GOOD MORNING 

How To Intervene In The Caries Process: Dentin Caries In

Primary Teeth
Ruth M. Santamaría et al.,

Caries Research 2020;54:306–323, DOI: 10.1159/000508899

Abstract:
For an ORCA/EFCD consensus, this review systematically assessed available evidence regarding interventions
performed and materials used to manage dentin carious lesions in primary teeth. A search for systematic
reviews (SRs) and randomized clinical trials (RCTs) with a follow-up of at least 12 months after intervention was
performed in PubMed, LILACS, BBO, and the Cochrane Library. The risk of bias tool from the Cochrane
Collaboration and the PRISMA Statement were used for assessment of the included studies. From 101 screened
articles, 2 SRs and 5 RCTs, which assessed the effectiveness of interventions in terms of pulp vitality and success
of restoration, and 10 SRs and 1 RCT assessing the success of restorative materials were included. For
treatments involving no carious tissue removal, the Hall technique showed lower treatment failure for
approximal carious lesions compared to complete caries removal (CCR) and filling. For the treatment of deep
carious lesions, techniques involving selective caries removal (SCR) showed a reduction in the incidence of pulp
exposure. However, the benefit of SCR over CCR in terms of pulp symptoms or restoration success/ failure was
not confirmed. Regarding restorative materials, preformed metal crowns (PMCs) used to restore multisurface
lesions showed the highest success rates compared to other restorative materials (amalgam, composite resin,
glass ionomer cement, and compomer), and in the long term (12– 48 months) these were also less likely to fail.
There is limited evidence supporting the use of PMCs to restore carious lesions with single cavities. Among
nonrestorative options, silver diammine fluoride was significantly more effective in arresting caries than other
treatments for treating active carious lesions of different depths. Considerable heterogeneity and bias risk were
observed in the included studies. Although heterogeneity observed among the studies was substantial, the
trends were similar. In conclusion, less invasive caries approaches involving selective or no caries removal seem
advantageous in comparison to CCR for patients presenting with vital, symptomless, carious dentin lesions in
primary teeth. There is evidence in favor of PMCs for restoring multisurface carious lesions in primary molars
Introduction:
Caries is no longer seen as an infectious disease
Kidd, 2011
Existing dentin caries in primary teeth, management includes a wide range of
approaches, including those where carious tissue removal is not involved, such as

1. Nonrestorative cavity control (the use of silver fluoride products (mainly silver
diammine fluoride [SDF]
2. the Hall technique (HT)
3. On a wider scope, management techniques involving caries removal include those
in which carious tissue is selectively removed, such as
The (one-step) selective caries removal (SCR),

Stepwise caries removal (i.e., selective dentin carious tissue removal at the first
step and in a second visit selective removal to firm dentin)

Nonselective caries removal (non-SCR), involving removal of all demineralized

dentin in the cavity to reach hard dentin, leaving no softened dentin(no longer
recommended)
• The decision around when to use which treatment approach should follow the
modern view of carious lesion management, which emphasizes
controlling/inactivating the carious process using less invasive management
approaches.

• The number of clinical studies and reviews assessing and comparing the
effectiveness of these diverse techniques and materials has increased over the last
years.

• Despite the current scientific evidence regarding caries management in primary

teeth, there is still no agreement on the most effective approach/material in terms of
clinical success to treat carious primary teeth with dentin involvement.
Materials and Methods:
PICO:
Question 1

1. Are minimal invasive carious lesion management approaches more effective in

terms of absence of signs or symptoms of pulpal disease or success of restorations
or lesion arrestment than the conventional therapy (non-SCR and restoration) for
managing dentin carious lesions of different depths in primary teeth?

2. What is the success/failure rate of different materials used for managing

asymptomatic dentin carious lesions (occlusal or approximal) in primary teeth
regarding integrity of the restoration or lesion arrest
 Search Strategy:

• Meta-analyses, SRs, and in the case of no studies for these levels of evidence, also
randomized clinical trials (RCTs).
• Excluded studies in which caries removal was assisted by chemomechanical agents
and compared to complete caries removal (CCR). We defined the search strategy
based on the combination of different predefined MeSH terms of the PubMed
database.
• Citations from: MEDLINE/PubMed, Cochrane Library, and MEDLINE via Ovid
up to March 2019 were retrieved. Moreover, other electronic databases such as
LILACS (Latin American & Caribbean Health Sciences Literature), and BBO
(Brazilian Library in Dentistry).
Inclusion Criteria:
Participants Children 3–12 years of age
primary dentition
Intervention
1. Only studies that compared a minimum of one of the following treatment
approaches to non-SCR/CCR were included: − No carious tissue removal – such as
NRCC (i.e., the carious lesion is opened to allow access to the lesion for brushing,
allowing continuous removal of the biofilm and remineralization using fluoride
products and advising a sensible diet.
2.caries arresting methods (e.g., SDF or other remineralization agents), and sealing
techniques including those with no caries removal using filling materials or preformed
metal crowns (PMCs) (the HT; where the carious lesion is separated from the oral
environment and substrate by putting in a PMC, consequently slowing or stopping the
caries process
• SCR to soft dentin: the excavation of carious dentin from the peripheral walls of a
deep carious lesion (excavated to hard dentin), followed by selective removal of soft
dentin from the pulpal wall; or
• SCR to firm/leathery dentin: the excavation to firm/leathery dentin (physically
resistant to hand excavation) in the pulpal aspect of the cavity. Periphery of the
cavity should be excavated to hard dentin.
• Stepwise caries excavation is the excavation of dentin carious tissue removal and
temporary filling at the first step and in a second visit some months later, selective
removal to firm dentin. CCR to reach hard dentin.
• No caries treatment or extraction. − Comparator/control intervention (non-SCR):
that is, CCR to sound enamel and clear sound dentin (hard dentin) at one visit,
usually using rotary instruments followed by restoration.
PICO
Question 2.
• All types of materials used for restoration (i.e., amalgam [AMG], glass ionomers
[self-setting or light-cured], composite resin [CR], compomer [CP], all types of
PMCs), and management (i.e., fluoride products and SDF) of dentin carious lesions
in primary teeth, independently of the extension of the lesion and type of cavity.
• Outcome: overall success of treatment (i.e., the absence of clinical signs or
symptoms of pulpal pathology (or pain), or caries arrestment, or restoration
success.
• subjective assessment of treatment by participants (children’s parents/guardians),
regardless of the outcome measure or any adverse events (e.g., gingival
inflammation) or safety issues (e.g., allergies) related to the interventions.
• Follow-up: at least 12 months after intervention.
Critical Appraisal :
• Four investigators (R.M.S., M.H.A., A.F.G.Z., and G.G.) independently performed
the search and identified the articles for potential inclusion.
• Data from all included studies were extracted and assessed using designed data
extraction forms (A fifth investigator (G.F.G.) resolved disagreements.
• Two reviewer teams estimated the risk of bias using the guidelines outlined by the
Cochrane “risk of bias” tool.
• Seven criteria were considered for each included study: sequence generation,
allocation concealment, masking of participants and personnel, masking of outcome
assessment, incomplete outcome data, selective outcome reporting, and “other bias.”
• Each criterion was judged as “low,” “high,” or “unclear” risk of bias. PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was used
for analysis of the reporting of SRs [Moher et al., 2009].

• PRISMA assessment was performed in duplicate by the 2 reviewer teams.

• 27 included items and considered the sum of positive answers as the final score,
with higher scores indicating better reporting quality.
Assessment of Heterogeneity:

Assessed the variability across studies according to the fol - lowing: −

Methodological heterogeneity:
variations related to study design and risk of bias.
Clinical heterogeneity:
• variations related to participants,
• Interventions
• Control/comparison group(s)
• Lesion location
• Lesion depth
• Surface(s) involved, materials used, and outcomes.
Results:

• PICO 1: Management Approaches for Dentin Carious Lesions in Primary Teeth

Two SRs and meta-analysis were included:
(1) Ricketts et al. [2013] assessed the effects of stepwise, selective, or no caries
removal compared to complete caries removal for the treatment of dentin caries
lesions in primary and permanent teeth;

(2) Tedesco et al. [2018] assessed different approaches involving selective and no
dentin caries removal to treat dentin carious lesions in primary teeth: atraumatic
restorative treatment (ART), ultraconservative treatment (UCT; restoration of small
cavities with ART and removal of biofilm from accessible large cavities), HT, IRT
(interim restorative treatment).
Selective Carious Tissue Removal
• SCR was considered for the treatment of deep carious lesions: lesions defined as
radiographically extending into the inner third or quarter of dentin, or clinically
assessed at risk of pulpal exposure.
• The SR by Ricketts et al. [2013] reported a significant risk reduction for pulpal
exposure for one-step SCR (RR 0.23, CI 0.08–0.69) and stepwise caries removal
(RR 0.31, 95% CI 0.17–0.57) compared to CCR for the treatment of deep carious
lesions. In addition, there were no differences in pulpal symptoms .
• However, for this comparison the quality of evidence was considered low. In
addition, there was insufficient evidence to determine whether there was a
difference in restoration failure between SCR and CCR.
• For this review, it should be considered that the extension of the SCR (to soft or
firm/leathery dentin) might have varied throughout the included studies.
Furthermore, the exact indication of the carious tissue removal extension.
• An RCT [Franzon et al., 2015] which compared the 2-year clinical and radiographic
outcomes of SCR (to leathery dentin) and CCR performed in deep carious primary
molars showed
• No statistical benefit of SCR (66%) over CCR (86%) in terms of restoration
survival (p = 0.03).
• However, the mean incidence of pulp exposure during excavation was significantly
lower in SCR (2%) compared to CCR (27.5%; p < 0.01).
• pulp exposure during caries excavation and restoration failure – according to the
modified United States Public Health Service (USPHS) Criteria [Franzon et al.,
2015] – were considered together as the outcome, there was no significant
difference in success rates between SCR (64%) and CCR
• Phonghanyudh et al. [2012] assessed the integrity and 1-year survival of the
restoration (resin-modified glass ionomer cement [RMGIC]) for SCR (selective or
complete soft dentin caries removal by hand excavation) versus CCR (rotary
instruments) of lesions located in ≥1/3 of dentin.

• No significant differences were reported in overall success (teeth without

restoration failure, absence of pulp symptomatology, etc.) of SCR versus CCR.

• In terms of cavity type, the cumulative survival rate of Class I restorations was
higher (92–100%) than that of Class II restorations (79 and 88%).
No Carious Tissue Removal:

• Lesions were located on the occlusal (32%) and approximal surfaces (68%). The
reported dmft of the study population was 2.47.
• After 2 years, no dentinal caries removal using the HT showed lower failure in terms
of absence of signs and symptoms of irreversible pulpitis (2%; p < 0.000) or loss of
restoration (5%; p < 0.000) in comparison to CCR and filling (15 and 46%,
respectively).
-Innes et al.,
• Restorations placed in the control group were mainly multisurface fillings restored
with conventional GIC (69%). The SR and meta-analysis by Tedesco et al. [2018]
• Caries arrestment is considered as the primary outcome, there are no differences in
the success rates of dentin carious lesions (International Caries Detection and
Assessment System [ICDAS] codes 4–5) treated with no carious tissue removal and
sealed with resin materials compared to techniques involving caries removal .
• Comparison the quality of evidence was considered low due to the overall high risk
of bias in the included studies.
• In addition, this review showed that for asymptomatic dentin carious lesions on
occluso-proximal surfaces, without considering the lesion depth, the HT showed the
best results in terms of restoration success, followed by the NRCC, and then
treatment modalities involving CCR and conventional restoration (CP, high-
viscosity GIC [HVGIC], CR, AMG, etc.)
• Asymptomatic dentin carious lesions of different depths (moderate-to-deep lesions
close to pulp) treated with 3 treatment modalities ART/HVGIC, UCT, and
CCR/AMG were compared.
-Mijan et al.
• In the UCT, no caries removal was performed; however, small cavities were
restored with ART/HVGIC, including SCR, and medium/large cavities were left
opened for daily supervised brushing.
• The results of this trial showed no difference in the tooth survival (absence of signs
and symptoms of irreversible pulpitis) of primary molars treated .
• Tooth survival for molars was higher for Class I cavities than for multiple-surface
cavities (p = 0.009). The study was performed in a high caries risk population
(dmft >5).
• Assessed the pulp symptomatology and failure of restora - tion of approximal
asymptomatic dentin carious lesions of different depths (ICDAS codes 3–5) treated
with 2 non-caries removal techniques (NRCC and HT) vs. CCR with CP filling.
-Santamaria et al.
 No Treatment of Carious Lesions or Extraction

For no carious treatment, only 1 RCT was included .This study compared 4 different
interventions:
(1) Full dental treatment (ART and extractions),
(2) Only extractions
(3) Only restorations using ART, and
(4) No treatment.
No additional preventive oral health interventions were reported.
After 24 months, pulpal involvement was present in 48.3% of the participants. Broken
down by interventions, pulpal involvement was 17.5%, 19.2%, 67.1%, and 82.9%,
respec - tively, for the 4 interventions.
PICO 2: Materials for Management of Dentin Carious Lesions in
Primary Teeth
• The included studies considered primarily restoration failure when loss, fracture,
or wear of the restoration was observed and an intervention was required.
• An SR and meta-analysis [Pires et al., 2018] compared the success/failure rates of
different restorative materials (AMG, CR, CP, conventional GIC, RMGIC) placed
in primary molars (2,687 teeth) in Class I and II cavities.
• The order from lowest to highest probability of failure Study ID was RMGIC, CR,
CP, AMG, and GIC.
• Effectiveness of different approaches/materials for the treatment of dentin caries
in primary teeth. The subgroup analysis demonstrated that CR and CP Class I and
III restorations show favorable success rates (86– 91%) over a 2-year period,
while CP, AMG, and GIC Class II restorations show highly variable success rates .
• Chisini et al. [2018] reported that independently of the material, Class I
restorations fail less (7.6%) than Class II (14.7%).
• An SR and meta-analysis on ART restorations from de Amorim et al. [2018] showed for
primary posterior teeth that the mean survival rates of single-surface ART/ HVGIC
restorations were significantly higher (94.3 ± 1.5%) over 2 years compared to multiple-
surface ART/ HVGIC restorations (65.4 ±3.9%).

• However, these rates were considered similar when compared to AMG restorations in
primary molars.

• Dorri et al. [2017] showed that ART/HVGIC may increase the risk of restoration failure
when compared to conventional fillings using composite and AMG on multisurface carious
primary molars, over a follow-up period from 12 to 24 months (OR 1.11, 95% CI 0.54–
2.29).

• However, the findings were considered unreliable due to the low quality of evidence
• Donly et al., reported on preformed crowns for restoring single and predominantly
multisurface carious primary teeth. There was a wide variation in the studies related
to treatment setting (chairside or general anesthesia), use of local anesthesia,
number of operators, extension of the lesion surfaces involved, and so on.
• Studies reported that in the long-term (12–48 months) PMCs were less likely to fail
than conventional fillings (AMG, CR, GIC, RMGIC, and CP).
• [Innes et al., 2007], it was reported that there was no statistically significant
relationship between Class I GIC restorations and the risk of a “minor” failure
(restoration failure or reversible pulpitis, p = 0.272), but for Class II GIC
restorations the relationship was significant (p = 0.018).
• Aiem et al. [2017] also compared different types of esthetic preformed crowns for
treating multisurface carious primary molars.
• The results of this review were inconclusive due to the overall high risk of bias
with significantly dissimilar outcome measures used.
• A recently published RCT [Donly et al., 2018] assessed the clinical success of
zirconia crowns compared to PMCs for restoring primary molars using a split-
mouth design.
• Fifty pairs of teeth requiring crowns were evaluated over a 2-year period. The
size or extension of the carious lesions was not reported. After 2 years, 70
crowns (70%) were assessed (zirconia crowns = 36 [51%], PMC = 34 [49%]).
• There were no failures in any of the groups. The authors concluded that zirconia
crowns perform comparably to PMCs for restoration of primary molars.
• An SR and meta-analysis by Chibinski et al. [2017] aimed to evaluate the caries-
arresting effect of SDF compared to active treatments or placebos for treating
active caries lesions of different depths (moderate-to-deep lesions close to pulp).
• caries arrest at 12 months using SDF was 66% higher (RR 1.66, 95% CI 1.41–
1.96) than that by other active material (GIC restorations and fluoride varnish).
In this SR, the evidence was graded as high quality
Secondary Outcomes

• The SR from Ricketts et al. [2013] reported on patient, parent/caregiver, and

dentist perception outcomes during treatment when non-caries removal (HT) and
CCR were compared.
• No dentinal caries removal using the HT was preferred by 77% of children, 83% of
parents/caregivers, and 81% dentists compared to CCR and restoration. Most
children (89%) were assessed by the dentist as experiencing “no pain, discomfort”
to “mild, not significant” during the intervention, compared to 78% in the CCR
group.
• Santamaria et al. [2015] showed more child-related, negative behavior when CCR
and restoration (37%) was performed compared to NRCC (21%) and HT (13%).
• Pain intensity was rated as “low” in all treatment modalities. NRCC and HT were
rated as “easy” to perform for most dentists (>77%), compared to 50% in the non-
SCR and CP filling arm. There were no significant differences in parents’ rating their
child’s level of comfort.

• Innes et al. [2015] reported that in the long term (12– 24 months), PMCs were less
likely to cause pain than fillings. In addition, children had more discomfort with
fillings than PMCs.

• Apparently, there is an increased risk of gingival bleeding from crowns compared to

fillings in the short and long term. Adverse events were not reported in the included
studies.
Study Outcome Summary of Findings and Assessment of
Heterogeneity:

• PICO 1 :
• For treatment of asymptomatic moderate-to-deep lesions, the HT involving no
carious tissue removal showed lower restoration failure for multisurface cavities,
when compared to CCR and restoration
• -Ricketts et al., 2013
• Considering arrestment of lesions, the available evidence endorsing the similarity
between sealing dentin carious lesions with resin materials without carious tissue
removal and interventions involving caries tissue removal (selective to
firm/leathery dentin or CCR) is limited, and low in terms of quality [Tedesco et al.,
2018].
• Treatment success was superior when daily toothbrushing with fluoridated
toothpaste and biofilm removal was supervised. The evidence for this technique is
very limited, and low in terms of quality.
• Concerning treatment of deep carious lesions (lesions extending into the inner
third or quarter of dentin), SCR, one-step, and stepwise caries removal showed
reduction in the incidence of pulp exposure in asymptomatic, vital, carious
deciduous teeth over CCR .
• The superiority of one over the other in terms of pulp symptoms could not be
confirmed. − There is extremely limited evidence for no treatment or extraction of
teeth with dentin carious lesions, and so far, these approaches cannot be
recommended.
PICO 2
• There is great variation in the success rate of restorations, depending on the lesion
extension, material, and operative technique used. − Irrespective of the technique
used (standard or HT), PMCs were shown to have the highest success rates
compared to other filling materials and were less likely to fail than fillings.
• Considering only filling materials, probability of failure was ranked from lowest
to highest: RMGIC, CR, CP, AMG, and conventional GIC with a single SR and
meta-analysis .
• However, some clinical heterogeneity was observed among the included studies
regarding caries risk of participants, isolation technique used, criteria for
restoration assessment, different material brands, and so on.
• In general, conventional GIC showed increased failure risk than other filling
materials (e.g., CP, RMGIC, AMG, and CR) [Dorri et al., 2017; Chisini et al.,
2018; Pires et al., 2018].
• ART/HVGIC may increase the risk of restoration failure, essentially in multisurface
cavities.
• In contrast, ART/HVGIC was demonstrated to be an adequate management option
for treating single-surface carious lesions in primary teeth
-de Amorim et al.,
• In addition, when conventional restorations were put in comparison, ART/HVGIC
survival rates showed resemblance with those of conventional treatment of AMG
and resin composite restorations
• In contrast, this could be due to the low quality of evidence, and thus were
considered unreliable.
• Regardless of the material used, survival of single-surface restorations is
considerably greater than that of multisurface restorations over a 2-year period.
• Regarding esthetic PMCs for restoring carious front teeth, there is still inconclusive
evidence supporting its use over other techniques (i.e., strip crowns), primarily due to the
limited follow-up .

• For primary molars, evidence from a single RCT [Donly et al., 2018], showed that zirconia
crowns are comparable to PMCs for restoration of primary molars.

• Aiem et al., stated that prevents us from making recommendations on their effectiveness
compared to PMCs.

• SDF was demonstrated to be significantly more effective in arresting caries than other
treatments (fluoride varnish application and GIC restorations) or placebos for treating
active caries lesions of different depths
Quality Assessment:

• Heterogeneity was observed in the included SRs and RCTs regarding to subject
characteristics, depth of treated lesions, extension of cavities, restorative materials
used, and outcome measures; however, the trends were similar.
• In addition, the databases searched and reporting of effect scores differed
considerably among the SRs. Most studies were found to have considerable risk of
bias .
• All SRs reported quality of evidence as either poor or low-to-moderate level.
Regarding the risk of bias of SRs, the estimated risk of bias according to PRISMA
was low for PICO 1 (100%).
• For PICO 2, most of included SRs presented low risk of bias (>80%), with 3
studies presenting a substantial (52%) [Aiem et al., 2017] or moderate (74%)
Grading the “Body of Evidence”:
Discussion:

• Systematic literature review aimed to assess an appropriate intervention during the

caries process of dentinal lesions in terms of treatment approach (PICO 1) and
material used (PICO 2) in primary teeth.
• Comparison of different methods of SCR, non-SCR, and treatment ap proaches, as
well of the different materials used for restorations from the selected articles, were
summarized based on their benefits and limitations to concur on appropriate
approaches to treat caries in primary teeth.
• Eligible published studies including PICO 1 (2 SRs and 5 RCTs) and PICO 2 (10
SRs and 1 RCT) that strictly met the inclusion criteria were incorporated in the
analysis.
• Mean age varied from 5.6 to 7.7 years within the clinical trials, and from 3 to 13
years within the SRs
• Most RCTs were identified as having considerable risk of bias. Randomization was
reported for all studies, occasionally without detailed clarification.
• On the other hand, many studies did not report on allocation concealment and
blinding of participants.
• In general, the most frequently downgraded domains were performance and
detection bias (blinding of participants/personnel or outcome).
• However, blinding in some of the studies could not be assured due to the
dissimilarities of compared techniques and materials used (e.g., techniques with
caries removal vs. no caries removal.
• PMCs vs. direct restorations, etc.), and the associated procedures were specific
enough to identify the allocation to a certain intervention
• It was disappointing to have downgraded some clinical studies because these were not
satisfactory in a risk of bias protocol that is essentially not applicable for this kind of
studies.
• The protocols used for risk of bias assessment should consider and acknowledge the
limitations of clinical treatment modalities.
• Another example of possible bias in the included studies was the variability of caries
diagnostic methods and indices (dmft/DFMT, ICDAS, etc.) for treatment assessment
(USPHS, own
• developed criteria, etc.), often without reporting calibration of examiners. The
considerable risk of bias of some included studies and the heterogeneity in comparisons
and outcomes hindered the ability to perform a metaanalysis to complete
recommendations.
• Related to the review process, a potential risk of bias was that one of the review
authors (R.M.S.) carried out one of the included studies.
• Recent consensus meeting reports stated terminology and recommendations on
carious tissue removal in primary and permanent teeth.
• In the present review, one of the causes of heterogeneity within the included studies
was the depth of caries removal (i.e., the amount of tissue left or removed).
• Caries removal varied between studies (soft to firm dentin), generally due to the
diverse and inhomogeneous use of criteria for assessing the remaining dentin tissue
after carious removal.
• Nature of the selective removal of carious tissue and the instinctive reliance of
clinicians in terms of the type of carious dentin layer that is reached. This variation
might have impacted whether the pulp was exposed during caries removal.
• Treatment of deep carious lesions in primary teeth, it seems advantageous to use
techniques which involve SCR (to soft or to firm/leathery dentin) in order to reduce
pulp exposure.
• From the included studies there is insufficient evidence to determine whether it is
necessary to re-enter as in the stepwise caries removal technique. However, an SR
and meta-analysis

• Schwendicke et al compared one-step incomplete and stepwise caries removal with

complete caries removal showed risk reduction for pulpal exposure and pulpal
symptoms for both management techniques.

• In the present review, the reported risk of failure for both techniques seemed to be
comparable, but due to limited quality of data for this outcome, conclusions could
not be drawn
• Effect of SCR on the adhesion of the restorative materials or bonding techniques, or
how carious tissue removal was performed (hand, mechanical, chemomechanical,
etc.).
• Although there is still insufficient evidence to recommend any single method/
technique for caries management, studies which involved no carious tissue removal
such as the HT and sealing with resin-based materials.
• Tedesco et al., 2018] reported no adverse consequences when caries was left, and
the lesion sealed.
• Tedesco et al. [2018] showed a notable similarity in efficacy of sealing with resin
materials regarding arrestment of asymptomatic occlusal carious lesions when
compared to techniques involving carious tissue removal
• Indicating that entering the carious lesion may not be necessary and that rather an
accurate pulp diagnosis and adequate lesion sealing contribute to treatment success.
• In addition, techniques involving no caries removal or restoration of the affected
teeth (NRCC and UCT) showed similar results to complete caries removal and
restoration in terms of signs or symptoms of pulp damage.
• Treatment success was higher when daily toothbrushing was supervised. However,
data on these management approaches were of a limited quality and inconclusive.
• The use of NRCC is considered as an advantageous method to control carious lesion
progression, to change patient/parents’ behavior, and to promote oral health
-[Gruythuysen et al., 2011].
• Factors that support or reduce the success of NRCC, and some of these would seem
to be closely related to our capacity as clinicians to change patient behavior or to
aspects related to the patient and his/her family context.
• Chibinski et al., 2017 SDF showed superiority in terms of caries arrest when
compared to other fluoride treatments or placebos, and the quality of this evidence
was graded as high.
• Effectiveness of SDF for caries arrest in cavitated lesions in primary and permanent
teeth.

-Rosenblatt et al.,

• In general, SDF offers multiple advantages for the treatment of pediatric patients such
as easy application, noninvasiveness, safety, and so on.

• In addition, the use of SDF buys the dentist some time until more traditional
restorative methods can be utilized, if required.

• Disadvantages such as the permanent black staining of the carious lesions, which can
be a concern for more esthetic-oriented parents/children.
• Irrespective of the technique used – standard (i.e., caries removal and tooth preparation) or HT –
PMCs had the highest success rates compared to other filling materials and were less likely to fail than
fillings.
• In general, there is evidence in favor of PMCs for the restoration of carious primary molars. Zirconia
primary molar crowns show promise in terms of restoration success for the treatment of primary
molars compared to PMCs [Donly et al., 2018].
• Aiem et al., 2017 the cost of zirconia primary molar crowns could limit their use in daily practice,
mainly considering that in many countries restorations with esthetic crowns are not covered by the
statutory insurance, thus costs should be covered either by the patient or his private additional
insurance.
• The cost-benefit of zirconia crowns for parents and health systems as compared to PMCs should also
be considered in further studies.
• Among direct restorative materials, there is evidence against conventional GIC for the restoration of
multisurface cavitated primary carious teeth as it showed increased failure risk. RMGIC, on the other
hand, had the lowest failure risk followed by CR, CP, AMG, and GIC.
• Regarding ART using HVGICs, there is weak evidence supporting its use for the treatment of
multisurface carious lesions in primary teeth. Irrespective of the material used, single-surface
restorations fail less than multisurface restorations over a 2-year period
• Technique and material per se are important for treatment success, an accurate
diagnosis of the carious lesion and pulpal status are crucial and can impact the
results.
• Authors of included studies in this review reported the inclusion of asymptomatic
primary teeth with no clinical or radiographic signs of pulp damage.
• Thus, in daily practice for managing patients with reported pain, or other signs or
symptoms of irreversible pulpitis, an other treatment modality should be considered,
which involves pulp management (pulpotomy or pulpectomy) or extraction and the
use of space maintainers.
• In addition, patients included in most studies were individuals with high caries risk
(dmft >3), presenting a high number of restored surfaces.
• Included in clinical studies, is rarely considered as a variable of analysis and this
may influence the survival of restorations. Patients’ caries risk has been shown in
permanent teeth to significantly influence the longevity of restorations
• In general, the management of carious lesions in primary teeth is challenging. In
contrast to treatment in adults, pediatric dentistry has to consider factors such as
age, cognitive development, pain perception and ability to describe it, child and
parents’ cooperation, type of treatment, and so on.
• These play a central role in the selection and provision of dental treatment. To
conclude, for disease control or restoration longevity, there is no single ideal
therapy for managing dentin caries in pediatric patients.
• The current evidence shows that in symptomless, carious primary teeth, less
invasive techniques involving SCR and those involving no caries removal (SDF
application or the HT) could be advantageous in terms of reduction of pulp
exposure or restoration failure, as compared to nonselective caries removal.
• In addition, for treatment of multisurface carious lesions the use of PMCs is
recommendable.
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