2.2 Caries Management & Prevention

The Control vs Restore Decision

A central principle of contemporary caries management is the distinction between controlling caries (non-surgical, biological management) and restoring it (operative intervention). The decision is driven by lesion activity, cavitation status, and patient-level caries risk, not by lesion depth alone.

When to Control (Non-Operative Care)

Non-operative care is indicated for:

• Initial active lesions (ICDAS 1-2) without cavitation
• Moderate active lesions (ICDAS 3-4) where the surface is cleansable and the patient can maintain plaque control
• Arrested lesions of any severity where plaque is controlled and there is no pulpal involvement
• Root caries that is non-cavitated or accessible to cleaning and fluoride

When to Restore (Operative Care)

Operative intervention is indicated when:

• The lesion is cavitated in a site the patient cannot clean (plaque stagnation)
• The lesion has crossed the enamel-dentine junction radiographically into dentine
• There is pulpal involvement or symptoms of irreversible pulpitis
• Restorative need exists (e.g., fractured restoration with caries)

Fluoride: The Cornerstone of Prevention

SDCEP (Scottish Dental Clinical Effectiveness Programme) and the Delivering Better Oral Health (DBOH) toolkit provide the UK evidence base for fluoride use.

Toothpaste Concentrations by Risk

Key advice for all strengths: brush twice daily, spit don't rinse, avoid eating/drinking for 30 minutes after brushing.

Fluoride Varnish

Sodium fluoride varnish (2.26% NaF, 22,600 ppm fluoride) is the highest-concentration topical fluoride available in general practice. It is applied professionally:

• 2 times per year for low-to-moderate risk patients
• 2-4 times per year for high-caries-risk patients

Contraindications include ulcerative gingival conditions, stomatitis, and known allergy to colophony (pine rosin) or fluoride varnish components.

Silver Diamine Fluoride (SDF)

38% Silver Diamine Fluoride (containing approximately 44,800 ppm fluoride ions) is a minimally invasive agent that arrests caries through the combined action of silver (bactericidal, biofilm disruption) and fluoride (remineralisation).

UK Regulatory Position

SDF is licensed in the UK only for the management of dentine hypersensitivity. Its use for caries arrest is off-label. The SDCEP Prevention and Management of Dental Caries in Children (3rd edition, 2025) endorses SDF as a caries management option for primary teeth, provided the clinician:

• Explains the off-label use to the parent/carer and young person
• Feels competent and can justify the prescription
• Documents the off-label decision

Indications and Contraindications

Adverse Effects

• Permanent black/brown discolouration of carious tooth tissue (the principal drawback)
• Temporary staining of soft tissues (1-3 weeks)
• Rare chemical burns to gingiva
• Staining of clothing and operatory surfaces

Application Protocol

1. Clean the tooth and remove loose debris
2. Protect soft tissues with petroleum jelly
3. Dry the lesion
4. Apply SDF (minimum 1 minute contact time)
5. Blot dry; instruct patient to avoid eating/drinking for 30-60 minutes
6. Review at 2-4 weeks; reapply at 6-monthly intervals for ongoing arrest

A hard, darkened lesion on follow-up indicates successful arrest.

Sealants

Fissure sealants prevent caries in susceptible pits and fissures by creating a physical barrier.

• Indicated for high-caries-risk children and adults with deep fissures or early (non-cavitated) lesions
• Resin-based sealants are the gold standard; glass ionomer sealants are used where moisture control is compromised
• Retention is technique-sensitive: isolation (ideally rubber dam) and etching are critical
• Sealants should be checked at recall and repaired or replaced if partially lost

Deep Caries Management: Selective Excavation

The traditional approach of complete caries removal to hard dentine risks pulp exposure, particularly in deep carious lesions. Contemporary evidence supports selective (partial) caries removal:

Evidence: Multiple randomised controlled trials demonstrate that selective excavation significantly reduces pulp exposure rates without compromising caries arrest. The stepwise approach allows the formation of tertiary (reparative) dentine and reduces the bacterial load before final restoration.

Recall Intervals: NICE CG19

NICE Clinical Guideline 19 (CG19) recommends individualised recall intervals based on a structured risk assessment:

Risk Assessment Process (Three Stages)

1. Identification of risk and protective factors (medical, social, dietary, fluoride exposure, caries history, periodontal status, plaque, saliva)
2. Evaluation of the impact of these factors in context of past and current disease experience
3. Prediction of future disease occurrence to assign an appropriate interval

Past caries experience is the most reliable single predictor of future caries. For new or unfamiliar patients, a precautionary (shorter) interval is recommended initially.

Behaviour Change: Brief Intervention

Dental teams are well-placed to deliver Brief Intervention for behaviour change, using evidence-based communication tools:

• Ask, Advise, Assist, Arrange (the 4A model)
• Motivational interviewing techniques (open questions, reflective listening, summarising)
• SMART goal-setting (Specific, Measurable, Achievable, Relevant, Time-bound)

The aim is to support patient-led change in sugar frequency, plaque control, and fluoride use, rather than to lecture or impose.