Introducing an Innovative Approach for Managing Proximal Non-Cavitated Carious Lesions in Juvenile Permanent Dentition: Combining Orthodontic Separators and Silver Fluoride Application

Abstract

Background and objectives: The aim was to introduce an innovative, easy and cheap clinical approach for the control of multiple proximal non-cavitated lesions via the application of 38% silver fluoride after placement of orthodontic separators in the permanent dentition in high-caries-risk children.

Materials and methods: The case series describes the management of initial proximal carious lesions using silver fluoride (SF) products in the permanent dentition of two adolescent patients with prior proximal caries progression. Both presented with multiple asymptomatic carious lesions that were identified through the use of bitewing radiographs and classified according to the ADA proximal caries classification system. Using orthodontic separators prior to the planned application of SF, most of the surfaces could then be quickly directly examined to check for surface integrity. Follow-up examinations were conducted clinically and radiographically for at least one year to monitor lesion progression.

Results: None of the 25 enamel lesions (E1/E2) exhibited signs of progression after single SF application, while 2 out of 11 dentine lesions (D1) showed progression and required restorative intervention. The progressed lesions potentially had non-cleansable micro-cavitations that were either clinically undetected or not fully reached with the micro-brush in SF application. Thus, this should have been repeated or combined with SF application via soaked superfloss to potentially achieve better results.

Conclusions: Single application of 38% silver fluoride directly onto active enamel lesions in juvenile permanent teeth with the prior use of orthodontic separators combined with a caries-risk-specific prevention program appears to be highly effective and should be considered as a viable minimally invasive option for patients and clinicians due to its cost-effectiveness and time efficiency.

Keywords: caries diagnosis; initial caries; minimal invasive; silver fluoride.

Figure 1

Case 1—Baseline in 11/2019: Bitewings show multiple proximal lesions but without clear cavitation on the right (a) and left side (b). The patient was 13 years old and had a history of fixed orthodontic appliances. Only non-invasive caries management options were undertaken, as due to COVID-19 pandemic, the patient did not show up for micro-invasive or restorative treatment until 2022—see Figure 2. For a Lesion assessment, see Table 1.

Figure 2

Case 1—After more than 2 years, the bitewings on the right (a) and left side (b) in 02/2022 show caries progression with a solely non-invasive caries management approach, like instructions to floss and apply fluoride varnish, before the COVID-19 pandemic. The patient is now 15 years old, and the bitewings depict the status before the decision to apply SF on the initial/non-cavitated lesions alongside the restorative treatment (composite restorations in moderate lesions, and for the deep lesion in tooth 26, selective caries removal with the application of biodentine (Septodont) prior to the restoration); see Figure 3; for a lesion assessment, see Table 1.

Figure 3

Clinical photos after placement of orthodontic separators proximally but prior to SF application (04/2022, patient’s age: 15 years) in the upper (a) and lower jaw (b). Tooth 26 was already treated restoratively occluso-mesially with selective caries removal and indirect pulp capping with biodentine. The black staining in 26 occurred due to SF application on the distal lesion of 25 after tooth preparation and biodentine application but before composite filling in 26, as the D1 lesion in 25 was distally clinically non-cavitated (similar to 24).

Figure 4

Clinical photos in 04/2022 directly after application of SF (riva star, SDI) in upper (a) and lower jaw (b); same day as application of separators for 2 h; patient’s age: 15 years. Partial irritation and black staining of the gums can be seen interproximally, which usually disappears within a few days and does not cause long-term effects as the follow-up photos (see Figure 5) demonstrate.

Figure 5

One-year follow-up after SF in 06/2023; patient’s age: 17 years. Clinical photos after staining the plaque and self-brushing of the patient. Composite restorations on 24 and 26 unfortunately still show the discolorations due to SF application on neighboring teeth during the same treatment session (a). The staining of the other initial proximal lesions is not or is barely visible and does not cause aesthetic concerns (b). Possibly a re-application of SF to the proximal lesions should be considered.

Figure 6

Bitewings on the right (a) and left side (b) 16 months after SF application show the stages of proximal lesions as well as the integrity of the restorative procedures (06/2023, age: 17 years old) indicating a clear reduction in caries activity and stability of the lesions. For a lesions assessment, see Table 1.

Figure 7

Case 2—Baseline: bitewings in 2019 show the proximal non-cavitated lesions on the right (a) and the left side (b) at the age of 13. Only non-invasive caries management options including regular recall and fluoride varnish application were undertaken at this point. For a lesion assessment, see Table 2.

Figure 8

Case 2—Bitewings on the right (a) and left side (b) after slightly more than three years in 2022 show the progression and development of new proximal caries lesions. At this stage, at the age of almost 16, the decision was taken to apply SF proximally; 36 was treated with a composite restoration due to a clinically assessed cavitation. For a lesion assessment, see Table 2.

Figure 9

Clinical photos in 2022 (patient’s age is almost 16) after applying the orthodontic separators proximally in the upper (a) and lower jaw (b) and immediately after SF application and light curing (c,d). The black staining on the healthy enamel will disappear with brushing at home or can also be brushed away with a polishing paste in the office.

Figure 10

Case 2—Bitewings (03/2023) on the right (a) and left side (b) at the 1-year follow-up after SF application. The patient’s age is almost 17. The radiographic situation shows both the progression (only in second quadrant (b)) and stagnation of (both enamel and D1) proximal lesions after single application of SF within regular recall visits.