Introduction
Material and methods
Search strategy
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Patients: adolescents and adults, permanent dentition
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Intervention: non-, micro-invasive and restorative treatment of proximal caries lesions
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Outcome: caries or lesion progression (non-, micro-invasive), survival of restoration
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Meta-analyses, systematic reviews and in case of no studies for these high evidence levels also randomized controlled trials (RCTs) and/or cohort studies
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Primary teeth, occlusal caries
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Case presentations, case series
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No clinical outcomes reported
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Studies comparing different treatment techniques (e.g. selective vs non-selective carious tissue removal)
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Endodontically treated teeth
Screening and selection
Assessment of heterogeneity
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Study and subject characteristics
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Methodological heterogeneity (variability in study design and risk of bias).
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Analysis performed (descriptive or meta-analysis)
Quality assessment
Data extraction
Outcome measures and statistical analysis
Results
Non-operative/non-invasive treatment of proximal caries lesions
Author/year | Country | Sample | Study design | Analysis | Main results |
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Non-invasive treatment | |||||
Shwartz et al. (1984) | USA and Sweden | 5 groups: Swedish gr. 1 10–11 years old, N = 100 Swedish gr. 2 17 years old, N = 99 Swedish 3 21–22 years old, N = 100 US gr.1 117 4–17 years old US gr. 2 17–18 years old, N = 337 | 4–10-year longitudinal cohort study in 5 cohorts of different ages with differences in (regular) fluoride exposure (e.g. mouthrinse, topical fluoride, fluoridated water) and socio-economic status | Lesion progression on bitewing radiographs | Different lesion progressions in primary and permanent dentition; also affected by age and fluoride exposure/use. Lesion progression in settings with fluoride exposure generally slow, taking a lesion at least 4 years to progress through the enamel of permanent teeth. Progression extremely variable between individuals and also between lesions. |
Mejàre et al. (2004) | Sweden | 536 children aged 11–13 years at baseline; 250 re-examined at age 26–27 examinations in community dental services | 15-year prospective cohort study with regular non-operative caries care | Caries incidence (DFT/DFS) lesion progression on bitewing radiographs | Fewer new enamel lesions developed on approximal surfaces during young adulthood than during adolescence; the caries incidence rates for enamel lesions decreased from 4.3 in the age group 12–15 years to 2.7 new caries lesions/100 surface years in the age group 20–27 years. Lesion progression rate of lesions extending to enamel-dentin border was 32.5/100 surface years for the youngest and 10.9/100 surface years for the oldest age group. Caries incidence of outer dentin lesions on approximal surfaces was low but increased from 0.2 in the age group 12–15 years to 0.9 new outer dentin lesions/100 surface years in the age group 20–27 years. The incidence rates varied considerably between different tooth surfaces. At the age of 26–27, the proportions of occlusal and approximal DFS were almost equal. |
Arrow (2007) | Australia | 157 children aged 7 within school dental service | 5-year longitudinal cohort study | Lesion progression on bitewing radiographs | Time to occurrence of enamel lesions in approximal surfaces relatively short while progression into dentine took longer. Clinicians were able to assign the risk of lesion progression in a child. Residence in a fluoridated area has a marked retarding effect on enamel lesion progression but not on initiation of enamel lesions. |
Martignon et al. (2010) | Denmark | 115 male 20 years old Danish recruits | 6-year prospective cohort study with regular non-operative caries care | Caries incidence lesion progression on bitewing radiographs | Mean number of filled surfaces was 7.5; of which, 23% were posterior proximal. Radiographically, the mean number of proximal lesions was 5.5. Over the 6-year period, there was progression of lesions into deeper radiolucency or fillings in 57% of cases. The questionnaire showed a poor compliance with regular flossing/tooth-stick use (18%). |
Author/year | Study group and design | Non-operative intervention (control group) | Evaluation system | Outcome for non-operative (control group/teeth) |
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Martignon et al. (2006) | 1.5-year split-mouth RCT on resin sealing 15–39 years old, N = 82 Columbia and Denmark | Instruction to floss all the proximal lesions 3 times per week | Pairwise analysis and subtraction radiography | Progression pairwise 47% and with subtraction radiography 84% progression. Compliance concerning flossing was poor (15%). |
Trairatvorakul et al. (2011) | 1-year split mouth RCT on sealing with glass-ionomer cement; 7–19 years old; N = 41, Thailand | Twice daily use of 1000 ppm sodium-fluoride dentifrice, tray application of 1.23% acidulated-phosphate fluoride gel at baseline and at 6-month recall; no flossing instructions | Blinded examiner bitewing radiograph recording of lesion depths with software | Stable mean lesion depth |
Alkilzy et al. (2011) | 3-year split mouth RCT on sealing with polyurethane tape; mean age 21.3 ± 5.6 years, N = 50, Germany | Oral home care with dental floss and fluoridated toothpaste | 2 blinded examiners radiographic bitewing evaluation (D0–D4) | Only two (7%) of the control teeth with oral home care progressed |
Meyer-Lueckel et al. (2012), Paris et al. (2010) 1.5 year results | 3-year split-mouth RCT on resin infiltration, placebo-controlled young adults (N = 22), 29 pairs of proximal caries lesions, Germany | Risk-related instructions for diet, flossing and fluoridation | Radiographic bitewing evaluation digital subtraction radiography (DSR) and pairwise comparison (E1–D3) | 35% progression in pairwise, 42% with digital subtraction radiography |
Martignon et al. (2012) | 3-year split-mouth RCT on sealant vs infiltration adult students/patients from Universidad El Bosque (N = 90), Columbia | Placebo treatment (non-invasive treatment unclear, but likely regular home care without specific instructions) | Pair-wise and digital-subtraction radiography | 74% of lesions in outer third of dentin progressed while 64% of lesions around the EDJ progressed |
Meyer-Lueckel et al. (2016) | 1.5-year RCT on resin infiltration, split mouth in several private practices high caries risk children and young adults, N = 87; 238 pairs of proximal caries lesions, Germany | Instructions for a non-cariogenic diet, flossing and fluoridation, and individualized non-invasive interventions | Pairwise comparison of radiograph evaluated independently by 2 blinded evaluators | Progression in 58 of 186 control lesions (31%) |
Arthur et al. (2018) | 3-year split-mouth RCT on infiltration; high caries risk participants, N = 22, Brasil | Placebo infiltration (regular home care) | Radiographic pair-wise comparison | 5/27 (18.5%) of control lesions had progressed no significant additional effect |
Peters et al. (2018) | 2-year split-mouth RCT on resin infiltration + fluoride varnish high caries risk 18–23 years old, N = 42, USA | Mock infiltration (placebo) + fluoride varnish | Subtraction radiography, pair-wise comparison, non-cavitated initial carious lesions (E2/D1) patient and evaluators blinded | Progression rate of 22% (7/32) in the control group |
Micro-invasive treatment of proximal caries lesions
Author/year | Country | Sample | Study design | Analysis | Main results |
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Ammari et al. (2014) | Chile, Brazil, Colombia, Denmark, Germany, Greenland, Thailand, USA | 401 subjects from 7 to 40 years of age Navy clinic, dental school, public health clinic | Systematic review and meta-analysis of RCTs | Lesion progression on bitewings | The results suggest that sealing non-cavitated proximal caries seems to be effective in controlling proximal caries in the short and medium term (up to 36-month follow up), compared with non-invasive treatment. The authors conclude that further long-term randomized clinical trials are necessary to increase this evidence. |
Dorri et al. (2015) | Brazil, Colombia, Chile, Denmark, Germany, Greenland, Thailand | 365 subjects from 4 to 30 years of age University or dental public health clinics | Cochrane review (systematic review and meta-analysis) of RCTs | Lesion progression using digital subtraction radiography (DSR) | The quality of evidence for micro-invasive treatments was moderate. It remains unclear which micro-invasive treatment is more advantageous, or if certain, clinical conditions or patient characteristics are better suited for micro-invasive treatments than others. The available evidence shows that micro-invasive treatment of proximal caries lesions arrests non-cavitated enamel and initial dentinal lesions (limited to outer third of dentin, based on radiograph) and is significantly more effective than non-invasive professional treatment (e.g. fluoride varnish) or advice (e.g. to floss). |
Krois et al. (2018) | Brazil, Chile, Colombia, Denmark, Germany, Greenland, New Zealand, Thailand | 486 subjects with mean ages from 6 to 27 years Dental school, public health clinics, public schools, navy clinic, practices | Systematic review and meta-analysis of RCTs | Lesion progression on bitewings | There is robust evidence that micro-invasive treatment (sealing and infiltration) is more efficacious than non-invasive treatment for arresting proximal carious lesions. Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing and infiltration should be guided by practical concerns beyond efficacy. |
Liang et al. (2018) | Chile, Colombia, Denmark, Germany, Greenland, Thailand | 303 subjects from 6.5 to 39 years of age Dental school, public health clinics, navy clinic, practices | Systematic review and meta-analysis of RCTs | Lesion progression on bitewings | Resin infiltration and resin sealant, but not glass ionomer cement (GIC), could reduce the caries progression rate. Resin infiltration is effective in arresting the progression of non-cavitated proximal caries involved in EDJ, while the therapeutic effects of resin sealant for different lesion depths still needs to be further confirmed. Dentists should carefully select appropriate micro-invasive interventions according to the different depths of non-cavitated proximal lesions. |
Peters et al. (2018) | USA | 42 subjects from 18 to 23 years of age Military academy | RCT | Split-mouth RCT, lesion progression on bitewings | Resin infiltration demonstrated significant adjunctive support for the management of progressing early carious of high caries risk individuals. However, longer-term evidence from clinical trials in such populations is needed. |
Study outcome results and assessment of heterogeneity
Restorative treatment of proximal caries lesions
Material | N | n | Follow-up time of included studies (years) | n failure | Survival proportion ± SD (%) | AFR ± SD | mAFR ± SD | Sample-size-weighted mAFR |
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Amalgam | 1 [5] | 427 | 7 | 43 | 89.9 | 1.4 | 1.5 | 1.5 |
Bulk-fill composite | 386 | 2–10 | 20 | 94.8 ± 7.7 | 1.1 ± 0.9 | 1.1 ± 1.0 | 1.2 | |
Chemical-cured composite | 83 | 27–30 | 31 | 62.7 ± 0.3 | 1.3 ± 0.1 | 1.6 ± 0.1 | 1.6 | |
Conventional composite | 1481 | 1–30 | 210 | 85.8 ± 12.1 | 1.4 ± 1.4 | 1.5 ± 1.5 | 2.2 | |
Glass ionomer-based restoration system | 1 [26] | 25 | 4 | 2 | 92.0 | 2.0 | 2.1 | 2.1 |
Indirect composite | 158 | 5–11 | 28 | 82.3 ± 2.1 | 2.7 ± 1.7 | 2.9 ± 1.8 | 2.9 | |
Ormocer | 515 | 2–8 | 56 | 89.1 ± 7.3 | 2.1 ± 1.3 | 2.3 ± 1.5 | 2.2 | |
Silorane | 249 | 1–10 | 17 | 93.2 ± 5.0 | 2.4 ± 2.2 | 2.5 ± 2.2 | 2.5 | |
Ceramic | 112 | 3–10 | 26 | 76.8 ± 16.8 | 3.0 ± 2.0 | 3.5 ± 2.4 | 3.8 |