ABSTRACT The COVID-19 pandemic resulted in severe limitation and closure of dental practices in many countries. Outside of the acute (peak) phases of the disease, dentistry has begun to be

practised again. However, there is emerging evidence that SARS-CoV-2 can be transmitted via airborne routes, carrying implications for dental procedures that produce aerosol. At the time of

writing, additional precautions are required when a procedure considered to generate aerosol is undertaken. This paper aims to present evidence-based treatments that remove or reduce the

generation of aerosols during the management of carious lesions. It maps aerosol generating procedures (AGPs), where possible, to alternative non-AGPs or low AGPs. This risk reduction

SARS-CoV-2 may be transmitted via airborne routes has implications for practising dental procedures that generate aerosols. * There are evidence-based treatments including use of

high-viscosity glass-ionomer sealants, atraumatic restorative treatment, silver diamine fluoride, the Hall Technique and resin infiltration, which remove or reduce aerosol generation during

the management of carious lesions. * This risk reduction approach for aerosol generation may guide practitioners to overcome the less favourable outcomes associated with temporary solutions

or extraction-only approaches in caries management. SIMILAR CONTENT BEING VIEWED BY OTHERS DENTAL PERIODONTAL PROCEDURES: A SYSTEMATIC REVIEW OF CONTAMINATION (SPLATTER, DROPLETS AND

AEROSOL) IN RELATION TO COVID-19 Article Open access 24 March 2021 THE COVID-19 PANDEMIC AND DENTISTRY: THE CLINICAL, LEGAL AND ECONOMIC CONSEQUENCES - PART 2: CONSEQUENCES OF WITHHOLDING

DENTAL CARE Article 18 December 2020 CAN ORTHODONTIC CARE BE SAFELY DELIVERED DURING THE COVID-19 PANDEMIC? RECOMMENDATIONS FROM A LITERATURE REVIEW Article 26 June 2020 BACKGROUND The novel

coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has precipitated the COVID-19 pandemic. The World Health Organisation (WHO)1 has recommended a society-wide

quarantine approach (during acute or peak phases of the disease), social distancing and handwashing followed by contact tracing. Alongside this, most countries have suspended elective and

non-urgent dental care,2,3 closing many practices with only emergency treatment provision.4,5,6 This acute phase of the pandemic is subsiding, although further acute phases are being seen in

different countries. There is increasing dental need across populations and dental practices are suffering financially, so practices are opening and commencing care. However, the WHO has

taken a cautious and risk assessment approach and recommended that situations where aerosol generating procedures (AGPs) are carried out should be reduced to a minimum, with additional

precautions in place. It is still controversial but there is growing concern over possible airborne transmission of SARS-CoV-2.4,5,6,7 Although there has been much written about possible

spread of COVID-19 through aerosols generated in the dental surgery, reviews of the evidence show there is little directly relating to respiratory viruses, despite over 70 years of research

into bio-aerosols in dental settings.8,9,10,11 Studies of microbial content of aerosols and splatter generated during dental procedures have mostly involved aerobic

bacteria.9,10,11,12,13,14,15 Viral studies are sparse, focusing on blood-borne HIV and hepatitis B.8,16 This limits confidence in the assumptions around transmission of SARS-CoV-2 during

dental treatment. Although there seems to be little supporting evidence for mass transmission of respiratory pathogens through provision of dental care in the past, evidence is still

emerging around transmission of this novel virus, where there is no innate immunity in the global population. In general, management of dental caries has traditionally involved using

instruments that have potential to generate bio-aerosols containing saliva, blood and tooth debris; the high-speed air rotor,17,18,19,20,21 slow-speed handpiece22,23,24 and use of the

air-water syringe to complete steps for most dental materials.16,17,25,26 Until uncertainty around the level of risk associated with SARS-CoV-2 transmission between dental staff and patients

is resolved or an acceptable level of risk is agreed, and because many aspects of dental treatment generate aerosols, a precautionary position is to keep aerosol generation as low as

possible. AIM This paper presents evidence-based management for dental caries that removes or reduces the generation of aerosols and aids personalised care planning based around AGP

reduction. CARIES MANAGEMENT STRATEGIES WITH REDUCED AEROSOL GENERATION Although they are changing frequently, in response to evidence, we have set this paper against a background of local,

national and international standards and recommendations. These include use of patient flow and environment cleaning processes, and standard and enhanced PPE use, as well as other measures

put in place to practice safely practice while COVID-19 is still a health threat. Dental professionals are familiar with infection control strategies, but after an outbreak of a highly

infective, potentially airborne-transmitted virus, extra protective measures have to be adopted. In this time of emerging evidence resulting in constant change, these measures should

continue to be in line with national and local regulations, with vigilance to changes and by reference to Public Health England. The paper will consider the alignment of traditional AGPs for

caries management with 'non-AGPs' and 'low AGPs' (see Tables 1 and 2). Non-AGPs are those that generally do not include steps that generate aerosols, such as the use of

rotary instruments and air-water syringes where air and water are used together in a spray, or procedures that can be modified to be carried out in a way that does not generate aerosols and

compromise the quality of the procedure. Low AGPs are those that also contain steps that might generate a lower amount of aerosol, such as the air-water syringe where the air and water are

used independently of one another. Non-AGPs still have potential for salivary contamination and low AGPs may need the air-water syringe in some instances. However, there is less aerosol

produced if the water is used to wash without combining it with air to give a spray.16,26 Use of rubber dam with sealing around tooth holes and high-volume evacuation help minimise risk.

Because of the possibility of viral load in the blood of COVID-19-positive patients, it is preferable to avoid pulpal exposures. The non-invasive and minimally invasive procedures, such as

selectively removing carious tissues during atraumatic restorative treatment (ART) and the Hall Technique (HT), are discussed below and make pulp exposures less likely. However, if a pulp

exposure did look likely during caries removal, an indirect pulp cap should be considered. The procedures discussed here are based around minimal intervention dentistry approaches, aiming to

maintain the dentition throughout the course of life by handling the disease, dental caries, in a biological manner; treating the cause and not just its symptoms (the carious lesions).27

The non-AGPs and low AGPs for managing carious lesions can be grouped into: * 1. Control the disease - prevention, early detection and managing the carious lesion (whether confined to enamel

or cavitated) through controlling the biofilm, by making the lesion cleansable with non-restorative cavity control (NRCC) or by removing the plaque and using chemicals to stop its progress

and promote remineralisation (commonly silver diamine fluoride [SDF]; topical fluoride) * 2. Cover and seal the biofilm and carious lesion - involves no caries removal and creates a seal to

deprive the carious biofilm of nutrients, oxygen etc, causing the carious lesion to arrest, such as fissure sealing and resin infiltration for non-cavitated lesions and the HT * 3. Carious

tissue removal - only decomposed, infected dentine and unsupported demineralised enamel should be removed selectively using hand instruments (eg ART and/or chemo-mechanical caries removal

[CMCR]). The online supplementary information file details further sources and some video tutorials of these techniques. METHODS TO CONTROL CARIOUS LESIONS PREVENTION Primary preventive

approaches (also known as non-invasive strategies for the management of caries) can reduce the risk of progressive dental tissue loss and avoid the need for treatments using rotary

instruments. The main preventive approaches have to be through the community and home, with behavioural components such as sugar restriction, plaque removal and oral health education.

Clinicians hold a pivotal role in supporting oral health behaviours. For remineralisation, fluoride-based agents are accepted as the primary medicament. Although there is less supporting

evidence, other remineralisation agents such as self-assembling peptide P11-428 might be considered. Preventive sealants cover plaque-retentive areas, occlusal fissures and pits, which are

most vulnerable to caries.29,30 However, resin-based sealants involve a washing step to remove the acid etch thoroughly, generating some aerosol. Nevertheless, this risk can be avoided by

using low-viscosity or high-viscosity glass-ionomer cement (LVGICS/HVGIC) and excess material can be removed with hand instruments. A Cochrane review found no difference in the preventive

effect of resin, LVGIC or HVGIC sealants.30 EARLY DETECTION The purpose of treating dental caries is primarily to stop its progression within the tooth as well as restoring the lost dental

hard tissues when needed. Early detection of carious lesions will reduce the need for aerosol-producing restorative care required for advanced lesions. In addition, patients with active

dental caries need to have their disease risks addressed as part of the long-term disease management.31,32 NON-RESTORATIVE CAVITY CONTROL FOR DENTINAL LESIONS WHAT IT IS AND WHEN TO USE IT

NRCC is a method of using 'cleaning' to prevent biofilm maturation and carious lesions progression. It can be used for dentinal carious lesions in the primary and permanent

dentition, root carious lesions and cavitated coronal smooth surface lesions. HOW IT WORKS AND CLINICAL EFFECTIVENESS By making the carious surface accessible and having plaque frequently

and thoroughly removed, the carious process will arrest. In primary teeth, the effectiveness of NRCC in medium and large cavities together with ART restorations in small cavities has been

tested in comparison to amalgam and ART restorations.33 Tooth survival after 3.5 years was 89% and not significantly different from either amalgam (91%) or ART restorations (90%), and in a

randomised control trial of occluso-proximal cavitated lesions, survival (of pulp and tooth) was 92% at 2.5 years compared to 98% for teeth treated with the HT.34 NRCC has a less robust

evidence base than the other treatment options discussed in this paper, with most of the reports of success being related to particular situations and carried out by dentists who support

this technique. The choice to use NRCC is less dependent on the shape or type of lesion than it is on the attitude of the patient towards prevention and the skill of the dentist in behaviour

change.35 NON-AGP USE NRCC consists of three concurrent stages: * 1. Working with the patient to make plaque control more successful (improving oral hygiene procedure/habits). The patient

has to be ready to change behaviours that led to development of the disease in the first place. Success depends on the clinician's ability to change the patient's (or in the case

of a child, the parent's) behaviour towards taking responsibility. So, 'prevention' becomes very much more than simply providing instruction of what to do (knowledge) and how

to do it (skills), but has to involve an aspect of refocusing the patient to feeling empowered to make a difference to their own oral health (attitude). Daily removal or disruption of the

biofilm by brushing with a fluoridated toothpaste will slow down the carious process and can even halt it * 2. Creating a cavity shape where the carious biofilm/dentine is accessible to a

toothbrush (lesion exposure). In some cases, overhanging enamel has to be removed. To avoid use of rotary instruments, hand instruments can be used to gain access to the lesion (see ART) *

3. Treatment with 38% SDF and/or a 5% NaF varnish therapy to reduce carious activity and promote remineralisation.33 These additional measures can support success of the NRCC approach if the

carious lesion is active or there is increased risk that carious lesion activity will recur. In the primary dentition, the goal is to avoid the lesion causing pain and/or infection until

the tooth exfoliates. For the permanent dentition, with grossly broken down teeth, root carious lesions or coronal smooth surface lesions, the main goal is to avoid the lesions leading to

pain and/or infection while also avoiding or delaying the need for restoration. SDF FOR DENTINE LESIONS WHAT IT IS AND WHEN TO USE IT SDF is a clear, colourless liquid that arrests active

cavitated carious lesions and remineralises demineralised enamel and dentine.36 Some products have a blue tint, but these are not available in the UK. Although licensed to treat dentine

sensitivity in the UK and some other countries, it is more usually used 'off-label' to arrest carious lesions. It turns active carious lesions black; therefore, consent to

treatment must be obtained and it must be handled with care as it will temporarily stain skin, mucosa and most surfaces on contact. SDF is an effective way of treating active lesions for

primary and permanent teeth (coronal dentine and root).37,38 It can be used opportunistically while the patient is in the dental chair by applying to other high-risk surfaces. SDF is

effective in arresting early childhood caries39 and exposed root surfaces.40 It is more successful when used in cleansable lesions and accessible areas of the mouth.41 When caries is more

severe or affects multiple teeth, repeated applications of SDF controls the disease (for example, applied after two weeks and six weeks, then six months as required).42 HOW IT WORKS AND

CLINICAL EFFECTIVENESS SDF penetrates infected dentine,43 making the lesion twice as hard as healthy dentine.44 It produces a dense superficial layer and fills in micro-cavities with solid

metallic silver.45 It also acts directly on the plaque biofilm,46,47 inhibiting bacterial growth.48,49 Removing carious tissue before SDF application is not necessary as it does not improve

caries arrest.50 SDF has been shown to have some effect in preventing carious lesions in primary teeth, with one review showing that, by applying it at least once per year, 61% of new caries

lesions might be prevented.51 SDF is clinically effective as well as cost-effective, and has the advantage of combined use with all other caries management techniques.51,52 NON-AGP USE

Carious tissue is not removed at all. To minimise droplet and aerosol production, the surface is dried with cotton instead of compressed air, then SDF is applied using a micro brush.

Arresting lesions using SDF can provide a solid foundation for restorations53,54 and can be combined with ART in primary or permanent teeth or the HT. There are currently no clinical trials

of efficacy, so combinations may be thought of as a 'belt and braces' approach to synergise the benefits of both treatments. METHODS FOR SEALING THE CARIOUS LESION FISSURE SEALING

OVER NON-CAVITATED CARIOUS LESION WHAT IT IS AND WHEN TO USE IT Sealant materials can control non-cavitated lesions on occlusal surfaces where there is no significant breach in the surface

integrity of the tooth, even if the lesion can be seen clinically (through shadowing), or radiographically, to extend into dentine.55,56,57,58,59,60 These are also known as micro-invasive

treatments. HOW IT WORKS AND CLINICAL EFFECTIVENESS As well as being highly effective for prevention of dental caries,30 placing a well-sealed fissure sealant over a carious lesion will

arrest it and stop it from progressing.57,58,59,60 While shallow or moderately deep lesions are likely to be successfully managed, there is not enough evidence to make recommendations for

deeper lesions for long-term management. Although they may provide a good seal, they will not add much to the strength of the tooth. Their application is limited to teeth where there is less

weakening of the tooth structure (that is, less extensive lesions) and the tooth structure can support them. In cases where the lesion is extensive, the sealant may not be able to withstand

breakdown of the lesion surface if the forces are high. Although they have a lower retention rate than resin sealants, the therapeutic effect of GIC on the tooth seems to balance the bulk

material loss. There is good evidence to support a high caries-preventive effect from high-viscosity glass-ionomer sealants.30 However, there is little directly comparable evidence, as yet,

on their relative performances sealing dentinal carious lesions. NON-AGP USE Resin fissure sealant application involves use of the air-water syringe, creating an aerosol. Clinicians could

consider using GIC or HVGIC ART sealants instead, as these do not require rinsing or desiccation for placement, to prevent further progression of lesions. More long-term treatment may be

required later, but there may be sufficient success from the sealant to allow it to be managed by re-sealing rather than replacing with a restoration. RESIN INFILTRATION WHAT IT IS AND WHEN

TO USE IT Resin infiltration (RI) is a technique that arrests non-cavitated carious lesions.61,62 It can treat non-cavitated lesions on smooth and approximal surfaces in both dentitions

effectively. Lesions have to be limited to enamel and the outer third of dentine.61,62,63,64,65 It can also camouflage the whitish appearance of hypomineralised enamel on smooth

surfaces.62,64 Similar to sealants, this is also known as a micro-invasive treatment. HOW IT WORKS AND CLINICAL EFFECTIVENESS A very low-viscosity resin infiltrate is introduced into the

micro-porosities of carious lesions to fill them through capillary action and arrest their progress.65 Systematic reviews show RI to be an effective micro-invasive treatment at timespans up

to 36 months.61,65 LOW AGP USE The diffusion of the RI results from surface and sub-surface dehydration conditions created by hydrochloric acid followed by ethanol. The air-water syringe has

to be used to rinse and dry which may produce aerosols. Rubber dam, sealing material and high-volume evacuators should be used.5,66 HALL TECHNIQUE WHAT IT IS AND WHEN TO USE IT The HT is a

method for treating asymptomatic carious primary molar teeth where the lesion has extended into dentine (cavitated or non-cavitated). The correct size of preformed metal crown is chosen and

then pushed over the tooth to seal the carious lesion.67 The HT has been used in some secondary care settings for temporary management of partially erupted permanent molars affected by molar

incisor hypomineralisation. However, there are currently no clinical trials to support this use. If practitioners are considering using the HT as a temporary non-AGP measure for permanent

molar teeth, there are a few points, besides the lack of supporting evidence, that they should consider. Firstly, the crowns should only be placed on teeth that are not yet in occlusion.

Secondly, the HT in this cas , unlike primary teeth HT use, provides only a temporary solution until more definitive restorative treatment and this will necessitate an AGP to remove the

crown. Finally, permanent tooth preformed crowns are less easy to fit than those for primary teeth and almost always need to be trimmed with scissors, crimped and polished. HOW IT WORKS AND

CLINICAL EFFECTIVENESS It provides full coronal coverage and the risk of future carious lesion development on another surface of the tooth is avoided.67 The HT is technically simple to carry

out and is well accepted by children, their parents and dentists.68,69 It has a strong evidence base showing high long-term success rates in randomised control trials (>90%) compared to

conventional restorations (50-80%) and comparable to conventional crowns.68,69,70 The high rate of success, its durability and cost-effectiveness have meant use of the HT has increased, with

a recent survey including 709 paediatric dentists from six continents showed that 92% had heard about it and 51% were using it.71 NON-AGP USE The HT is AGP-free as there is no removal of

carious tissue and no tooth preparation. No local anaesthesia is required. The luting cement is GIC. As with all clinical procedures, careful case selection with accurate lesion and pulp

status diagnoses (clinically and radiographically) are essential for success. Parents have to be happy with the appearance before placement, although children generally like the crown's

appearance. METHODS FOR CARIOUS DENTINE LESION MANAGEMENT ATRAUMATIC RESTORATIVE TREATMENT WHAT IT IS AND WHEN TO USE IT ART involves using hand instruments to access carious lesions

through enamel and to remove a selected amount of demineralised dental tissues. This is also known as a minimally invasive treatment. HOW IT WORKS AND CLINICAL EFFECTIVENESS ART restorations

with HVGIC have shown high success in long-term follow-up studies for single surfaces, in the primary and permanent dentitions, with meta-analyses showing weighted mean annual failure

percentages of 5% in primary molars over the first three years, and 4.1% over the first five years in permanent posterior teeth.29 However, there are not enough studies on multi-surface

restorations in the permanent dentition to recommend it as a long-term strategy yet. A recent systematic review reported no significant differences in survival percentages between ART and

traditionally produced multiple-surface restorations in primary molars,72,73 and for single-surface restorations in primary molars and posterior permanent teeth.73 Large-sized multi-surface

ART/HVGIC restorations in primary molars were less successful because of poor restorative material performance rather than the caries removal technique. However, ART may be a good short-term

strategy for large multi-surface cavities or for stabilising the dentitions before other restorative interventions. NON-AGP USE ART involves no rotary, aerosol-producing instruments during

opening of the cavity and selective removal of the carious tissue. ART's success is determined not only by the shape and the sharpness of the hand instruments, but also the technique

used as well as the knowledge of the affected dental tissues and experience of the dental practitioner. In some deeper lesions in permanent teeth, stepwise carious tissue removal may have

been the treatment of choice but involves a second high-speed air rotor step to remove the restoration. Therefore, following selective carious tissue removal, a restoration designed to last

in the long term should be placed. The restoration seal should be checked and maintained as necessary on a regular basis. CHEMO-MECHANICAL METHODS FOR CARIOUS TISSUE REMOVAL Currently, there

are sodium hypochlorite-based and enzyme-based CMCR agents in the market. A recent systematic review found CMCR time-consuming, but effective, for caries removal.74 The manufacturer's

recommendations are that the caries removal agents are washed out, but could well be removed with spoon instruments and cleaned with wet cotton pellets. LIMITATIONS OF NON-AGP AND LOW AGP IN

MANAGEMENT OF CARIOUS LESIONS The majority of carious lesions in children and young adults can be treated with non-AGP measures because they are usually the first lesion on a tooth. One of

the difficulties with applying non-AGPs in adults is that most lesions occur in relation to a failing restoration (previously known as secondary caries) and it does not seem possible to

remove restorative materials without using rotary instruments and creating aerosols. However, repairing existing restorations rather than replacing them should be considered where possible.

CONCLUSION Treatments that remove or reduce the generation of aerosols during the management of carious lesions can allow a successful risk reduction approach and are still effective.

REFERENCES * World Health Organisation. COVID-19 strategy update. 2020. Available at https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update-14april2020.pdf (accessed July

2020). * American Dental Association. COVID-19 Frequently Asked Questions. 2020. Available online at

https://success.ada.org/en/practice-management/patients/coronavirus-frequently-asked-questions (accessed July 2020). * Centers for Disease Control and Prevention. Dental Settings: Interim

Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic. 2020. Available at

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html (accessed July 2020). * Ge Z, Yang L, Xia J, Fu X, Zhang Y. Possible aerosol transmission of COVID-19 and special

precautions in dentistry. _J Zhejiang Univ_ _Sci B_ 2020; 21: 361-368. * Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral

medicine. _J Dent Res_ 2020; 99: 481-487. * Fennelly K P. Particle sizes of infectious aerosols: implications for infection control. _Lancet Respir Med_ 2020; DOI:

10.1016/S2213-2600(20)30323-4. * Lewis D. Mounting evidence suggests coronavirus is airborne-but health advice has not caught up. _Nature_ 2020; 583: 510-513. * Araujo M W B, Andreana S.

Risk and prevention of transmission of infectious diseases in dentistry. _Quintessence Int_ 2002; 33: 376-382. * Rautemaa R, Nordberg A, Wuolijoki-Saaristo K, Meurman J H. Bacterial aerosols

in dental practice - a potential hospital infection problem? _J Hosp Infect_ 2006; 64: 76-81. * Zemouri C, Awad S F, Volgenant C M, Crielaard W, Laheij AM, de Soet JJ. Modeling of the

Transmission of Coronaviruses, Measles Virus, Influenza Virus, Mycobacterium tuberculosis, and Legionella pneumophila in Dental Clinics. _J Dent Res_ 2020; 99: 1192-1198. * Zemouri C, De

Soet H, Crielaard W, Laheij A. A scoping review on bio-Aerosols in healthcare & the dental environment. _PLoS One_ 2017; DOI: 10.1371/journal.pone.0178007. * Harrel S K. Airborne spread

of diseasethe implications for dentistry. _J Calif Dent Assoc_ 2004; 32: 901-906. * Szymańska J, Sitkowska J. Bacterial Hazards in a Dental Office: An update review. _Afr J Microbiol Res_

2012; 6: 1642-1650. * Manarte-Monteiro P, Carvalho A, Pina C, Oliveira H, Manso M C. Air quality assessment during dental practice: Aerosols bacterial counts in an universitary clinic. _Rev

Port Estomatol Cir Maxilofac_ 2013; 54: 2-7. * Labaf H, Owlia P, Taherian A, Haghgoo R. Quantitative analysis of changes in bacterial aerosols during endodontic, periodontic and

prosthodontic treatments. _Afr J Microbiol Res_ 2011; 5: 4946-4948. * Miller R L. Characteristics of blood-containing aerosols generated by common powered dental instruments. _Am Ind Hyg

Assoc J_ 1995; 56: 670-676. * Grundy J R. Enamel aerosols created during use of the air turbine handpiece. _J Dent Res _1967; 46: 409-416. * Al-Amad S H, Awad M A, Edher F M, Shahramian K,

Omran T A. The effect of rubber dam on atmospheric bacterial aerosols during restorative dentistry. _J Infect Public Health_ 2017; 10: 195-200. * Earnest R, Loesche W. Measuring harmful

levels of bacteria in dental aerosols. _J Am Dent Assoc_ 1991; 122: 55-57. * Purohit B, Priya H, Acharya S, Bhat M, Ballal M. Efficacy of pre-procedural rinsing in reducing aerosol

contamination during dental procedures. _J Infect Prev_ 2009; 10: 190-192. * Yamada H, Ishihama K, Yasuda K, Hasumi-Nakayama Y, Shimoji S, Furusawa K. Aerial dispersal of blood-contaminated

aerosols during dental procedures. _Quintessence Int_ 2011; 42: 399-405. * Dawson M, Soro V, Dymock D _et al._ Microbiological assessment of aerosol generated during debond of fixed

orthodontic appliances. _Am J Orthod Dentofac Orthop_ 2016; 150: 831-838. * Day C J, Sandy J R, Ireland A J. Aerosols and splatter in dentistrya neglected menace? _Dent Update_ 2006; 33:

601-606. * Toroğlu M S, Haytaç M C, Köksal F. Evaluation of aerosol contamination during debonding procedures. _Angle Orthod_ 2001; 71: 299-306. * Polednik B. Aerosol and bioaerosol

particles in a dental office. _Environ Res_ 2014; 134: 405-409. * Micik R E, Miller R L, Mazzarella M A, Ryge G. Studies on dental aerobiology: I. bacterial aerosols generated during dental

procedures. _J Dent Res_ 1969; 48: 49-56. * Frencken J E, Peters M C, Manton D J, Leal S C, Valeria V, Eden E. Minimal Intervention Dentistry (MID) for managing dental caries - a review.

_Int Dent J_ 2012; 62: 223-243. * Alkilzy M, Tarabaih A, Santamaria R M, Splieth C H. Self-assembling peptide P11-4 and fluoride for regenerating enamel. _J Dent Res_ 2018; 97: 148-154. * de

Amorim R G, Frencken J E, Raggio D P, Chen X, Hu X, Leal S C. Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: an updated

systematic review and meta-analysis. _Clin Oral Investig_ 2018; 22: 2703-2725. * Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington H V. Pit and fissure sealants for

preventing dental decay in permanent teeth. _Cochrane Database Syst Rev_ 2017; DOI: 10.1002/14651858.CD001830.pub5. * Gannam C V, Chin K L, Gandhi R P. Caries risk assessment._ Gen Dent_

2018; 66: 12-17. * Mejàre I, Axelsson S, Dahlén G _et al._ Caries risk assessment. A systematic review. _Acta Odontol Scand_ 2014; 72: 81-91. * Mijan M, de Amorim R G, Leal S C _et al._ The

3.5-year survival rates of primary molars treated according to three treatment protocols: A controlled clinical trial. _Clin Oral Investig_ 2014; 18: 1061-1069. * Santamaria R M, Innes N P,

Machiulskiene V, Schmoeckel J, Alkilzy M, Splieth C H. Alternative caries management options for primary molars: 2.5-year outcomes of a randomised clinical trial. _Caries Res_ 2017; 51:

605-614. * van Strijp G, van Loveren C. No removal and inactivation of carious tissue: non-restorative cavity control. _In_ Schwendicke F, Frencken J, Innes N (eds) _Caries Excavation:

Evolution of Treating Cavitated Carious Lesions_. pp 124-136. Basel: Karger Publishers, 2018. * Mei M L, Nudelman F, Marzec B _et al._ Formation of fluorohydroxyapatite with silver diamine

fluoride. _J Dent Res_ 2017; 96: 1122-1128. * Yee R, Holmgren C, Mulder J, Lama D, Walker D, Helderman W V P. Efficacy of silver diamine fluoride for arresting caries treatment. _J Dent Res_

2009; 88: 644-647. * Llodra J C, Rodriguez A, Ferrer B, Menardia V, Ramos T, Morato M. Efficacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars

of schoolchildren: 36-month clinical trial. _J Dent Res_ 2005; 84: 721-724. * Gao S S, Zhao I S, Hiraishi N _et al._ Clinical trials of silver diamine fluoride in arresting caries among

children. _JDR Clin Transl Res_ 2016; 1: 201-210. * Oliveira B H, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: A

systematic review with meta-analysis. _J Am Dent Assoc_ 2018; 149: 671-679. * Fung M H T, Duangthip D, Wong M C M, Lo E C M, Chu C H. Randomized clinical trial of 12% and 38% silver diamine

fluoride treatment. _J Dent Res_ 2018; 97: 171-178. * Seifo N, Robertson M, MacLean J _et al._ The use of silver diamine fluoride (SDF) in dental practice. _Br Dent J_ 2020; 228: 75-81. * Li

Y, Liu Y, Psoter W J _et al._ Assessment of the silver penetration and distribution in carious lesions of deciduous teeth treated with silver diamine fluoride. _Caries Res_ 2019; 53:

431-440. * Chu C H, Lo E C M. Microhardness of dentine in primary teeth after topical fluoride applications. _J Dent_ 2008; 36: 387-391. * Seto J, Horst J A, Parkinson D Y, Frachella J C,

DeRisi J L. Enhanced tooth structure via silver microwires following treatment with 38 percent silver diamine fluoride. _Pediatr Dent _2020; 42: 226-231. * Mei M L, Li Q L, Chu C H, Lo E C

M, Samaranayake L P. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. _Ann Clin Microbiol Antimicrob_ 2013; 12: 4. * Milgrom P, Horst J A,

Ludwig S _et al._ Topical silver diamine fluoride for dental caries arrest in preschool children: A randomized controlled trial and microbiological analysis of caries associated microbes and

resistance gene expression. _J Dent_ 2018; 68: 72-78. * Knight G M, McIntyre J M, Craig G G, Mulyani, Zilm P S, Gully N J. Differences between normal and demineralized dentine pretreated

with silver fluoride and potassium iodide after an in vitro challenge by Streptococcus mutans. _Aust Dent J_ 2007; 52: 16-21. * Zhao I S, Gao S S, Hiraishi N _et al._ Mechanisms of silver

diamine fluoride on arresting caries: a literature review. _Int Dent J_ 2018; 68: 67-76. * Chu C H, Lo E C M, Lin H C. Effectiveness of silver diamine fluoride and sodium fluoride varnish in

arresting dentin caries in Chinese pre-school children. _J Dent Res_ 2002; 81: 767-770. * Seifo N, Cassie H, Radford J R, Innes N P T. Silver diamine fluoride for managing carious lesions:

An umbrella review. _BMC Oral Health_ 2019; 19: 145. * Horst J A, Heima M. Prevention of dental caries by silver diamine fluoride. _Compend Contin Educ Dent_ 2019; 40: 158-164. * Chu C H,

Lee A H C, Zheng L, Mei M L, Chan G C F. Arresting rampant dental caries with silver diamine fluoride in a young teenager suffering from chronic oral graft versus host disease post-bone

marrow transplantation: A case report. _BMC Res Notes_ 2014; 7: 3. * Young D A, Frostad-Thomas A, Gold J, Wong A. Secondary Sjögren syndrome: A case report using silver diamine fluoride and

glass ionomer cement. _J Am Dent Assoc_ 2018; 149: 731-741. * Wright J T, Tampi M P, Graham L _et al._ Sealants for preventing and arresting pitandfissure occlusal caries in primary and

permanent molars. _Pediatr Dent_ 2016; 38: 282-308. * Wright J T, Crall J J, Fontana M _et al._ Evidence-based clinical practice guideline for the use of pitandfissure sealants: A report of

the American Dental Association and the American Academy of Paediatric Dentistry. _J Am Dent Assoc_ 2016; 147: 672-682. * Handelman S L, Washburn F, Wopperer P. Two-year report of sealant

effect on bacteria in dental caries. _J Am Dent Assoc_ 1976; 93: 967-970. * Handelman S L, Leverett D H, Solomon E S, Brenner C M. Use of adhesive sealants over occlusal carious lesions:

Radiographic evaluation. _Community Dent Oral Epidemiol_ 1981; 9: 256-259. * Zhang W, Mulder J, Frencken J E. Is preventing micro-cavities in dentine from progressing with a sealant

successful? _Br Dent J_ 2019; 226: 590-594. * Handelman S L. Effect of sealant placement on occlusal caries progression. _Clin Prev Dent _1982; 4: 11-16. * Liang Y, Deng Z, Dai X, Tian J,

Zhao W. Micro-invasive interventions for managing non-cavitated proximal caries of different depths: a systematic review and meta-analysis. _Clin Oral Investig_ 2018; 22: 2675-2684. * Höchli

D, Hersberger-Zurfluh M, Papageorgiou S N, Eliades T. Interventions for orthodontically induced white spot lesions: a systematic review and meta-analysis. _Eur J Orthod_ 2017; 39: 122-133.

* Anand V, Arumugam S B, Manoharan V, Kumar S A, Methippara J J. Is resin infiltration a microinvasive approach to white lesions of calcified tooth structures?: a systemic review. _Int J

Clin Paediatr Dent_ 2019; 12: 53-58. * Borges A B, Caneppele T M F, Masterson D, Maia L C. Is resin infiltration an effective esthetic treatment for enamel development defects and white spot

lesions? A systematic review. _J Dent_ 2017; 56: 11-18. * Dorri M, Dunne S M, Walsh T, Schwendicke F. Micro-invasive interventions for managing proximal dental decay in primary and

permanent teeth. _Cochrane Database Syst Rev_ 2015; DOI: 10.1002/14651858.CD010431.pub2. * Scottish Dental Clinical Effectiveness Programme. Management of Acute Dental Problems During

COVID-19 Pandemic. 2020. Available online at https://www.sdcep.org.uk/published-guidance/acute-dental-problems-covid-19/ (assessed July 2020). * Innes N P T, Evans D J P, Bonifacio C C _et

al._ The Hall Technique 10 years on: Questions and answers. _Br Dent J_ 2017; 222: 478-483. * Innes N P, Evans D J P, Stirrups D R. The Hall Technique; A randomized controlled clinical trial

of a novel method of managing carious primary molars in general dental practice: Acceptability of the technique and outcomes at 23 months. _BMC Oral Health_ 2007; 7: 18. * Santamaria R M,

Innes N P T, Machiulskiene V, Evans D J P, Splieth C H. Caries management strategies for primary molars: 1yr randomized control trial results. _J Dent Res_ 2014; 93: 1062-1069. * Elamin F,

Abdelazeem N, Salah I, Mirghani Y, Wong F. A randomized clinical trial comparing Hall vs conventional technique in placing preformed metal crowns from Sudan. _PLoS One_ 2019; DOI:

10.1371/journal.pone.0217740. * Hussein I, Al Halabi M, Kowash M _et al._ Use of the Hall technique by specialist paediatric dentists: a global perspective. _Br Dent J_ 2020; 228: 33-38. *

Tedesco T K, Calvo A F B, Lenzi T L _et al._ ART is an alternative for restoring occlusoproximal cavities in primary teeth - evidence from an updated systematic review and meta-analysis.

_Int J Paediatr Dent_ 2017; 27: 201-209. * Frencken J E, Liang S Z Q. Survival estimates of atraumatic restorative treatment (ART) versus traditional restorative treatment: a systematic

review with meta-analyses. _Br Dent J_ 2020; in press. * Hamama H H H, Yiu C K Y, Burrow M F, King N M. Systematic review and meta-analysis of randomized clinical trials on chemomechanical

caries removal. _Oper Dent_ 2015; DOI: 10.2341/14-021-LIT. Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Ege University, School of Dentistry, Department of Paediatric

Dentistry, Bornova, Izmir, 35100, Turkey Ece Eden * Radboud University, Department of Oral Function and Prosthetic Dentistry, College of Dental Sciences, Radboud University Medical Centre,

Nijmegen, 6525 GA, The Netherlands Jo Frencken * Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Hong Kong Sherry Gao * Director of Clinical

Innovation, DentaQuest, Boston, MA 02129 USA; University of Washington, Department of Oral Health Sciences, Seattle, 98195, USA Jeremy A. Horst * Professor and Honorary Consultant,

Paediatric Dentistry, School of Dentistry, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK Nicola Innes Authors * Ece Eden View author

publications You can also search for this author inPubMed Google Scholar * Jo Frencken View author publications You can also search for this author inPubMed Google Scholar * Sherry Gao View

author publications You can also search for this author inPubMed Google Scholar * Jeremy A. Horst View author publications You can also search for this author inPubMed Google Scholar *

Nicola Innes View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to Ece Eden. ETHICS DECLARATIONS None. ELECTRONIC

SUPPLEMENTARY MATERIAL FURTHER RESOURCES (DOC 0B) RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Eden, E., Frencken, J., Gao, S. _et al._ Managing

dental caries against the backdrop of COVID-19: approaches to reduce aerosol generation. _Br Dent J_ 229, 411–416 (2020). https://doi.org/10.1038/s41415-020-2153-y Download citation *

Received: 01 July 2020 * Accepted: 10 August 2020 * Published: 09 October 2020 * Issue Date: October 2020 * DOI: https://doi.org/10.1038/s41415-020-2153-y SHARE THIS ARTICLE Anyone you share

the following link with will be able to read this content: Get shareable link Sorry, a shareable link is not currently available for this article. Copy to clipboard Provided by the Springer

Nature SharedIt content-sharing initiative