Alternatives to Drill and Fill of Cavities

Beyond the drill: ten evidence-based alternatives for treating tooth decay

The era of "drill and fill" as the default response to dental caries is ending. A robust and growing body of evidence supports at least ten distinct alternative approaches — from topical agents that arrest cavities in seconds to antibodies that may one day regrow entire teeth. The strongest evidence exists for silver diamine fluoride (SDF), which arrests 81% of carious lesions at a cost under $1 per treatment, and resin infiltration (ICON), which reduces caries progression by 80% over seven years. Remineralization strategies using fluoride varnish, hydroxyapatite, and CPP-ACP can reverse early enamel lesions before they ever need a filling. Meanwhile, historical evidence — largely forgotten — shows vitamin D supplementation reduced childhood caries by 47% across 24 controlled trials. These alternatives are not fringe: SDF was added to the WHO Essential Medicines List in 2021, and minimally invasive dentistry is now codified in ADA clinical guidelines. What follows is a detailed analysis of each approach, its evidence base, limitations, and where it fits in the spectrum of caries management.

1) Silver diamine fluoride stops most cavities cold — but turns them black

Silver diamine fluoride (38% SDF) is the single most disruptive innovation in caries management this decade. A topical liquid containing ~25% silver and ~5.9% fluoride, SDF works through a dual mechanism: silver ions destroy cariogenic bacteria and form antimicrobial silver phosphate deposits, while fluoride promotes remineralization by forming fluorapatite. One drop treats approximately five teeth, and the entire application takes under three minutes with no drilling, no anesthesia, and no pain.

The evidence is substantial. A 2016 meta-analysis of eight studies on primary teeth found an overall 81% caries arrest rate (95% CI: 68–89%). The large CariedAway trial — a pragmatic RCT of 2,998 children across 47 New York City schools — demonstrated SDF with fluoride varnish was non-inferior to glass ionomer sealants for both caries arrest (56% vs. 46%) and prevention (81% vs. 82% caries-free at two years). Interim results from the ongoing NIH Phase III trial (2024) showed 54% of cavities stopped progressing with SDF versus 21% with placebo. Semi-annual application outperforms annual application, with one RCT reporting arrest rates of 91% versus 79%.

SDF is applicable to cavitated dentin caries in both primary and permanent teeth, including root caries in elderly patients — a far wider range than most alternatives. It was first approved in Japan in 1970, has been used in Australia and Brazil since the 1980s, received FDA clearance as a Class II medical device in 2014 (off-label for caries arrest), and was added to the WHO Essential Medicines List in October 2021 — the first dental caries treatment ever included. As of 2022, at least 46 U.S. states provide Medicaid coverage, and 100% of U.S. pediatric dentistry residency programs have adopted it.

The critical limitation is cosmetic: SDF irreversibly stains arrested carious tissue jet black due to silver phosphate precipitation. This is purely cosmetic and clinically insignificant, but it is unacceptable for many patients on anterior teeth. SDF also does not restore lost tooth structure — it arrests decay but leaves the cavity, often requiring a follow-up restoration (the SMART technique pairs SDF with glass ionomer cement). Contraindications include silver allergy and direct pulp exposure.

2) Remineralization can reverse early cavities before they need filling

The modern understanding of caries as a dynamic process of demineralization and remineralization has opened a window for non-restorative treatment of early lesions. Three remineralization approaches have meaningful evidence, all effective primarily for non-cavitated enamel lesions (ICDAS 1–2) — the white spot stage before surface breakdown occurs.

Fluoride varnish (5% sodium fluoride, ~22,600 ppm) is the gold standard for professional remineralization. A 2016 meta-analysis found it produced 63.6% greater remineralization than no treatment, and Cochrane reviews confirm it reduces caries incidence in permanent teeth by up to 43%. The ADA's landmark 2018 guideline formally recommended fluoride varnish every 3–6 months for non-cavitated lesions on all tooth surfaces. For cavitated lesions, the ADA prioritizes SDF but notes intensive fluoride varnish (weekly for three weeks) as an alternative. Fluoride varnish is universally adopted in pediatric dentistry worldwide and remains the benchmark against which other remineralization agents are measured.

CPP-ACP (casein phosphopeptide–amorphous calcium phosphate), marketed as GC Tooth Mousse and MI Paste, uses milk-derived peptides to stabilize calcium and phosphate ions and deliver them to enamel surfaces. Systematic reviews confirm it promotes remineralization of white spot lesions, with enhanced effects when combined with fluoride (MI Paste Plus). A 2024 review of 14 RCTs found CPP-ACP effective for white spot lesion remineralization, though results were inconsistent across studies. The major limitation is a contraindication in patients with milk protein allergy. Notably, the ADA's 2018 guideline did not include CPP-ACP due to insufficient qualifying evidence, though it is widely used in orthodontic practice for managing white spots around brackets.

Hydroxyapatite (HAp) toothpastes represent the fastest-growing category. Because hydroxyapatite constitutes 96–97% of enamel, nano- or micro-crystalline HAp particles act as biomimetic building blocks, depositing directly onto demineralized surfaces. Three major RCTs have demonstrated non-inferiority to fluoride toothpaste: Schlagenhauf et al. (2019) in orthodontic patients, Paszynska et al. (2021) in children's primary teeth, and Paszynska et al. (2023) in adults at 18 months. A 2025 comparative RCT ranked nano-hydroxyapatite as the most effective remineralizing agent for white spot lesions, ahead of CPP-ACPF, CPP-ACP, and fluoride gel. HAp has been approved as an anti-caries agent in Japan since 1993 (Apagard, by Sangi Co.) but has no FDA approval or ADA Seal in the United States. A 2025 National Advertising Division ruling against Boka toothpaste underscored that U.S. brands cannot make remineralization claims without product-specific clinical trials. HAp's key advantage is safety — no fluorosis risk, making it especially suitable for children who may swallow toothpaste.

No remineralization approach can reverse a cavitated lesion (ICDAS 5–6). Once the enamel surface has physically broken down, the body cannot regenerate the lost structure through mineral deposition alone. These agents work by refilling subsurface porosity beneath an intact enamel surface.

3) ICON resin infiltration offers the strongest evidence for arresting early interproximal decay

ICON (DMG, Hamburg) is a micro-invasive resin infiltration system introduced in 2009 for treating non-cavitated proximal caries and white spot lesions. The procedure uses 15% hydrochloric acid to remove the pseudo-intact surface layer, ethanol to desiccate the pore system, and a low-viscosity TEGDMA resin that penetrates lesion pores by capillary action, creating a physical diffusion barrier against acids and bacteria. It requires no drilling, no anesthesia, and takes approximately 15–30 minutes per tooth.

The evidence for ICON is among the strongest of any alternative. A landmark seven-year RCT by Paris et al. (2020) found 9% progression of infiltrated proximal lesions versus 45% of untreated controls — an 80% relative risk reduction (hazard ratio 6.6, p = 0.002). A Cochrane review (Dorri et al., 2015) concluded resin infiltration is "significantly more effective" than non-invasive professional treatment, with pooled odds of progression at 0.24 (95% CI: 0.14–0.41). A 2018 meta-analysis confirmed these findings at both 18 months (OR 0.14) and 3 years (OR 0.15).

ICON is effective for lesions extending radiographically up to the outer third of dentin (E2/D1 on radiographs, corresponding to ICDAS 1–2). It cannot be used on cavitated lesions, deep dentin caries, occlusal pit-and-fissure caries, or hypomineralization defects. Technique sensitivity is a real concern: one retrospective study found only 46% survival at 32 months when performed by untrained operators, compared to excellent results with trained clinicians. The infiltrant is not radiopaque, making radiographic monitoring difficult. ICON is FDA-cleared and has a dedicated CDT billing code (D2990). It is well-established in Europe and expanding in the United States, with material costs of $40–90 per patient and patient charges of $150–500 per tooth.

4) The Hall Technique (sel them off)

The Hall Technique is a deceptively simple approach: a preformed metal crown (stainless steel crown) is cemented directly over a carious primary molar with no drilling, no caries removal, and no anesthesia. It works by sealing the carious lesion under an impervious barrier, starving bacteria of substrate and allowing the pulp to lay down reparative dentin.

Developed informally by Scottish GDP Dr. Norna Hall over 15 years, the technique was first described in the literature in 2006 after analysis of her 978 crowns in 259 children revealed 80.5% survival at five years. The definitive RCT (Innes et al., 2007) demonstrated 93% success for Hall crowns versus just 39% for conventional fillings at 23 months — a striking result confirmed at five years (92% vs. 42%). A 2022 meta-analysis of 11 publications found Hall Technique was 49% more likely to succeed than other restorations and over six times less likely to fail.

The technique is limited almost exclusively to primary molars with cavitated dentin caries but without clinical or radiographic evidence of irreversible pulpitis. A clear band of dentin must remain between the lesion and the pulp on radiographs. The crown produces a temporary bite-height increase that self-corrects within weeks. Limitations include the metallic appearance and the requirement for an orthodontic separator placement visit. The Hall Technique is now included in all UK dental school curricula, and a 2024 survey found 51% of U.S. pediatric dentists view it as a viable alternative, though adoption remains lower in the United States than in the UK.

5) Chemomechanical removal, ozone, lasers, and air abrasion each fill a niche

Chemomechanical caries removal (CMCR) uses enzyme-based gels — Papacarie (papain-based, Brazil, 2003), Carisolv (NaOCl-based, Sweden, 1998), and BRIX 3000 (high-concentration papain, Argentina, 2012) — to selectively soften infected dentin for gentle manual excavation. The key advantage is significantly reduced pain: meta-analyses show a –1.01 reduction on the Wong-Baker FACES pain scale compared to drilling. A 2025 RCT confirmed BRIX 3000 and Carisolv both reduced pain significantly compared to rotary instruments in permanent teeth. The consistent limitation is longer treatment time — Papacarie averages 4+ minutes per lesion, and BRIX 3000 approximately 14 minutes for larger cavities. CMCR remains a niche technique, strongest in Brazil, India, and Argentina, with limited adoption in the U.S. or Western Europe. None of the current agents have broad FDA clearance for routine use.

Ozone therapy uses high-concentration ozone gas (2,100 ppm via the HealOzone device) to kill cariogenic bacteria by oxidizing cell membranes. Early studies from Prof. Edward Lynch's group at Queen's University Belfast reported extraordinary results — up to 98% caries reversal at 12 months for root caries. However, the 2004 Cochrane review found "no reliable evidence" due to high risk of bias, and a 2020 systematic review rated the certainty of evidence as "very low." Critically, nearly all positive studies originated from Lynch's own research group, and Lynch held patents on the technology. The UK's National Institute for Health and Care Excellence (NICE) declined to recommend HealOzone in 2005. The device is CE-marked in Europe but not FDA-approved. Ozone therapy remains a fringe approach with a conflicted evidence base.

Laser caries removal using Er:YAG (2,940 nm) or Er,Cr:YSGG (2,780 nm) lasers ablates carious tissue through thermomechanical microexplosion of interstitial water. Multiple RCTs confirm significantly less pain and reduced anesthesia needs — 86% of adolescents in one study preferred laser for future treatments. However, the 2016 Cochrane review found insufficient evidence to support laser as an alternative to drilling, and a 2025 meta-analysis of 20 studies confirmed laser is consistently twice as slow as conventional drilling with no significant difference in restoration survival. Equipment costs of $20,000–$80,000 and a plateaued market share of approximately 4% reflect practical barriers. BIOLASE, the leading manufacturer, filed for bankruptcy in October 2024 before being acquired by South Korean firm MegaGen in September 2025.

Air abrasion propels fine aluminum oxide particles (27–125 μm) at high velocity to remove carious tissue without heat, vibration, or noise. Developed by Dr. Robert Black in the 1940s and revived in the 1990s with the advent of adhesive dentistry, it is best suited for small, incipient pit-and-fissure caries. It is essentially painless and often eliminates the need for anesthesia. Equipment costs are far more accessible than lasers ($1,000–$20,000), and newer bioactive glass particles (Sylc) provide the dual benefit of cutting and remineralization. Limitations include inability to handle large cavities, airborne particle management, and lack of tactile feedback. Air abrasion remains a niche tool, primarily used adjunctively rather than as a standalone caries removal method.

6) Vitamin D - proven in the 1930's to reduce childhood caries

Perhaps the most striking finding in the entire alternative caries literature is the historical evidence for vitamin D. May Mellanby's 1932 landmark trial, published in the British Medical Journal, assigned children with active caries to three dietary groups over approximately 26 weeks. Children on a grain-free diet supplemented with vitamin D (~2,000 IU/day via cod liver oil) developed only 0.4 new cavities per child while 4.7 teeth showed healing ("hardening" of previously soft carious lesions). By contrast, children on a normal diet with oatmeal and low vitamin D developed 5.8 new caries per child. The Mellanbys concluded that vitamin D promoted dentin remineralization while phytic acid in cereals — particularly oatmeal — interfered with calcium absorption.

These results were not isolated. In 2013, Philippe Hujoel published a systematic review and meta-analysis in Nutrition Reviews analyzing 24 controlled clinical trials involving 2,827 children — mostly conducted between the World Wars. The pooled result: a 47% reduction in caries incidence with vitamin D supplementation (relative rate 0.53, 95% CI: 0.43–0.65). The effect was consistent across vitamin D₂, vitamin D₃, and UV radiation. Hujoel called vitamin D "a promising caries-preventive agent" while noting the low certainty reflected historical trial design limitations, not necessarily inefficacy.

The biological mechanisms are well-characterized. Vitamin D regulates intestinal calcium and phosphorus absorption essential for tooth mineralization, modulates odontoblast gene expression during dentin formation, and — critically — induces production of cathelicidin (LL-37) and β-defensins in oral epithelial cells. These antimicrobial peptides directly attack Streptococcus mutans and other cariogenic organisms. Modern observational data corroborates the intervention trials: a 2013 study found children with vitamin D deficiency were 10 times more likely to have severe early childhood caries, and a 2023 meta-analysis of 13 studies confirmed deficiency increases caries risk by 22%. A 2019 RCT showed high-dose prenatal vitamin D (2,400 IU/day) reduced enamel defects in offspring compared to standard dosing.

Despite this evidence, vitamin D has not been formally incorporated into standard dental prevention guidelines alongside fluoride. A 2025 narrative review in Clinical Oral Investigations called it "a forgotten preventive agent against caries." No modern RCT meeting contemporary CONSORT standards has been conducted — a gap that, given the strength and consistency of the historical data, is difficult to justify.

7) Other nutritional and systemic interventions - Xylitol, Vit, K, probiotics while pregnant

Xylitol, a five-carbon sugar alcohol that S. mutans cannot metabolize, has modest but real caries-preventive effects. A 2022 meta-analysis of 30 studies found an overall 17% preventive fraction, most effective when used as 100% xylitol products 3–5 times daily at 5–10 grams per day. The Finnish Current Care Guidelines and Canadian Dental Association recommend xylitol at these doses. However, the 2015 Cochrane review rated the evidence as "low quality," and frequencies below three times daily showed no benefit.

Arginine-based products work by shifting the oral microbiome: arginolytic bacteria metabolize arginine to produce ammonia, raising biofilm pH above the critical demineralization threshold. A two-year study found 1.5% arginine in fluoride-free toothpaste more effective than 1,100 ppm fluoride toothpaste for caries inhibition. Products include Colgate's Pro-Argin line and BasicBites chews containing arginine bicarbonate and calcium carbonate. However, systematic reviews cite "insufficient evidence" and note significant conflicts of interest in the research.

Oral probiotics, particularly Lactobacillus reuteri, show promising pediatric results. A landmark trial found daily supplementation to mothers (last month of pregnancy) and infants (first year of life) resulted in 82% of children caries-free at age nine versus 58% with placebo. A 2026 meta-analysis of 18 RCTs confirmed a 20% caries reduction in children (RR 0.80, moderate certainty), though adult trials showed no significant benefit.

Vitamin K2 (menaquinone) — identified by researchers as Weston Price's mysterious "Activator X" — activates osteocalcin, which directs calcium to bones and teeth and promotes dentin formation. The mechanistic rationale is strong, but no large-scale dental RCTs exist. Evidence is extrapolated primarily from bone health studies, making K2's role in caries management theoretically compelling but clinically unproven.

8) Tooth regeneration drugs

The most transformative development is TRG-035, an anti-USAG-1 antibody developed by Dr. Katsu Takahashi at Kitano Hospital, Osaka. USAG-1 protein normally suppresses BMP and Wnt signaling pathways that control tooth development; neutralizing it activates dormant tooth buds. In preclinical studies published in Science Advances (2021), the antibody regenerated missing teeth in mice and induced growth of new teeth in ferrets. A Phase I clinical trial launched in September 2024 at Kyoto University Hospital is testing safety in 30 healthy adult males, with pediatric trials in children with congenital tooth agenesis planned next. This could eventually enable regrowth of teeth lost to decay, trauma, or aging.

Tideglusib, a GSK-3β inhibitor originally developed for Alzheimer's disease, stimulates dental pulp stem cells to produce reparative dentin. In a striking 2017 study, biodegradable collagen sponges soaked in Tideglusib placed in mouse tooth cavities achieved near-complete dentin repair within six weeks at doses 1,000 times lower than those used in neurological trials. The regenerated tissue had mineral ratios identical to native dentin. A 2024 study demonstrated a novel Tideglusib-based dental adhesive improved bond strength and promoted dentinal repair over two years. Human dental trials are in preparation but have not yet begun.

Self-assembling peptides (P11-4, marketed as Curodont Repair in Europe) form scaffolds within early carious lesions that nucleate hydroxyapatite, promoting biomimetic enamel regeneration. Bioactive glass nanoparticles incorporated into dental adhesives can release therapeutic ions on demand when local pH drops — creating "smart" restorative materials that fight secondary caries in real time. And specifically targeted antimicrobial peptides (STAMPs) are being engineered to selectively kill S. mutans without disrupting the commensal oral microbiome, addressing the root cause of caries at the ecological level.

9) Conclusion: matching the right tool to the right lesion stage

The alternative caries treatment landscape in 2026 is not a single replacement for the drill — it is a staged toolkit matched to lesion severity. For incipient, non-cavitated enamel lesions (ICDAS 1–2), remineralization with fluoride varnish, hydroxyapatite, or CPP-ACP can reverse damage entirely; ICON resin infiltration provides a more definitive physical barrier with seven-year data. For cavitated dentin caries not involving pulp, SDF can arrest decay at 81% effectiveness for under $1, the Hall Technique provides 93% success in primary molars without any drilling, and chemomechanical agents offer painless excavation. Laser and air abrasion provide drill-free preparation for small-to-medium cavities, though neither has displaced conventional handpieces due to cost and speed constraints. Systemically, vitamin D supplementation at adequate doses represents a remarkably under-utilized intervention with nearly a century of supporting evidence. And on the horizon, USAG-1 antibodies and Tideglusib hint at a future where teeth can be regrown rather than repaired. The drill is no longer the only answer — and for many lesions, it is no longer the best one.

Caries in Vitamin D Life

Not just caries