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When to intervene in the caries process? An expert Delphi consensus statement

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Abstract

Objectives

To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions.

Methods

Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.

Results

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations will be placed for reasons of form, function and aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated carious lesions which are cleansable. Cavitated lesions which are not cleansable usually require invasive/restorative management, to restore form, function and aesthetics. In specific circumstances, mixed interventions may be applicable. On occlusal surfaces, cavitated lesions confined to enamel and non-cavitated lesions radiographically extending deep into dentine (middle or inner dentine third, D2/3) may be exceptions to that rule. On proximal surfaces, cavitation is hard to assess visually or by using tactile methods. Hence, radiographic lesion depth is used to determine the likelihood of cavitation. Most lesions radiographically extending into the middle or inner third of the dentine (D2/3) can be assumed to be cavitated, while those restricted to the enamel (E1/2) are not cavitated. For lesions radiographically extending into the outer third of the dentine (D1), cavitation is unlikely, and these lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.

Conclusions

Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions.

Clinical relevance

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.

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Funding

The conference was kindly sponsored by DMG (Hamburg, Germany). This included travel, accommodation and conference costs for panel members.

Author information

Authors and Affiliations

  1. Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany

    Falk Schwendicke & Sebastian Paris

  2. Preventive & Pediatric Dentistry, University of Greifswald, Greifswald, Germany

    Christian Splieth

  3. Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna-Alma Mater Studiorum, Bologna, Italy

    Lorenzo Breschi

  4. Conservative & MI Dentistry, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s Health Partners, King’s College London, London, UK

    Avijit Banerjee

  5. Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor, MI, USA

    Margherita Fontana

  6. Faculty of Dentistry, University of Hong Kong, Pokfulam, Hong Kong, SAR, China

    Michael F. Burrow & Edward Lo

  7. Melbourne Dental School, University of Melbourne, Melbourne, Australia

    Felicity Crombie & David J. Manton

  8. Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand

    Lyndie Foster Page & William Murray Thomson

  9. Department of Dentistry, University of Barcelona, Barcelona, Spain

    Patricia Gatón-Hernández

  10. Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil

    Patricia Gatón-Hernández

  11. Cariology Unit, Department of Oral Rehabilitation, University of Talca, Talca, Chile

    Rodrigo Giacaman

  12. Department of Pediatric and Preventive Dentistry, DAV (C) Dental College, Yamunanagar, Haryana, India

    Neeraj Gugnani

  13. Department of Conservative Dentistry and Periodontology, University Hospital, LMU Munich, Munich, Germany

    Reinhard Hickel

  14. Institute of German Dentists, Cologne, Germany

    Rainer A. Jordan

  15. Department of Dentistry, Faculty of Health Sciences, University of Brasília, Brasilia, Brazil

    Soraya Leal

  16. Faculty of Dentistry, AMU University, Marseille, France

    Hervé Tassery

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  1. Falk Schwendicke
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  2. Christian Splieth
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Contributions

FS, DJM: Organised the meeting, administered the consensus process and drafted parts of the first version of this document

AB, MF, SP: Drafted parts of the first version of this document

All authors: Provided input into the draft document, participated in the consensus process, revised the document and are accountable for the final version

Corresponding author

Correspondence to Falk Schwendicke.

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Conflict of interest

The authors declare that they have no conflict of interest.

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This article did not involve undertaking of any study of humans or animals.

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For this type of study, formal consent is not required.

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The sponsor had no role in design or conduct of the conference or the content of this manuscript. No honoraria were given to any of the panel members.

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Appendix

Appendix

The expert group represented members of the European Association for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) as well as (mainly overseas) non-members. The group was organised and the process was led by two members, FS and DJM. These members also organised financial support for the meeting. The members of the expert group were chosen based on their clinical and scientific expertise, allowing sufficient breadth of experience, as well as geographic aspects. All experts were familiar to one or both organisers. Note that some experts came from the same institution; no weighting or adjustment during the consensus was performed for this, as any kind of possible bias introduced by this was assumed to be limited and was accepted, but also as no valid rules for such weighting or adjustment are available.

Both ORCA and EFCD approved and supported the initiative, its aims and the meeting, and the then-president-elect of ORCA and the then-acting-president of EFCD were members of the group. As described, all members of the group provided a conflict of interest declaration and no member was found to be subject to relevant conflict of interest related to the consensus statement.

Prior to the meeting, a working paper, which also formed the basis for the present consensus document, was drafted by a smaller group of members, whose task it was to sum up and synthesise the available evidence for the different levels of invasiveness (NI, MI, invasive) as well as the evidence base towards possible intervention thresholds. Note that no systematic review process was performed, but existing reviews were considered. The compiled draft was sent to the overall group, who commented on it extensively, in two rounds. The resulting manuscript was the basis of the following steps and included consensus recommendations. Only these recommendations were voted on during the subsequent Delphi process; the text itself (excluding the recommendations) was not submitted to any further consensus process as we felt the core of the consensus was the recommendations.

A two-staged confidential e-Delphi survey was then undertaken. Between the two Delphi rounds, the consensus panel meeting was held. The reporting for this Delphi follows the guidance on Conducting and REporting DElphi Studies (CREDES) [6], with all points being laid out below once more for reasons for clarity.

Rationale for the choice of the Delphi technique

  1. 1.

    Justification: A stepwise approach of coming to a consensus on a set of evidence-grounded statements, after discussion first via e-mail/text, then in a form of a meeting, was decided to be built on the Delphi technique. This technique is transparent, anonymous in voting and accepted by the community. Further, it was feasible and fitted to the specific design of this consensus process. By combining an open-ended approach with a Delphi, we aimed to allow a systematic but nevertheless comprehensive approach.

Planning and design

  1. 2.

    Planning and process. The consensus rules (see below) were agreed to by the panel via e-mail before starting the Delphi process. Modifications are described below. The Delphi asked for an agreement to each consensus statement (as can be found in the consensus recommendations section of the main paper), with a scale of 1–10 (do not at all agree to agree fully) being used. A multi-stage Delphi was planned, without removal of any items prior to concluding at maximum three rounds. Each round closed after a 4-week period. One reminder via e-mail was sent for each round. Panellists were allowed to comment on each item. The survey was conducted via Delphi Manager 3.0, University of Liverpool, UK, and Surveyjet (Calibrum, https://calibrum.com), and survey data was analysed descriptively.

  2. 3.

    Definition of consensus. The following consensus rules applied. (1) Agreement to an item was defined by marking grades 7–10 on a scale from 1 to 10. (2) Minimum 70% of all participants needed to agree to an item for this to be consensually accepted. Items which did not meet these criteria after the planned 2 rounds were to be dropped (no item was eventually dropped). For reasons of transparency, we additionally report on the mean agreement and the standard deviation

Study conduct

  1. 4.

    Informational input: The material provided to the panel is described in the main text. Its attainment has been described above.

  2. 5.

    Prevention of bias: To identify possible risk of bias, all members filled out a conflict of interest form. To prevent bias, a systematic, evidence-grounded approach was chosen. Note that the topic itself does only limitedly lend itself for financial/commercial bias. The planning and conduct were performed independent from the sponsor.

  3. 6.

    Interpretation and processing of results: There was, as discussed, stable agreement to all items after the second round.

  4. 7.

    External validation: No external validation was sought.

Reporting

  1. 8.

    Purpose and rationale: These have been provided.

  2. 9.

    Expert panel: The criteria for the selection of experts were provided.

  3. 10.

    Description of the methods: Preparatory steps, synthesis of the evidence, piloting of the statements, survey rounds and conference have been described.

  4. 11.

    Procedure: The Delphi steps have been described.

  5. 12.

    Definition and attainment of consensus: The following consensus rules applied. (1) Agreement to an item was defined by marking grades 7–10 on a scale from 1 to 10. (2) Minimum 70% of all participants needed to agree to an item for this to be consensually accepted.

  6. 13.

    Results: The results are reported in the main text. Note that between steps, at the panel meeting, a discussion on all items was held; these discussions had not been planned a priori but found necessary after the first round and the revision of the manuscript. Some items, mainly those showing low agreement in round 1, were revised in language or content, and all items provided to the group in the second round. A consensus was reached on all items in the second Delphi round. All panellists except one took part in both Delphi rounds.

  7. 14.

    Discussion of limitations: A limited group of people have been invited and came to this consensus, which is a limitation. Moreover, and as laid out, most statements are not supported by strong evidence, as this is missing.

  8. 15.

    Adequacy of conclusions: The conclusions reflect the outcomes of the Delphi and aim for applicability of the deduced guidance points.

  9. 16.

    Publication and dissemination: The consensus paper will be translated in various languages and published in national journals for dissemination.

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Schwendicke, F., Splieth, C., Breschi, L. et al. When to intervene in the caries process? An expert Delphi consensus statement. Clin Oral Invest 23, 3691–3703 (2019). https://doi.org/10.1007/s00784-019-03058-w

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