Each time a patient returns with a new carious lesion, even after topical fluoride application and oral hygiene instructions, it tells us that a one-step prevention approach is not enough.
Early caries involves more than a lack of minerals. It is about microbial imbalance, changes in salivary physiology, behavioral aspects, and structural changes. To manage early lesions before they become a restorative issue, a protocol must address the biological aspects one by one.
Dr. Ekta Pandya.
That is why I use a multimodal protocol consisting of in-office application of povidone-iodine, regeneration with self-assembling peptide P11-4, silver diamine fluoride application, fluoride varnish application, and nightly home use of CPP-ACP (casein phosphopeptide-amorphous calcium phosphate).
The objective is simple: arrest or reverse early lesions before picking up the drill.
Every step prepares the way for the next. The biological approach to caries management is sequential, and so, too, must be the protocol.
In-office approach: Recall appointment
Prophylaxis
Start by removing plaque, calculus, and biofilm. This step sounds basic, but it determines whether the rest of the protocol can work.
Both povidone-iodine and self-assembling peptide therapies require clean tooth surfaces to perform predictably. Residual plaque can reduce antimicrobial contact and limit penetration into early enamel lesions.
10% povidone-iodine, full mouth
Apply eight to 10 drops of 10% povidone-iodine to all teeth using a cotton-tip applicator. Allow 30 to 60 seconds of contact time. Ask the patient to expectorate, but do not rinse.
This antimicrobial step helps reduce the cariogenic bacterial load before remineralization therapy. In my experience, this is especially useful for patients with recurrent white spot lesions, high plaque levels, orthodontic history, xerostomia, frequent carbohydrate exposure, or repeated new lesions at recall.
Screen for iodine allergies, thyroid conditions, and any medical history that contraindicates the use of iodine.
Self-assembling peptide P11-4
For non-cavitated enamel lesions, particularly E1/E2 lesions and white spots, use self-assembling peptide P11-4. Skip this step if there are no active lesions.
Follow the manufacturer’s instructions to prepare the lesion. A general procedure would be:
- Clean and isolate the lesion.
- Etch using 35% phosphoric acid for 20 seconds.
- Rinse the etched area and air-dry it.
- Apply Curodont Repair Fluoride Plus.
- Allow five minutes of undisturbed contact.
This peptide acts as a scaffold for the biomimetic formation of hydroxyapatite inside the lesion body. That is how this strategy differs from others that try to remineralize only the enamel surface. It is not just the hardening of the outer surface.
5% sodium fluoride varnish
Once the peptide exposure period is completed, 5% sodium fluoride varnish should be applied to the treatment site and the entire dentition.
The final step of the in-office procedure entails the application of fluoride varnish, which ensures a surface fluoride reservoir while the peptide scaffold facilitates subsurface remineralization.
Post-treatment instructions are quite straightforward: avoid consuming food or drinks for 30 minutes, and do not brush your teeth until morning.
Home routine
Nightly
After brushing and flossing, the patient should apply MI Paste/Recaldent or another CPP-ACP agent as required. It can be applied with a finger, toothbrush, or delivered via a custom-fabricated tray.
Guidelines
- Apply after the oral hygiene routine.
- Keep on overnight.
- Do not rinse afterward.
- Do not consume food or drinks following application.
CPP-ACP continuously provides available calcium and phosphate, creating a remineralizing environment.
An additional nonstaining antimicrobial mouthwash could be considered when the patient presents with xerostomia symptoms or requires a longer recall period. The application of nano silver fluoride is being investigated as an alternative to silver diamine fluoride (SDF) for its lower risk of staining.
Monthly home application
In addition, I advise patients to use a monthly home application of 10% povidone-iodine using a cotton-tip applicator. The patient applies this treatment to all surfaces, using one applicator per quadrant, leaves it for 60 seconds, and then expectorates without rinsing. This procedure is done immediately before CPP-ACP application.
Protocol modification for aging dentition: Root caries and crown margins
Aging dentitions need a different approach, since root dentin is more susceptible than enamel. Xerostomia caused by medications, decreased saliva production, or mouth breathing can turn the oral cavity into an environment prone to root caries activity.
Crowns, bridges, and large fillings are yet another complicating factor. Each restoration margin can serve as a site for plaque accumulation and secondary caries formation.
For such patients, 38% SDF usually acts as a key treatment modality. In situations where arresting active root caries, hardening affected dentin, or protecting crown/restoration margins is the priority and staining is acceptable, I use SDF on such areas.
The aesthetic considerations need to be weighed before proceeding with treatment. SDF is indicated for posterior root carious lesions, cavitated carious lesions, risk factors for recurrent caries, and restoration margins where discoloration would not hinder the patient’s acceptance.
SAP P11-4 is still relevant in the management of non-cavitated carious lesions in aesthetic areas or in cases where staining is unacceptable. The two treatments are not alternatives but complement one another. The use of SDF is indicated for lesion arrest and hardening, while SAP P11-4 is more suitable for non-cavitated enamel lesions.
Clinical application
In treating high-risk caries cases, we should avoid depending only on one product. The objective is to control the disease process through a combination of strategies: biofilm elimination, inhibition of pathogenic bacteria, regeneration of the initial lesion, if possible, reinforcement of the tooth surface with fluoride, and maintaining remineralization at home.
In cases of white-spot enamel lesions, it is important to act sequentially: cleaning, disinfection, regeneration, sealing, and maintenance.
For patients with root caries or compromised crown margins, it is important to act strategically: Arrest first and rebuild later, if necessary.
Dr. Ekta Pandya is a New York-based dentist and clinic associate at the New York University College of Dentistry, where she is actively involved in the full-mouth rehabilitation program. She works closely with clinicians to develop advanced skills in comprehensive treatment planning, occlusion, and interdisciplinary care. Pandya focuses on translating complex concepts into practical, real-world applications, empowering dentists to deliver predictable, patient-centered outcomes in restorative dentistry.
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