Proximal caries: seal or infiltrate early lesions?

shutterstock_34500700 - caries sign

Dental caries is the world’s most prevalent disease and early proximal carious lesions as very common. Non-invasive (NI) strategies to manage these lesions include, diet and bio-film management often combined with topical fluorides. Recently micro-invasive strategies of sealing and lesion infiltration have been used for proximal lesions.

The aim of the review was to assess the effectiveness of micro-invasive treatments of proximal carious lesions.


Searches were conducted in the Medline, Embase and Cochrane Central databases. Randomised controlled trials (parallel or split mouth) comparing micro-invasive strategies against each other, against non-invasive treatment or placebo were considered.

Two reviewers independently selected studies extracted data and assessed risk of bias using the Cochrane domain-based tool. The primary outcome was radiographically lesion progression radiographically analysed using odds ratios.  Pairwise and Bayesian network meta-analyses and a trial sequential analysis (TSA) was carried out.  The overall evidence was assess using GRADE.


  • 13 studies reported in 15 papers were included.
  • The studies were split-mouth involving 468 patients and 1748 lesions in total.
  • The average follow-up period was 25 months (range 12-36months).
  • Based on pairwise meta- and trial-sequential analysis,
  • There was firm evidence on the superior efficacy of sealing/infiltration over NI; OR=0.25 (95%CI; 0.18–0.32).
    • Sealing was superior to NI. OR=0.29 (95%CI; 0.18–0.46) as was infiltration OR=0.22(95%CI; 0.15–0.33).
    • There was no significant difference between infiltration versus sealing. OR= 0.70 (95%CI; 0.34–1.47)
  • Based on the findings,
    • Sealing or infiltration instead of NI would avoid 278 (95% CI: 235–318) per 1000 treated lesions progressing (44% NI and 16% sealed or infiltrated lesions would progress) [Moderate evidence].
    • Sealing instead of NI would avoid 282 (95% CI: 188–358) per 1000 treated lesions to progress [Moderate evidence].
    • Infiltration instead of NI would avoid 266 (95% CI: 216–303) per 1000 treated lesions to progress. The certainty of the evidence underlying this comparison was graded as high.
  • Funnel plot inspection did not indicate publication bias in any of the comparisons.


The authors concluded: –

There is robust evidence that micro-invasive treatment (sealing and infiltration) is more efficacious than non-invasive treatment (NI) for arresting proximal carious lesions. Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing or infiltration should be guided by practical concerns beyond efficacy.


As the authors note the 2015 Cochrane review by Dorri et al (Dental Elf- 9th Nov 2015) found evidence to show that micro-invasive treatments were more effective than NI treatment. The Cochrane review included 8 trials. This new well conducted review now increases the number of studies included to 13 while the network meta-analysis enables a comparison of the two micro-invasive techniques.  The overall odds of reduction of lesion progression was seen to be similar in both the Cochrane review and this new review; OR 0.24, (95% CI 0.14 to 0.41) compared with OR=0.25 (95%CI; 0.18–0.32).

This new review finds that both micro-invasive approaches had similar reductions in lesion progression. However, as the authors point out the follow up period is on average only 2 years and almost all of the studies were conducted in a University setting.  Additional data from studies with longer follow up intervals as well as more practice based /primary care settings would be helpful.


Primary Paper

Krois J, Göstemeyer G, Reda S, Schwendicke F. Sealing or infiltrating proximal carious lesions. J Dent. 2018 Jul;74:15-22. doi: 10.1016/j.jdent.2018.04.026. Epub 2018 Apr 30. Review. Erratum in: J Dent. 2018 Sep;76:137-138. PubMed PMID:29723548.

Original review protocol on PROSPERO

Other references

Dental Elf- 9th Nov 2015

Micro-invasive treatments can slow caries progression




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