Arresting root caries with nonrestorative strategies: A systematic review with network meta-analysis

To assess the effectiveness of professionally-applied and self-applied nonrestorative strategies for arresting root caries.

A systematic search was conducted to include randomized controlled trials evaluating the clinical effectiveness between nonrestorative strategies (professional or self-applied strategies) and controls in arresting root caries. The search was conducted on PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Embase, and Scopus. Gray literature was searched in ClinicalTrials.gov and Google Scholar. Risk of bias (RoB) was assessed via RoB 2.0. Network Meta-analyses (NMAs) for effectiveness assessment, Surface Under the Cumulative Ranking (SUCRA) for treatment effectiveness ranking, and Confidence in Network Meta-Analysis (CINeMA) for the evidence certainty were conducted.

Seventeen studies reporting root caries arrest rates of nonrestorative strategies were included. Fifteen of them were eligible for NMA, with two at low risk of bias and thirteen raised some concerns. The total number of participants and active root caries lesions at baseline that were used for quantitative analysis were 2869 and 5233, respectively. Professionally-applied strategies that were superior to positive control included quarterly 5% sodium fluoride (NaF) varnish, 5% NaF varnish with casein phosphopeptide-amorphous calcium phosphate (CPP‑ACP), 40% chlorhexidine (CHX) varnish, and annual applications of 38% silver diamine fluoride (SDF) with or without potassium iodide (KI). Among self‑applied strategies, daily use of 5000 ppm fluoride dentifrice, 1450 ppm fluoride dentifrice containing 1.5% arginine, and 1400 ppm fluoride dentifrice combined with a 250 ppm amine fluoride and potassium fluoride (AmF/KF) mouthrinse were more effective than negative control. By SUCRA rankings, the annual 38% SDF plus KI was the most effective professionally applied strategy, while the daily 1400 ppm dentifrice plus a 250 ppm fluoride (AmF/KF) mouthrinse ranked highest among self‑applied strategies. The certainty of evidence ranged from low to moderate.

Annual professional application of 38% SDF with or without KI, quarterly applications 5% NaF with or without CPP-ACP, or 40% CHX can arrest root caries with statistically better outcomes compared with positive controls. Daily self-application of 5000 ppm fluoride dentifrice, 1450 ppm fluoride dentifrice containing 1.5% arginine, or 1400 ppm fluoride dentifrice with 250 ppm fluoride mouthrinse can arrest root caries, with statistically better outcomes compared with negative controls. However, given the low to very low certainty of the evidence, these findings should be interpreted with caution.

This review provides evidence to inform the selection of optimal treatments and oral hygiene measures for patients with root caries.