: For non-cavitated lesions and cleansable cavitated lesions.
  • Invasive/Restorative: For non-cleansable cavitated lesions and deep occlusal lesions (D2/3).
  • Proximal: Use radiographic depth (E1-D3) to estimate cavitation and guide treatment.

Clinical judgment remains essential, and patients must provide informed consent based on a comprehensive review of options.

Funding and Ethical Standards

Funding

The conference was sponsored by DMG (Hamburg, Germany), covering travel, accommodation, and conference costs for panel members.

Ethical Standards

  • Ethical Approval: Not required for this type of study.
  • Informed Consent: Not required.
  • Disclaimer: The sponsor had no role in the design, conduct, or content of the manuscript. No honoraria were provided.

Appendix: Delphi Process Methodology

The expert group included members of ORCA, EFCD, and international experts. The process involved:

  1. Evidence Synthesis: A working paper was drafted based on existing reviews.
  2. Iterative Review: The group commented on the draft in two rounds.
  3. E-Delphi Survey: A two-stage confidential survey using a 1–10 agreement scale.
  4. Consensus Definition: Defined as ≥70% of participants marking grades 7–10.

Conflict of Interest11

The authors declare that they have no conflict of interest.

Study Conduct

Informational Input

The material provided to the panel is described in the main text. Its attainment has been described previously.

Interpretation and Processing of Results

There was stable agreement to all items after the second round.

External Validation

No external validation was sought.

Prevention of Bias12

To identify possible risk of bias, all members filled out a conflict of interest form. To prevent bias, a systematic, evidence-grounded approach was chosen. Note that the topic itself does only limitedly lend itself for financial/commercial bias. The planning and conduct were performed independent from the sponsor.

Reporting Standards

  • Purpose and Rationale: These have been provided.
  • Expert Panel: The criteria for the selection of experts were provided.
  • Description of Methods: Preparatory steps, synthesis of the evidence, piloting of the statements, survey rounds, and the conference have been described.
  • Procedure: The Delphi steps have been described.

Definition and Attainment of Consensus

The following consensus rules applied:

  1. Agreement to an item was defined by marking grades 7–10 on a scale from 1 to 10.
  2. A minimum of 70% of all participants needed to agree to an item for it to be consensually accepted.

Results and Revisions

The results are reported in the main text. At the panel meeting, a discussion on all items was held; these discussions had not been planned a priori but were found necessary after the first round and the revision of the manuscript.

Some items, mainly those showing low agreement in round 1, were revised in language or content, and all items were provided to the group in the second round. A consensus was reached on all items in the second Delphi round. All panellists except one took part in both Delphi rounds.

Discussion of Limitations

  • A limited group of people were invited to this consensus, which is a limitation.
  • Most statements are not supported by strong evidence, as such evidence is currently missing.

Conclusions and Dissemination

  • Adequacy of Conclusions: The conclusions reflect the outcomes of the Delphi and aim for applicability of the deduced guidance points.
  • Publication and Dissemination: The consensus paper will be translated into various languages and published in national journals for dissemination.

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Footnotes

  1. Original PDF page 1: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.1 ↩

  2. Original PDF page 2: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.2 ↩

  3. Original PDF page 3: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.3 ↩

  4. Original PDF page 4: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.4 ↩

  5. Original PDF page 5: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.5 ↩

  6. Original PDF page 6: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.6 ↩

  7. Original PDF page 7: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.7 ↩

  8. Original PDF page 8: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.8 ↩

  9. Original PDF page 9: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.9 ↩

  10. Original PDF page 10: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.10 ↩

  11. Original PDF page 11: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.11 ↩

  12. Original PDF page 12: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.12 ↩

  13. Original PDF page 13: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.13 ↩

  14. Original PDF page 14: Schwendicke2019 Article WhenToInterveneInTheCariesProc, p.14 ↩

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