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Pozos-Guillén A, Molina G, Soviero V, Arthur RA, Chavarria-Bolaños D, Acevedo AMlesion into consideration as these techniques tendedto be cost-effective and could, therefore, be adoptedby conventional public dental health service inLACCs. This would be particularly beneficial forthe enhancement of oral-health care in deprivedcommunities by increasing accessibility to preventiveand restorative treatments. Some of the strategies forcaries lesion management have been presented below.Selection of an appropriate strategy should beginwith a careful and precise diagnosis at the lesionlevel. Inactive lesions are typically characterizedby the presence of shiny whitish/brownish areasof discoloration on non-cavitated lesions as wellas of shiny, smooth, hard on gently probing, anddiscolored brownish in cavitated lesions reachingdentin. These lesions typically do not require anyintervention other than monitoring as they are diseasescars, although restorations can be placed in cavitatedlesions in order to protect the pulp-dentin complexor restore the tooth’s function, form, and esthetics.13Conversely, opaque, rough and whitish tissueon non-cavitated lesions and the presence of soft orleathery (to gently probing) humid and yellowish/light-brownish tissue in cavitated lesion reachingdentin are clinical signs of active lesions that need tobe controlled. Clinicians must be trained to identifyearly signs of active demineralization which willenable them to intervene in a timely manner using noninvasive and micro-invasive strategies. For cavitatedlesions, it is essential to first take into considerationwhether the cavity can be cleaned or not as it willhelp with the decision-making process and selectionof the best treatment strategy. Non-invasive strategiesare sufficient for the management of cavities thatcan be cleaned, while those that cannot be cleanedmay require a combination of non-invasive, microinvasive, or minimally invasive strategies coupled withrestorations. This decision-making process should bebiologically informed, evidence-based, and shouldtake the needs of the patient into consideration.Management of non-cavitated lesions—Non-invasive/micro-invasive strategiesThe primary prevention of dental caries typicallyinvolves inhibition of lesion initiation as indicatedby the recent consensus on the term dental cariescare/management/control as “all actions taken tointerfere with mineral loss at all stages of the diseaseprocess” This includes primary, secondary, andtertiary preventive measures that incorporate bothnon-operative and operative treatments.1Disease triggering factors must be controlled inorder to prevent formation of caries lesions and arrestprogression of existing ones. Therefore, preventivestrategies should take biological, behavioral,psychosocial, and environmental factors intoconsideration in order to avoid negatively affectingthe oral environment.14 Oral hygiene measures, dietarycounseling, and other non-invasive strategies (such asthe application of fluoride and chlorhexidine varnishesand the use of xylitol lozenges) have been shown to beeffective in controlling active non-cavitated lesions inchildren.15 Some of these strategies will be reviewedin the subsequent section to highlight the need forsimultaneous management of the disease and lesion.Various experimental and clinical studies havedemonstrated that caries lesions originate in the enamelor exposed root dentine beneath accumulated andstagnated dental biofilms. The dental caries processinitiation and progression depend on the metabolicactivity of the dental biofilm which, in turn, is enhancedby frequent intake of dietary sugars. Therefore, regularand meticulous mechanical removal of the dentalbiofilm aids in arresting lesion progression.16However, previous studies have shown that personaloral hygiene protocols (by means of supervisedtooth-brushing) lacking fluoride administration,either via dentifrices or community-based methods,were effective in controlling gingivitis but failed toprevent coronal caries in children aged 10-13 yearsold.17 This reinforces the importance of fluoridatedproducts (e.g. dentifrices) and/or community-basedmethods for fluoride delivery in lesion control.The selection of appropriate strategies for theprevention of lesion formation and inhibition ofdisease progression can be challenging for the dentalprofessional, and the decision-making process shouldbe based on scientific evidence focusing on whenand how to implement the strategy while taking theneeds of the patient and the availability of financialand technical resources, especially in public healthsystems, into consideration. Selection of multipleBraz. Oral Res. 2021;35:e0553

Management of dental caries lesions in Latin American and Caribbean countriesstrategies may be necessary, and the risk of cariesexhibited by the patient may even be considered onthe decision-making process.18The recent global decrease in the prevalence ofdental caries can be attributed to the widespread useof fluoride-containing dentifrices,19,20 with numerousclinical studies showing that mechanical removalof the dental biofilm by daily tooth-brushing usingfluoridated dentifrices in concentrations of 1,000–1,500 ppm F significantly contributed to controllingenamel, dentin, and/or root caries lesions. 20-23Moreover, tooth-brushing twice a day using fluoridedentifrices at concentrations of 5000 ppm F wasshown to be more effective in arresting root caries inthe elderly population compared to dentifrices withconcentrations of 1,000–1,500 ppm F.23,24 Professionaldental biofilm management should be also consideredas a treatment option for dental caries.In addition to dentifrices, a wide range of topicalfluoride-based agents are available for individual use,25including high-concentration fluoride products (suchas acidulated phosphate gels, varnishes and solutions)which allow deposition of greater amounts of calciumfluoride globules onto the tooth surface formingfluoride reservoirs in the oral cavity. Progression ofnon-cavitated caries lesion in primary and permanentteeth can be significantly controlled by 5% NaFvarnishes,26 while 38% silver diamine fluoride (SDF)represent a more effective strategy for the controlof cavitated caries lesions reaching dentine whencompared to other active treatments (e.g. atraumaticrestorative treatment (ART) restorations or NaFvarnish).27 SDF has also been shown to be effectivein inactivating root caries lesions.24,28,29A m o n g n o n -f luo r id at e d ag e nt s, c a s e i nphosphopeptide-amorphous calcium phosphate(CPP-ACP) is a bioactive agent that has been shownto be effective in re-mineralizing tooth structures invitro and in vivo. A recent meta-analysis suggestedthat CPP-ACP, conventional fluoride toothpastes, andfluoride varnishes had similar efficacy with regard tocontrolling lesion development, and clinical parameterssuch as enamel micro-hardness, DMFS/dmfs (decayed,missing, filled surfaces) index scores, and EnamelDecalcification Index scores did not differ significantlybetween CPP-ACP and fluoride products.30 Moreover, a4Braz. Oral Res. 2021;35:e055combination of CPP-ACP and fluoride varnish wasshown to have superior anti-caries effect, particularlyin enamel lesions on young permanent teeth, as CPPACP could carry fluoride ions deeper into the lesions,enhancing re-mineralization. Nevertheless, there isinsufficient evidence on whether CPP-ACP agentsare more effective in controlling caries lesions whencompared to fluorides, and high quality, well-designedrandomized controlled trials are necessary.30The cariostatic effects of non-fluoridated chemicalagents such as arginine, chlorhexidine, triclosan, andxylitol have been evaluated in vivo and comparedwith conventional fluoride in several randomizedcontrolled trials. A recent systematic review comparedthe efficacy of non-fluoridated agents and fluoridein controlling caries in primary teeth and found noevidence of the former being superior. However, thiscould be attributed to a high risk of bias in most studiesreviewed,31 and well-designed randomized controlledtrials are necessary in order to make conclusiverecommendations. Chlorhexidine varnish was foundto be more effective in controlling root caries lesionscompared to placebos, and the results were consistent.32An in vitro study examined the use of theobromine(3,7-dimethylxanthine), a primary alkaloid derivedfrom the cacao plant commonly found in LACCs, as are-mineralizing component of dentifrices and foundit to be less effective than those containing fluoride.33The use of nanotechnology to enhance the anticaries effects of dentifrices, varnishes, surface coatingagents, and fluoride-releasing materials have also shownpromising results, with the use of oral medicine nanosystems for individual prophylaxis showing significantprogress with regard to ensuring bacterial symbiosisand maintaining good oral health. Nano-particles havealso been integrated into various cosmetic productstargeting enamel re-mineralization, thus creatingopportunities for new research into the developmentof enhanced delivery systems that serve as carriersfor minerals and/or biomaterials. Their clinical use forcontrol of caries lesions remains under evaluation.34Current evidence also recommends the use of pitand fissure sealants as a micro-invasive strategy forthe prevention and control of caries lesions.24 Resinbased fissure sealants act as a physical barrier betweenthe tooth surface and the stagnated dental biofilm and

Pozos-Guillén A, Molina G, Soviero V, Arthur RA, Chavarria-Bolaños D, Acevedo AMsuccessfully reduce the onset and progression of occlusalcaries lesions, particularly in permanent molars.35This evaluation is largely based on evidence that showsthat sealing a lesion reduces the bioavailability ofnutrients to microbial growth, thus preventing diseaseprogression up to 70% in non-cavitated occlusal lesionswhen compared to no sealing.35,36 Moreover, sealants aremore effective in arresting active non-cavitated occlusallesions when compared to fluoride varnishes, althoughthere is still no clear evidence on the best sealant (resinbased or glass ionomer).37 However, the questionableintegrity and stability of sealants placed on occlusallesions that appear non-cavitated clinically but extendinto the middle or inner dentine radiographically shouldbe taken into consideration, and a minimally invasiverestorative strategy (as described below) should beadopted in such cases.13In contrast to sealants, resin infiltration acts as abarrier not on the tooth surface but within the carieslesion. Filling the enamel lesion, the resin can occludethe porosities, thus preventing the lesion progressionby avoiding the penetration of the acids originatedin the dental biofilm located on the external toothsurface. Previous studies have shown that resininfiltration is more effective in controlling non-cavitatedproximal caries when compared to other non-invasiveapproaches, both in primary and permanent teeth.38,39Management of cavitated dentine lesionsAs mentioned above, the decision-makingprocess for the management of active cavitatedlesions is dependent on whether the cavity can becleaned (where mechanical biofilm removal canbe carried out at home by tooth-brushing) or not.The former can be managed non-invasively, and itis assumed that the disease process is halted andlesion progression is arrested upon adequate removalof the biofilm. Accessibility for adequate cleaningcan be increased by slightly widening the cavitymargins to remove overhanging enamel/dentine.40However, patient motivation is crucial in this case, andregular monitoring for proper mechanical removalof biofilm is essential. This is particularly applicablein the case of primary dentition where the child’soral hygiene is the responsibility of their parents orcaretakers who must also be adequately informed andmotivated. Periodic clinical examination is necessaryfor assessment of lesion activity, and treatment successis achieved once the remaining tissues become hardindicating halting of lesion progression. The use of38% SDF solution (applied biannually) as an adjunctto mechanical biofilm removal may be recommendedfor the management of coronal cavitated carieslesions in primary25 and permanent dentition.3 Notall cleaned cavities require restorations, and thismethod is usually preferred when there is a need toprotect the pulp-dentin complex or restore the tooth’sfunction, form, and esthetics.13In contrast, active cavitated lesions that cannot becleaned, such as those on proximal or other poorlyaccessible surfaces, are understood to be prone toprogression and, therefore, may require restorativeprocedures facilitating dental biofilm control. Cavitieson proximal surfaces or in any other surfaces where thebiofilm cannot be properly removed should be assessedby visual-tactile methods (with the aid of tooth separatorsin the case of proximal surfaces) and/or by bitewingradiographs to assess depth. Proximal cavitation onlesions restricted to the enamel only are unlikely, whilelesions extending to the enamel-dentin junction or to theouter third of the dentin may or may not be cavitatedand those extending into the middle or inner third ofthe dentin are likely to be cavitated. Non-cavitatedlesions should be managed using non-invasive or microinvasive interventions as described in the previoussection, while cavitated lesions that are difficult to cleanshould be managed as described below.13Cavitation indicates severe contamination of thedentin with cariogenic microorganisms, althougharresting lesion progression is possible throughadequate sealing that stopped further microbialgrowth.41 Therefore, removal of all caries tissuesin order to reach a hard and virtually cleaned anddisinfected remaining dentin (non-selective removalof caries tissue up to hard dentin or NSRHD) isno longer promoted, and several strategies for themanagement of non-cleanable cavitated lesions withdentinal involvement have been presented below.However, it is important to highlight that these areapplicable only in case of absence of spontaneouspain, signs of pulpal exposure or irreversible pulpitis,or radiographic evidence of periapical lesions.Braz. Oral Res. 2021;35:e0555

Management of dental caries lesions in Latin American and Caribbean countriesCavitated lesions with dentinal involvement can bemanaged without prior removal of caries tissue tissues.The Hall technique, which involves placement of a preformed metal crown on decayed cavities without toothpreparation (as a mixed non-invasive and restorativetreatment) and anesthesia, has been shown to havehigh success rates in occlusal and occluso-proximallesions arrestment in primary molars,42-44 particularlywhen compared to conventional restorative treatmentsover 2–5 years of follow-up.43Upon comparing direct placement of resin sealantsor flowable resin composites without prior removalof caries tissues (as a mixed micro-invasive andrestorative treatment) to conventional compositerestorations placed after selective removal to firm/leathery dentine, the two were seen to exhibit similarefficacy with regard to controlling lesion progressionin occlusal cavities of primary molars radiographicallyshown to extend to the outer half of the dentine after18 months and 2 years of follow-up.45,46Additionally, placement of resin sealants withoutprior caries tissue removal and conventional resincomposite restorations (conducted after removal ofall c

Keywords: Dental Caries; Evidence-Based Dentistry; Latin America; Caribbean Region. Introduction The lack of consensus on dental caries management was recently recognized during a discussion between various expert authors from the Latin American and Caribbean countries (LACC), and the aim of this