Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review

This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research.

An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area.

Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has significantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7-88%, respectively, over 3 years follow-up).

Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.