Step 2: Develop Personalized Non-Operative Strategies for Caries Management

One of the foundational steps in non-operative caries management is reinforcing effective oral hygiene practices. Dental professionals should emphasize brushing with fluoride toothpaste twice daily and performing interdental cleaning, such as flossing or using interdental brushes. These practices are critical for disrupting plaque biofilm and reducing cariogenic bacterial activity, especially in high-risk individuals.^4,25

More importantly, involving the patient in understanding their disease can improve adherence. Visually showing the patient their lesions - either through radiographs or intraoral inspection with a mirror - can enhance motivation and accountability. Studies have shown that when patients can see the disease, they are more likely to engage in preventive behavior and follow oral hygiene recommendations.⁵

Instructing the patient to focus first on cleaning the affected areas before brushing the rest of the mouth can help ensure more thorough plaque removal at the site of disease activity. Tailored suggestions may include modifying the angle of brushing, switching to a toothbrush with a smaller or tapered head, or replacing dental floss with an interdental cleaner with a handle for improved access, particularly in posterior regions where carious lesions may be more difficult to reach.^1,4

Use of Fluoride: All patients should be advised to brush with fluoride-containing over-the-counter toothpaste at least twice per day. Fluoride toothpastes available in the United States are regulated by the U.S. Food and Drug Administration (FDA) and must contain clinically proven fluoride concentrations. Most over-the-counter formulations provide between 850 and 1150 parts per million (ppm) as sodium fluoride or sodium monofluorophosphate. This method is cost-effective, simple to implement, and widely accessible. Systematic reviews have demonstrated that regular use of fluoridated toothpaste results in a 24% average reduction in caries incidence in permanent teeth.^26,27

Fluoridated toothpaste can also be used topically and therapeutically. For patients with early-stage active lesions, a small amount of toothpaste can be applied directly to the cleaned lesion with a toothbrush or fingertip before bedtime. This enhances fluoride availability at a time when salivary flow is lowest, improving remineralization potential. In patients with caries activity who struggle with thorough brushing, a 0.05% sodium fluoride (NaF) mouthrinse once daily, or a 0.02% NaF mouthrinse twice daily, can be recommended. Clinical studies show fluoride mouthrinses reduce DMFS (Decayed, Missing, and Filled Surfaces) by approximately 27% compared to placebo or no rinse.²⁸

For individuals with high caries activity, higher-concentration fluoride products may be required. These include prescription-strength fluoride dentifrices containing 5000 ppm fluoride, gels, or tablets for daily use. Professional fluoride varnish application by a dental provider following plaque removal has also been shown to reduce caries in permanent teeth by an average of 43%.^26,29

In patients with porcelain or composite restorations, acidulated phosphate fluoride (APF) should be avoided due to its potential to etch and degrade restorative surfaces. In these cases, neutral sodium fluoride formulations are preferred for both in-office and at-home use.

Diet Modification: Diet modification should be considered an essential component of caries prevention, even in patients who do not currently present with active lesions. The dental professional should review the patient's caries risk factors and explain how dietary changes, particularly increased frequency or quantity of sugar intake can elevate risk. Life events such as pregnancy, job loss, divorce, retirement, or bereavement often lead to shifts in eating habits, including more frequent snacking or reliance on processed foods. These transitions may go unnoticed but can contribute to a shift from low to moderate or high caries risk. Simple, open-ended questions during recall visits can help identify these changes early and support timely preventive guidance.^30,31 Asking about lifestyle or health changes allows the dental provider to reinforce the importance of limiting fermentable carbohydrates and maintaining consistent oral hygiene and fluoride use, even during periods of stress or disruption.

For patients presenting with active carious lesions, dietary analysis is a critical step in identifying potential contributors to disease progression. A 24-hour dietary recall or a 3-day food log (including at least one weekend day) is typically used to capture what the patient has consumed, including foods, drinks, and medications. This information reveals patterns such as frequent snacking and prolonged exposure to fermentable carbohydrates. Based on this data, dental professionals can collaborate with the patient to develop practical, realistic strategies—such as limiting sugary foods to meal times, choosing water over sugar-sweetened drinks, and encouraging sugar-free alternatives.^19,30

Recent evidence supports the effectiveness of behavioral counseling methods: for instance, home-delivered bottled water combined with caregiver dietary guidance significantly decreased children’s sugary drink intake.³² Additionally, specific dietary screening questions, such as those addressing meal patterns and drink habits have been strongly associated with caries and useful in improving risk assessments.³³ However, it's important to recognize that dietary data is self-reported and susceptible to recall bias; therefore, it should be interpreted alongside clinical findings and risk indicators to create a comprehensive caries management plan.^30,31

Recalling the Patient: Recalls appointments should be tailored to each patient’s individual risk level. For individuals without active caries and with good oral hygiene, one to two visits per year are generally sufficient. However, high-risk patients, such as those who struggle with plaque control or have reduced salivary flow due to medication, medical conditions, or lifestyle habits, require more frequent care.

Initially, high-risk individuals should return every 2 to 3 weeks until plaque control is achieved. Once stabilized, ongoing recalls of 2 to 3 months are recommended for those with xerostomia or persistent plaque issues. Patients without dry mouth and with controlled caries may shift to recalls every 6 to 12 months. During recall visits, the provider should assess plaque control, monitor lesion activity or progression, update radiographs as necessary, and reinforce oral hygiene and dietary advice. Application of sealants or re-assessment of non-operative strategies may also be appropriate.³⁴

A randomized international trial found that risk-based protocols lead to better resource allocation and more targeted care, recommending intervals from 3 to 24 months based on risk indicators and age.³⁵ The CAMBRA model also advises bitewing radiographs every 6-18 months for high-risk, and every 18-24 months for moderate-risk adults, reinforcing the need for personalized recalls.³⁶