There are three significant studies published recently that merit discussion here. The first article is:

Pilcher L, Pahlke S, Urquhart O, O’Brien KK, Dhar V, et al. Direct materials for restoring caries lesions: Systematic review and meta-analysis-a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2023 Feb;154(2):e1-e98. doi: 10.1016/j.adaj.2022.09.012. Epub 2023 Jan 5. Erratum in: J Am Dent Assoc. 2023 Feb 15;: PMID: 36610925.

The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth. This was a systematic review and meta-analysis examining the question of which restorative material is best and protects the pulp. The review included 38 randomized controlled trials eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass isomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials. In conclusion there was limited evidence in difference in failure outcomes based on the restorative material. The clinical application of this study would indicate that the dental professional should choose the material they think is best indicated for the specific lesion in a given patient. 

The second article:

Muñoz-Sandoval C, Gambetta-Tessini K, Botelho JN, Giacaman RA. Detection of Cavitated Proximal Carious Lesions in Permanent Teeth: A Visual and Radiographic Assessment. Caries Res. 2022;56(3):171-178. doi: 10.1159/000525193. Epub 2022 Jun 10. PMID: 35605576.

The purpose of this study was detection of proximal carious lesions with the combination of clinical and radiographic methods. This cross-sectional study aimed at estimating the prevalence of cavitation in proximal carious lesions, based on a direct clinical assessment of previously detected radiographic lesions, in permanent molars and premolars. The results indicated that of the 508 proximal radiographic lesions examined by use of an orthodontic separator, 22% of all lesions were cavitated, which is the baseline for invasive restorative treatment. Only few lesions coded as E1 (2.1%) and E2 (9.8%) were cavitated. Fifty D1 (35.5%) and 22 D2 (41.5%) lesions were cavitated after separation. Most lesions coded as D3 (84.8%) were cavitated. Challenging conventional wisdom, most D1 and D2 lesions were not cavitated. The clinical implications from this study are challenging. It is not practical in private practice to place a separator on every radiographic lesion and wait a week for direct vision to determine if it is cavitated. While less than half of the D1/D2 lesions were cavitated, the problem is in identifying which ones are versus those that aren’t. It is clear that a conservative approach on E1/E2 lesions is appropriate, and definitely a more aggressive approach on D3 lesions is warranted (by the time a lesion is radiographically a D3 lesion, it is actually deeper in real life, and on a premolar, there may be 1mm or less sound dentin to the pulp). The real issue is determining with accuracy which D1/D2 lesions require restoration and which ones don’t. Until we have a chairside real-time technology with high sensitivity and specificity, dental professionals need to use their best clinical judgement based on all data, risk assessment, history with the patient, etc., and document, document, document.

The final study:

Ruff RR, Barry-Godín T, Niederman R. Effect of Silver Diamine Fluoride on Caries Arrest and Prevention: The Caried Away School-Based Randomized Clinical Trial. JAMA Netw Open. 2023 Feb 1;6(2):e2255458. doi: 10.1001/jamanetworkopen.2022.55458. PMID: 36757696; PMCID: PMC9912124.

The purpose of this trial was to determine the effectiveness of silver diamine fluoride with fluoride varnish vs traditional glass ionomer sealants with fluoride varnish after 2 years when provided to children via a school-based health care program. 2998 children aged 5 to 13 years of any race and ethnicity were recruited from block-randomized schools in 47 New York City primary schools. The children received a single application of silver diamine fluoride with fluoride varnish or an active comparator of glass ionomer sealants and atraumatic restorations with fluoride varnish. In this randomized clinical trial, silver diamine fluoride with fluoride varnish was noninferior to sealants and atraumatic restorations with fluoride varnish for caries arrest and prevention. Results may support the use of silver diamine fluoride as an arresting and preventive agent in school-based oral health programs.


I feel strongly about using the word “arrest” in conjunction with SDF, based on available scientific data and my personal experience with it. Having said that, it appears that SDF plus fluoride varnish is equivalent to GIC sealants/ART restorations with fluoride varnish in school aged children. I recommend SDF as a preventive agent in a variety of clinical applications based on the patient and a discussion of discoloration, recognizing that it is more effective on enamel lesions that dentin lesions.


Dr. V Kim Kutsch

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