European Archives of Paediatric Dentistry (2022) 23:659–666

https://doi.org/10.1007/s40368-022-00718-6

ORIGINAL SCIENTIFIC ARTICLE

Best clinical practice guidance for treating deep carious lesions

in primary teeth: an EAPD policy document
M. Duggal1 · S. Gizani2 · S. Albadri3 · N. Krämer4 · E. Stratigaki5 · H. J. Tong6 · K. Seremidi2 · D. Kloukos7,8 ·
A. BaniHani9 · R. M. Santamaría10 · S. Hu11 · M. Maden12 · S. Amend13 · C. Boutsiouki13 · K. Bekes14 · N. Lygidakis15 ·
R. Frankenberger16 · J. Monteiro17 · V. Anttonnen18 · R. Leith19 · M. Sobczak20 · S. Rajasekharan21 · S. Parekh22

Received: 10 April 2022 / Accepted: 5 May 2022 / Published online: 11 October 2022
© The Author(s) 2022

Abstract
Purpose The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help
clinicians manage deep carious lesions in primary teeth.
Methods Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional
techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding
EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon,
and gaps in our knowledge were identified.
Results There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride
are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to
give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions.
Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs)
using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual
failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation
and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual
failure rates.
Conclusion The management of deep carious lesions in primary teeth can be challenging and must consider the patient’s
compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing
carious primary teeth as a mainstream rather than a compromise option.

* S. Parekh
[email protected]
Extended author information available on the last page of the article

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660 European Archives of Paediatric Dentistry (2022) 23:659–666

Keywords Primary molars · Caries · Caries management · Patient factors:

Minimal intervention dentistry · Pulp treatment · Dental
materials • General health of the child
• Dental status
• Patient co-operation
Aim • Signs and symptoms of pulpitis
• Cavity size (extent and activity of the lesion)
The European Academy of Paediatric Dentistry (EAPD)
proposes this best-practice guidance to help practitioners
Parent factors:
manage deep caries in children during the delivery of oral
health care. A similar statement has been published by a
• Parent expectations (motivation and compliance)
Joint ORCA and EFCD Expert Delphi Consensus Statement
• Cost
(Spleith et al. 2020). Treatment options and materials for
permanent teeth are excluded from this document.
Dentist factors:

Selection of the topic guide • Clinician competence

• Materials available
Dental caries is a common, yet preventable disease that
affects 20–90% of 6 year-old children in Europe (WHO With a move towards MID vs. conventional restorative
2018). The management of dental caries in children has methods, it can be confusing to know which technique to
shifted towards controlling caries according to an individual use. This guidance aims to provide clinicians with the best
treatment plan including risk estimation, early diagnosis and evidence-based recommendations for treating deep carious
prevention plan to keep dentition healthy and arrest initial lesions in primary teeth where available or to recommend
lesions if needed (Pitts et al 2014). This was investigated good clinical practice where evidence is weak.
by the EAPD best clinical guidance management for early
caries lesions in children and young adults (Kühnisch et al.
2016).
Unfortunately, many children may present with deep cari- Methods
ous lesions which require restorative management, either
by conventional techniques or by implementing the concept Three expert groups were invited by EAPD to undertake
of Minimal Intervention Dentistry (Ericson et al. 2003; systematic reviews of the available literature for the man-
Frecken et al. 2012; Dorri et al. 2015; Schwendicke et al. agement of deep carious lesions in primary teeth, in par-
2019). Conventional approaches to deep carious lesions ticular focussed on:
have focussed on pulpal interventions to avoid extraction and
keep the tooth asymptomatic and functional until exfoliation, • Conventional management (systematic review, Strati-
whereas Minimal Intervention Dentistry (MID) techniques gaki et al. 2022)
aim to maintain teeth vital, asymptomatic and functional for • MID (umbrella review, BaniHani et al. 2021)
as long as possible, preferably until exfoliation. The type of • Materials (systematic review, Amend et al. 2022)
treatment provided should follow biological evidence-based
caries management concepts, which emphasise preserving This new guideline is based on the reviews presented
as much tooth structure as feasible, and in case of primary by the invited experts in the 12th EAPD virtual interim
teeth, until these exfoliate naturally (Frencken et al. 2012). meeting in Oslo in April 2021. The discussions were car-
For all these techniques, the clinician must also consider the ried out by those attending the three working groups con-
most suitable material to use. sisting of invited speakers and nominated delegates from
When a clinician is presented with a child patient with the EAPD member countries. Each working group was
deep carious lesions in the primary teeth, there are many moderated by two members of the EAPD Clinical Affairs
factors to be considered before an appropriate management Committee (CAC).
plan can be reached. These need to consider both the needs
of the patient, parent and dentist: • Conventional management: M Duggal, S Gizani, E
Stratigaki, HJ Tong, K Seremidi, D Kloukos, (Mod-
erators: J Monteiro, E Stratigaki)

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Table 1  Selection criteria of the three reviews undertaken

Name Review type Inclusion criteria Exclusion criteria Follow up Outcomes

Conventional Systematic review with Children and adolescents Permanent teeth At least 24 months Clinical success
meta-analysis with deep caries in Irreversible pulpitis Radiographic success
vital primary molars
Local or general anaes-
thesia
Rubber dam isolation
MID Umbrella review of Children with untreated Caries removal was At least 6 months Symptom free vital tooth
systematic reviews carious lesion(s) assisted by chemome- maintained until exfolia-
(with & without meta- extending into dentine chanical agents tion
analysis) (ICDAS 4 & 5) in Use of local anaesthesia Caries arrest
primary teeth and rubber dam
No dentine carious tissue
removal
Non restorative cavity
control (NRCC)
Selective or stepwise
caries removal
Materials Systematic review Primary teeth treated by Permanent teeth At least 12 months Modified USPHS criteria
vital pulp therapy or Drop-out rate > 30% Minimum of 40 Assessment of restoration
endodontic treatment restorations per quality
RCTs group
Lesions extending into
dentine requiring inter-
vention

• MID: S Albadri, R Santamaria, A BaniHani, S Hu, M • Direct Pulp Capping

Maden (Moderators: V Anttonen, R Leith) • Indirect Pulp Capping
• Materials: N Krämer, K Bekes, S Amend, C Bout- • Pulpotomy
siouki, D Kloukos, N Lygidakis, R Frankenberger • Pulpectomy
(Moderators: M Sobczak, S Rajasekharan)
The evidence demonstrated that pulp reaction to the treat-
Discussions were carried out and conclusions were ment and applied medicament rely on the status of the pulp
reached by agreement and consensus, and the recommen- before the intervention, and the conditions under which the
dations from the workshops were presented on the final pulp is being treated (patient’s compliance, effective use of
day of the interim meeting by the CAC moderators. This Local Anaesthesia (LA), and Rubber Dam Isolation).
was used as a basis by the CAC members to develop the
guidance. Recommendations:
The selection criteria for the three groups is summa-
rised in (Table 1). Due to the different selection criteria and • Use the least invasive technique for the best predictable
approaches used in the three reviews, it was not possible to clinical outcome.
determine recommendations using GRADE (Guyatt et al. • There was a unanimous agreement that a restoration pro-
2008). This implies that some of the recommendations are viding a good coronal seal is essential for the manage-
based on low-grade evidence and expert opinion. ment of vital pulp in primary teeth.
• Indirect Pulp Capping (IPC) and Pulpotomy (PP) have
high success rates and can be recommended as effective
Results treatment modalities for the management of deep caries
in primary teeth.
Workshop 1: conventional management of deep • Direct pulp capping has limited use in daily clinical
caries in primary molars practice in the event of pulp exposure, except in very
restricted non-infectious conditions and on asympto-
The systematic review and meta-analysis by Stratigaki et al. matic teeth.
2022, concentrated on the following techniques: • Calcium hydroxide has the poorest success rate of all
commonly used pulpotomy medicaments, and therefore

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it is recommended that calcium hydroxide should not high caries risk, to avoid/delay the need for more invasive
be considered as a material suitable to be used as a treatments in very young children.
pulpotomy medicament. • The use of pre-formed metal crowns (PMC) using the
• Formocresol (FC), Ferric Sulphate (FS) and Mineral Hall technique (HT) for the management of dentinal car-
Trioxide Aggregate (MTA) all demonstrate similar ies in primary teeth can reduce the risk of pain and res-
success rates when used as pulpotomy medicaments. toration failure for caries in the primary teeth. The Hall
Given that concerns have been expressed regarding the technique (HT) reduced discomfort and was preferred by
potential toxic effects of certain medicaments, such as patients and parents.
formocresol, it is recommended that clinicians should • Selective (one-step) or step-wise caries removal offer
use alternatives, such as FS or MTA that have similar some advantage over complete caries removal for the
reported outcomes. avoidance of pulp exposure for lesions extending to inner
• Pulpectomy is not recommended as a first line of treat- third or quarter of dentine. In the absence of other signs
ment for deep caries management of vital primary and symptoms indicating irreversible pulpitis, these tech-
molars, due to the existence of more conservative suc- niques should be considered to avoid pulp exposure and
cessful alternatives. Nevertheless, pulpectomy may be the need for pulp therapy.
considered over extraction in certain situations where • The failure rates for ART when used to restore multi-
tooth loss would compromise the child’s dental health surface caries is unacceptably high. Therefore, this tech-
and long-term occlusion (i.e., minimise space loss) or nique is not recommended for the restoration of multi-
such as in the absence of a permanent successor. surface carious lesions. ART could be considered as an
• Clinicians should consider clinical success as a primary adequate management option for single surface (occlusal)
indicator of a successful outcome, rather than consider- in certain instances for primary teeth.
ing further interventions based on radiographic failure
alone.
Gaps in knowledge:
Gaps in knowledge: • Further investigation is needed into the effectiveness and
safety of the HT, as there has only been one systematic
• More studies are needed to compare medicaments within
review to date.
the same technique • Comparison studies are needed into the cost effectiveness
• Further comparison studies are needed between tech-
of different MID treatments modalities
niques with longer follow-up rates
• More studies are needed to compare irrigation disinfect-
ant medicaments for pulp and surrounding tissues Workshop 3: materials

Workshop 2: minimal intervention dentistry The systematic reviews by Amend et al. 2022 was consid-
ered by the working group for the following materials:
Evidence provided by the umbrella review by BaniHani
et al., 2021 was used to consider the usability of the follow- • Amalgam
ing MID techniques for managing deep carious lesions in • Glass Ionomer cements (GIC)
primary teeth: • Glass carbomers
• Compomers
• The use of 38% Silver Diamine Fluoride (SDF) • Composites
• The use of pre-formed metal crowns (PMCs) using the • Full coverage crowns
Hall Technique
• Selective (one step) and step-wise caries removal Within the parameters chosen for the review, it was
• The use of Atraumatic Restorative Technique (ART) determined there was no evidence from well-designed, ran-
domised clinical studies in children available to determine
Recommendations: which materials are most effective for deep caries in primary
teeth. This implies that most of the recommendations are
• The use of 38% SDF once or twice per year can be advan- based on low-grade evidence and expert opinion.
tageous for caries arrest, with better outcomes for two
applications per year. It is recommended that clinicians
should consider the use of 38% SDF in children with a

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Recommendations: • Due to the low levels of evidence, no recommendations

for the use of specific isolation techniques could be made
• The European Academy of Paediatric Dentistry based for all dental materials.
on Minamata Convention do not recommend the fur-
ther use of Amalgam in the restoration of primary Gaps in knowledge:
teeth (Minamata 2013).
• Due to the low evidence studies (high or unclear risk • More RCTs with power calculations and parallel group
of bias), additional considerations regarding application design are needed comparing restorative interventions
technique (such as use of disinfectant, cavity conditioner • Narrow age range for included children and longer follow
before material placement or bilayer technique or coat- ups
ing) could not be considered. • A description of the caries experience among the
• Glass Ionomer Cements (GIC), High Viscosity GIC included participants
(HVGIC) and Resin Modified Glass Ionomer Cements • Detailed descriptions of the interventions (availability of
(RMGIC) are recommended for occlusal (class I) restora- preoperative radiographs, assessment of carious lesion
tions in primary teeth. depth, administration of local anaesthesia, isolation tech-
• High Viscosity GIC (HVGIC) and Resin Modified Glass nique, extent of carious tissue removal, restorative mate-
Ionomer Cements (RMGIC) are recommended with cau- rials and application mode, adhesive protocol etc.)
tion for occluso-proximal (class II) restorations of pri- • Operator experience should be clearly stated
mary dentition. These materials are not recommended • A precise report of the numbers of patients lost to follow-
in multi-surface reconstructions. up is essential
• Metal Reinforced GIC (MRGIC) are not recommended
in the restoration of primary molars. Clinical recommendations
• Glass Carbomer is not recommended for both occlusal
(class I) and occluso-proximal (class II) restorations of Recommendations for management of deep carious lesions
primary carious molars due to the high failure rate. in primary teeth were developed in line with the strength of
• Compomers are recommended for both occlusal (class I) the evidence (Fig. 1).
and occluso-proximal (class II) restorations of primary
carious molars. Strong
• Hybrid and bulk-fill composite resins are recommended
for both occlusal (class I) and occluso-proximal (class II) • It is recommended that application of 38% SDF can be
restorations of primary carious molars. advantageous for caries arrest, with better outcomes for
• It is recommended to use a calibrated polymerization biannual application.
lamp and ensure adequate polymerization, omitting the • Indirect Pulp Capping (IPC) or selective and step-wise
monomers at the surface. caries removal, and Pulpotomy (PP) have high success
• Due to lack of evidence, it was not possible to consider rates and can be recommended as effective treatment
dentine etching times and margin cavity preparation. modalities for the management of deep caries in primary
• Due to the selection criteria, only one RCT with Pre- teeth.
formed Metal Crowns (PMC) was included in the review, • The use of formocresol for pulpotomy is no longer rec-
using the Hall Technique (HT) in vital primary molars ommended, due to the availability of more biocompatible
(Santamaria et al. 2017). The study was found to have a medicaments.
low annual failure rate, but a high risk of bias, therefore • ART technique is not recommended for the restoration
clear recommendations could not be given due to lack of of multi-surface carious lesions.
evidence. • Glass carbomer cannot be recommended due to inferior
• There is a lack of RCTs evaluating restoration techniques marginal adaptation and fractures.
in primary anterior teeth. In the one included trial with • MRGIC cannot be recommended due to loss of anatomi-
high risk of bias (Alaki et al. 2020) zirconia crowns and cal form and marginal intergrity.
composite strip crowns were compared in the reconstruc- • Pre-formed metal crowns (PMCs) using the Hall tech-
tion of carious primary anterior teeth, but a recommenda- nique are recommended as a treatment option for the
tion could not be given for lack of evidence. management of dentinal caries.

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664 European Archives of Paediatric Dentistry (2022) 23:659–666

Fig. 1  Flowchart of treatment protocol of dentinal caries lesions in primary dentition

• The use of PMCs for endodontically treated primary relation to use of randomisation and allocation sequence
molar teeth is recommended. concealment diagnostic and outcome measures

o Studies should record the use of radiographic assess-

Weak ment
p The depth of caries should be specified using an
• Compomers are recommended for both occlusal (class objective classification such as that proposed by the
I) and occluso-proximal (class II) restorations of carious ICDAS
primary molars.
• Hybrid and bulk-fill composite resins are recommended • Quality of life, patient preference, cost effectiveness and
for both occlusal (class I) and occluso-proximal (class II) burden of care and impact of different treatments modali-
restorations of carious primary molars. ties on future compliance
• GIC, RMGIC and HVGIC are more favourable given the
lower annual failure rate compared to MRGIC.
Conclusion

Research recommendations The management of deep carious lesions in primary teeth

can be challenging and must consider the patient’s compli-
The EAPD interim seminar identified further research needs, ance, operator skills, materials and costs. The lack of high
to improve comparability of studies to include: quality RCTs meant that for some consensus statements only
a low level of evidence was available.
• Focus conducting trials with more appropriate study One of the important outcomes of this review was that
designs and standardised methodology, particularly in Minimal Intervention Dentistry (MID) techniques appear to

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European Archives of Paediatric Dentistry (2022) 23:659–666 665

be effective in arresting the progression of dentinal caries Declarations

in primary teeth when compared to no treatment and con-
ventional restorations. There is some evidence of improved Conflicts of interest All authors declare that they have no conflicts of
patients reported outcomes with such techniques, however interest.
further research is required. A major advantage of MID for Open Access This article is licensed under a Creative Commons Attri-
the management of dentine carious lesions is that many of bution 4.0 International License, which permits use, sharing, adapta-
these techniques can be carried out without aerosol genera- tion, distribution and reproduction in any medium or format, as long
tion. There is a clear need to increase the emphasis on utilis- as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
ing MID techniques in managing carious primary teeth as a were made. The images or other third party material in this article are
mainstream rather than compromise option in circumstances included in the article's Creative Commons licence, unless indicated
where the conventional approach is prohibited due to cost or otherwise in a credit line to the material. If material is not included in
co-operation (Splieth et al, 2020). the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
Due to the heterogenicity of the studies and the reviews, need to obtain permission directly from the copyright holder. To view a
it was not possible to develop guidance using best-practice copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
methods, such as GRADE. Detailed and explicit criteria for
ratings of quality and grading of strength, as well as consen-
sus protocols, and input from patients and parents will make
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Authors and Affiliations

M. Duggal1 · S. Gizani2 · S. Albadri3 · N. Krämer4 · E. Stratigaki5 · H. J. Tong6 · K. Seremidi2 · D. Kloukos7,8 ·

A. BaniHani9 · R. M. Santamaría10 · S. Hu11 · M. Maden12 · S. Amend13 · C. Boutsiouki13 · K. Bekes14 · N. Lygidakis15 ·
R. Frankenberger16 · J. Monteiro17 · V. Anttonnen18 · R. Leith19 · M. Sobczak20 · S. Rajasekharan21 · S. Parekh22

1 13
College of Dental Medicine, QU Health, Qatar University, Department of Paediatric Dentistry, Justus-Liebig-University
Doha, Qatar Giessen, University Medical Centre Giessen and Marburg
2 (Campus Giessen) Medical Centre for Dentistry,
Department of Paediatric Dentistry, School of Dentistry,
Schlangenzahl 14, 35392 Giessen, Germany
National and Kapodistrian, University of Athens, Athens,
14
Greece Department of Paediatric Dentistry, Medical University
3 Vienna, University Clinic of Dentistry, Sensengasse 2a,
School of Dentistry, Unit of Oral Health, University
1090 Vienna, Austria
of Liverpool, Liverpool, UK
15
4 Lygidakis Dental Clinic (Private Dental Practice),
Department of Paediatric Dentistry, Justus-Liebig University
2 Papadiamantopoulou str. & Vasilissis Sofias Ave,
Gießen, Giessen, Germany
11528 Athens, Greece
5
Department of Pediatric Oral Health and Orthodontics, 16
Medical Centre for Dentistry, Department of Operative
University Center of Dental Medicine, Basel, Switzerland
Dentistry and Endodontics, Phillips-University Marburg,
6
Discipline of Orthodontics and Paediatric Dentistry, Faculty University Medical Centre Giessen and Marburg (Campus
of Dentistry, National University of Singapore, Singapore, Marburg), Georg‑Voigt‑Str. 3, 35039 Marburg, Germany
Singapore 17
Department of Paediatric Dentistry, Sheffield Teaching
7
Department of Orthodontics and Dentofacial Orthopedics, Hospitals, Sheffield, UK
School of Dental Medicine, University of Bern, Bern, 18
Research Unit of Oral Health Sciences, University of Oulu,
Switzerland
Oulu, Finland
8
Department of Orthodontics and Dentofacial Orthopedics, 19
Dublin Dental University Hospital, Trinity College, Dublin,
251 Hellenic Air Force and VA General Hospital, Athens,
Ireland
Greece
20
9 Specialized Dental Practice, Warsaw, Poland
Department of Paediatric Dentistry, School of Dentistry,
21
University of Leeds, Leeds, UK Department of Paediatric Dentistry, School of Oral Health
10 Sciences, Ghent University, B‑9000 Ghent, Belgium
Department of Preventive and Paediatric Dentistry,
22
University of Greifswald, Greifswald, Germany Department of Paediatric Dentistry, UCL Eastman Dental
11 Institute, London, UK
Faculty of Dentistry, National University of Singapore,
Singapore, Singapore
12
Liverpool Reviews and Implementation Group, University
of Liverpool, Liverpool, UK

13