This umbrella review was conducted to systematically evaluate existing systematic reviews on Minimal Intervention Dentistry (MID) interventions used to manage dentine carious lesions in primary teeth. The primary objective was to determine how best to translate the available evidence into clinical practice and to provide recommendations for future research needs in this area.
Methodology
A thorough search was conducted by an experienced information specialist across multiple databases, including MEDLINE, Embase, the Cochrane Database of Systematic Reviews, Epistemonikos, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. The search strategy was constructed around four key concepts: primary teeth, caries/carious lesions, Minimal Intervention Dentistry, and systematic review/meta-analysis. The searches were limited to English language systematic reviews, with or without meta-analyses, published between January 2000 and August 2020. The PROSPERO database was also searched to identify forthcoming systematic reviews.
Two independent reviewers screened all titles and abstracts identified in the search. The interventions examined included methods that did not involve the removal of dentine carious tissue, such as fissure sealants, resin infiltration, the topical application of 38% Silver Diamine Fluoride (SDF), and the Hall Technique (HT). Other interventions included non-restorative caries control and selective removal of carious tissue, which involved both stepwise excavation and atraumatic restorative treatment (ART).
The systematic reviews were selected based on pre-defined criteria, and data were extracted and assessed for risk of bias using the ROBIS tool by two independent reviewers. The overlap of studies within the included systematic reviews was calculated using the corrected covered area method to ensure that the findings were not biased by repeated inclusion of the same primary studies across different reviews.
Results
A total of eighteen systematic reviews met the inclusion criteria. Of these, eight reviews assessed the caries-arresting effects of 38% SDF, one review focused on the Hall Technique, one on selective removal of carious tissue, and eight on interventions utilizing atraumatic restorative treatment (ART). The systematic reviews included were published between 2006 and 2020, covering a defined timeframe of randomized controlled trials ranging from 1969 to 2018.
The systematic reviews that assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded from the final analysis. This was because the pooled data in these reviews reported on caries arrest in both enamel and the outer third of dentine, with the majority of lesions being limited to enamel. As a result, fissure sealants and resin infiltration were not recommended for managing dentinal caries lesions in primary teeth.
The topical application of 38% SDF showed a significant caries arrest effect in primary teeth, with a success rate that improved when applied twice annually (ranging from 53% to 91%) compared to once a year (ranging from 31% to 79%). This finding suggests that more frequent applications of SDF may enhance its effectiveness in arresting caries.
Data on the Hall Technique (HT) were more limited, but they indicated that preformed metal crowns placed using HT were likely to reduce discomfort during treatment and decrease the risk of major failure, such as the need for pulp treatment or extraction, as well as pain, compared to conventional restorations. This suggests that the Hall Technique may be a viable option for managing carious lesions in primary teeth, especially in cases where conventional treatment methods might not be well-tolerated by young patients.
Selective removal of carious tissue, particularly in deep carious lesions, was associated with a significant reduction in the risk of pulp exposure. Specifically, one-step selective caries removal and stepwise excavation reduced the risk of pulp exposure by 77% and 69%, respectively. This highlights the potential of selective caries removal as a conservative approach that minimizes the risk of damaging the pulp, which is particularly important in maintaining the vitality of primary teeth.
ART was found to have a higher success rate when used in single-surface cavities compared to multi-surface cavities. Specifically, ART demonstrated an 86% success rate in single-surface cavities, whereas the success rate ranged from 48.7% to 88% in multi-surface cavities over a three-year follow-up period. This suggests that ART is most effective when used for smaller lesions and may be less reliable for more extensive carious lesions.
Conclusion
The findings of this umbrella review support the effectiveness of several Minimal Intervention Dentistry techniques for managing dentinal caries in primary teeth. These include the use of 38% SDF, the Hall Technique, selective removal of carious tissue, and ART for single-surface cavities. These approaches were found to be effective in arresting the progression of dentinal caries when compared to no treatment or conventional restorations.
The results of this review highlight the need to consider these MID techniques as mainstream options for managing carious primary teeth, rather than as alternatives only to be used when conventional methods are not feasible due to factors such as patient cooperation or cost. Moreover, the review underscores the importance of further research to refine these techniques and explore their long-term outcomes, particularly in multi-surface lesions where some of the interventions, like ART, may have variable success rates.
Overall, this review provides valuable insights into the current evidence base for MID techniques in managing carious lesions in primary teeth and offers clear recommendations for their integration into clinical practice. However, it also emphasizes the necessity of ongoing research to address existing gaps and further enhance the efficacy and applicability of these minimally invasive approaches in pediatric dentistry.
Source: Pubmed
