DECISION

MAKING IN
CARIES
MANAGEMENT
NON INVASIVE,
MICRO-INVASIVE
OR
MINIMALLY
INVASIVE?
WHEN IN ROME,
DO AS THE
ROMANS DO
Historical expectation !
◦(the dentist who drills is a good one, because
it is an active response), and/or financially.
◦ The “wait and watch” approach of
noninvasive therapy, largely based on self-
managment, is viewed with a certain amount
of skepticism, as are microinvasive
procedures.
Drill & Wait and
fill Watch
 Items to be discussed
•Fundamentals of evidence-based
dentistry
◦• Fundamentals of shared decision-
making
◦• Changing the treatment philosophy
from “drill and fill” to “heal and seal”
◦• Limits of noninvasive therapeutic
options
◦• Limits of microinvasive therapeutic
EVIDENCE-BASED
DENTISTRY
Evidence-based medicine
is a standardized, transparent procedure for
evaluating data from studies. After collecting
the relevant evidence in the medical literature
relating to a specific clinical problem, the
quality or validity of the evidence is assessed,
and the magnitude of the effect is evaluated
It’s about integrating individual clinical
expertise!
 SHARED
DECISION-
MAKING
◦In many European and North
American countries as well as
Australia, an effort is under way to
reinforce patient rights and actively
include patients in the medical
decision-making process
◦The health care goal is
to provide relevant
information to enable
STEPS IN
SHARED
DECISION-
MAKING
◦1. Agreement that a decision needs to be
made
◦2. Offer of shared decision-making
◦3. Presentation of treatment options
◦4. Risk/benefit analysis of the individual
options
◦5. Patient response, expectations
◦6. Which options are preferred?
◦7. Reasoning and decision-making phase
◦8. A joint decision is reached
 THE CHOICE OF
INVASIVE THERAPY
FOR APPROXIMAL
CARIES
DIFFERS WIDELY IN
THE WORLD.
Caries is held to be a process which can
be arrested at least in its early to
medium stages
• The findings relating to the specific
tooth surfaces can be transferred (such
as bitewing radiographs or Diagnodent
values and that no information is lost
• The patient is prepared to undergo
regular check-ups
 DILEMMA OF
FORECASTING HOW
CARIES WILL PROGRESS
BASED ON THE CLINICAL
AND RADIOGRAPHIC
CHARACTERISTICS
BY INSERTING THE
FIRST FILLING, THE
“DEATH SPIRAL”
OF
THE TOOTH IS
INITIATED!
 “MOST
DENTISTRY
IS RE-
DENTISTRY,”
DRILL AND FILL
 A SUBSTANTIAL
AMOUNT OF SOUND
TOOTH STRUCTURE
MUST BE REMOVED IN
THE INITIAL TREATMENT.
HEAL AND SEAL
Today, it is well accepted that
the caries process can be
arrested if the factors that
promote caries are reduced
Origin
◦It was shown that, in most cases, it took
several years to even a decade for
dentin caries to become detectable on a
radiograph. Consequently, there exists
enough time to choose the proper
moment for minimally invasive therapy.

◦N.B. The chosen measures depend on

the frequency of use and the patient’s
N.B. The probability of arresting a caries lesion
solely through noninvasive measures decreases as
the extent of the caries and cavitation increases.
 Factors affect decision
making

Risk Assessment Lesion

characteristics
a) Lesion cavitation
(

(b) Level of
cleansability
(c) Lesion activity
 Risk Assessment
◦These non-operative
prevention regimes should be
linked to the caries
susceptibility/risk assessment
of the individual patient
(a) Lesion cavitation

◦Cavitation itself is not a

strict criterion, but
largely used as a
surrogate for lesion
◦Non-cavitated active lesions should be treated
using evidence-based non-restorative methods.
◦Certain occlusal lesions might appear clinically
non-cavitated but radiographically extend
significantly into dentin. These lesions can be
treated non-restoratively (i.e., using fissure
sealants), but the integrity of the sealant needs
to be monitored as there is a possibility, until
more evidence has emerged, that a
“trampoline” effect may lead to failure of the
sealant and a restoration will be required.
 (b) Level of cleansability
◦Most cavitated lesions are non-
cleansable, and thus active.
These lesions cannot normally
be managed by biofilm
removal, remineralization, or
fissure sealing alone, will need
to be restored
HEAL AND SEAL
The patient performing non-invasive basic
interventions
◦• Risk-related noninvasive measures
(professionally or self-applied)
◦• Sealing of occlusal surfaces (healthy and
carious)
◦• Approximal caries infiltration or sealing
◦• Pulp-protecting caries excavation
◦• Adhesive restoration repair
◦• Minimally invasive adhesive restorative
IS IT POSSIBLE TO HEAL COMPLETELY?
◦the remineralization of the surface can be achieved
through the lasting modification of the local milieu. The
subsurface lesion exists under a shiny, relatively thick
pseudo intact surface layer which gives the lesion a
whitish appearance, and which can become brown after
the absorption of pigments

◦As the thickness of the surface layer increases,

further demineralization is prevented, as is the
remineralization of the subsurface lesion
 Enam
el
Surfac
Dark zone e

Lesion
transluce body
nt zone
THE BUILD-UP OF THE MINERAL
CONTENT OF THE SURFACE
LAYER
HELPS TO CLINICALLY ARREST
CARIES. A LEAVING A SCAR
 CLINICAL CONSIDERATION
◦For successful noninvasive means, the tooth
surface needs to be sufficiently accessible to
cleaning.
◦This is largely influenced by the surface
quality and extent of the caries. In
addition, the frequency at which a
cariogenic biofilm is regenerated is also
important, which especially depends on the
surface quality.
 RADIOGRAPHIC
CONSIDERATION
◦The degree of cavitation
correlates with the radiographic
extent of the lesion, that is, there
is a greater probability that
deeper approximal lesions on a
radiograph will be clinically
cavitated, compared with early,
 the frequency of occurrence of
cavitation of the proximal lesions
. As observed after tooth separation,
approximal caries lesions are cavitated in
10% of cases with radiographic extension
into the inner half of the enamel (E2), or
30% when they extend radiographically into
the outer third of the dentin (D1)
(c) Lesion
activity
CAVITATION BIOFILM
◦When a caries lesions is cavitated, it can be
assumed that a potentially cariogenic biofilm
has become permanently established. Even if
the patient regularly flosses, the biofilm will be
difficult to remove.
◦Stated simply, it can be assumed that the
frequency of generation of a cariogenic
biofilm depends on the size of the
cavitation of the enamel or root surface
 CARIES PROGRESSION
◦The frequency of generation of a cariogenic
biofilm obviously influences the probability of the
progression of caries.
◦Regarding detecting and assessing the
cariogenicity of plaque (biofilm), one problem is
that the visit to the dentist only offers a snapshot.
An informed patient tends to be more aggressive
about removing plaque before visiting the dentist,
◦this is only a quantitative and not a
qualitative factor.
FOR APPROXIMAL LESIONS
◦The frequent establishment of approximal plaque
correlates with a tendency of the gingiva to bleed.
The susceptibility of the gingiva to bleeding is quite a
good, but indirect, indicator of the level of a plaque
within recent days or weeks, at least in the case of
(cervical) smooth surface caries.
◦N.B. Increased bleeding of neighboring papillae
indicates a higher activity of approximal caries,
at least in periodontally healthy patient
 Age Dependence
◦The caries progression and development rate of new lesions is higher in
adolescents than in young adults
◦More new approximal caries lesions occur up to 19 years of age than in
young adults. This difference is even more pronounced with occlusal
lesions.
◦Consequently, starting at age 20 years, approximal lesions
increase in frequency in relation to occlusal lesions.
◦The median time of approximal caries (time in years that it takes 50%of
the lesions to progress from one stage to the next) from a sound status
until it reaches the inner enamel is about 6 years over the ages of 11
to 22 years
◦The median radiologic progression rate of caries lesions from the enamel–
dentin junction (EDJ) into the outer third of the dentin (D1) was
 Dependence on the Type of
Tooth
◦The median progression time of caries lesions at approximal
surfaces of various teeth also differs. To progress from the
EDJ up to the first third of the dentin D1 took about 5 years
for the distal surface of the first premolars and the
mesial surfaces of the lower second molars in the
mandible, as well as the distal surface of the upper
first molars
◦The median progression rate was 2–4 years for all other
surfaces from the EDJ to D1 (on the radiograph). After 15
years (at 27 years of age), the percentage of healthy distal
surfaces of the lower first premolars was substantially
higher than that of the distal surfaces of the lower first
Limits to Microinvasive Therapies
◦Starting at a certain level of tooth destruction,
the risk of only treating noninvasively (resulting in
consequences such as dental hard tissue
fractures or pain) becomes greater than the
anticipated benefits (such as lower cost)
◦Sealants represent a bridge between noninvasive
and minimally invasive interventions, and only a
slight amount of dental hard tissues needs to be
sacrificed during acid etching. The suggested
term for this intervention is “microinvasive
 Avoidance of
Overtreatment
◦To avoid overtreatment, only those caries
lesions should be sealed or infiltrated that are
expected to progress and have been shown
unarrestable by means of noninvasive measures

◦The assessment of the caries potential

progression in just a single session is less valid
than the information gleaned from monitoring
◦Occlusal caries lesions that remain stable over a long
period also do not have to be sealed. This is frequently
the case with older adults and seniors, assuming that the
risk of caries has not changed directly before the
examination.
◦Approximal lesions that are considered non progressive
do not require (microinvasive) treatment, as is frequently
the case with older patients with a low risk of caries.
◦Especially approximal caries in children (primary molars;
4–10 years of age), and adolescents and adults (14–35
years of age), manifest a relatively high progression
rates, so the danger of overtreatment in these age
groups is therefore considerably less
The Problem of Under
treatment
◦It is frequently feared that in sealing
and infiltrating, the true (histological)
extent of caries will be
underestimated, and accordingly
undertreated.
 Dentin involvement
◦One reason for this concern is that during excavation,
approximal caries, which is difficult to identify clinically,
frequently extends deep into the dentin

◦visual–tactile inspection is not very sensitive in

detecting the early and middle stages of approximal
caries

◦For many lesions that appear limited to the enamel on the

radiograph, the demineralization actually extends into the
◦This means that when D1 lesions are
identified on the radiograph and the surface
quality of the caries is known, one must judge
whether the caries can be arrested by
infiltration or sealing

◦In case of doubt, it can be recommended to

choose restorative therapy and not risk the
consequences of undertreatment. However,
 Residual micro-organisms
◦Non-cavitated caries lesions and lesions that are
restricted to the enamel generally only contain a few
bacteria, which cannot form a cariogenic biofilm because
of the minimal size of the cavities.
◦several authors have concluded that sealing non-
cavitated caries fissures and adhesive therapy after
“incomplete caries excavation” represents a lower-risk
alternative to radical caries excavation applied early-on,
followed by restoration
Limits to Invasive Therapies

◦The survival rate of direct restorations

(amalgam and resin composite) is an average of
about 10 years after insertion in the initial
treatment

◦An average 15-year-old person with a life-

expectancy of 80 years will therefore need to
 Decision trees
◦Findings 1: Caries on Occlusal Surfaces and Grooves
without a Restoration :
◦• If the caries is inactive, it should only be monitored (basic
prophylaxis).
◦• Surfaces categorized as ICDAS 0 and active caries of
stages ICDAS 1–2 and occasionally 3 should be sealed
◦if there is a higher risk of caries.
◦Active caries of stages ICDAS 4–6 should be filled in most
cases. If the lesions are very deep, consider stepwise caries
excavation technique or incomplete caries removal.
 ◦Findings 2: Caries in Occlusal Surfaces and
Grooves with a Restoration:

◦• If the caries lesions are limited to the enamel and/or

have small marginal gaps, the restoration should be
repaired, if noninvasive measures are not considered
enough.

◦• If it is anticipated that the caries lesion extends up

to the pulp and/or if the marginal gap is prominent,
replace the restoration.
 ◦Findings 3: Caries in Approximal Surfaces of
Posterior Teeth without a Restoration:
◦• In the case of inactive caries of stages ICDAS 1 and 2,
basic prophylaxis is sufficient, even given a radiographic
extension into the first third of the dentin.
◦• Active caries of stages ICDAS 1and 2 with a radiographic
extension of E1–E2 should be treated noninvasively (floss,
fluoride), if the risk of caries is low.
◦Active caries of stages ICDAS 1 and 2 with a radiographic
extension of E2–D1 should be infiltrated, if the risk of caries
is increased.
◦• Active caries of stages ICDAS 3–6 should be filled in most
cases. If the lesions are very deep, consider a stepwise
caries excavation technique or incomplete caries removal.
◦Findings 4: Caries in Anterior Teeth with a
Restoration:
◦• Initial marginal caries (ICDAS 1 and 2) that is
esthetically irrelevant and/or with minor marginal
gaps rarely requires invasive treatment.
◦In the case of esthetically relevant caries, minor to
moderate marginal gaps and/or caries of stages
ICDAS 1–4, consider either repairing or replacing the
restoration.
◦• If it is anticipated that the caries lesion extends to
the pulp and/or if the marginal gap is prominent,
replace the restoration.
Conclusions: Single application of 38% silver fluoride
directly onto active enamel lesions in juvenile permanent
teeth with the prior use of orthodontic separators
combined with a caries-risk-specific prevention program
appears to be highly effective and should be considered
as a viable minimally invasive option for patients and
clinicians due to its cost-effectiveness and time
efficiency.