Guideline on environmentally friendly and less invasive oral health care for preventing and managing dental caries

WHOPublicationCurrent editionCC BY-NC-SA 3.0 IGO

World Health Organization · 1st edition, 2025 · 68 pages

Evidence-based recommendations on mercury-free dental products, preventive strategies, and minimally invasive restorative techniques for clinicians and public-health professionals.

In one sentenceWHO recommends biannual fluoride varnish and silver diamine fluoride for caries prevention, sealants for high-risk children, and glass ionomer or resin-based composites for restorations, limiting BPA-containing materials in vulnerable populations.

Issuer: World Health Organization
Edition: 1st edition, 2025
Audience: Governments, intergovernmental organizations, non-State actors, oral health professional organizations, ministries of health and environment, health authorities, public health policymakers, health programme managers, NGOs, industry, oral health professionals and health workers
Evidence: GRADE-rated recommendations based on systematic reviews of clinical effectiveness, cost-effectiveness, toxicity and environmental impact; best-practice statements based on indirect evidence and consensus
Reviewed: 23 Oct 2026 · GMJ

Read the original on WHO Download PDF (68 pp)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This WHO guideline provides evidence-based recommendations for preventing and managing dental caries using mercury-free dental products, in support of the Minamata Convention on Mercury and the Global Oral Health Action Plan 2023–2030. It emphasizes preventive and minimally invasive approaches, including fluoride varnish, silver diamine fluoride, pit and fissure sealants, glass ionomer cements, and resin-based composites.

The guideline presents eight recommendations and two best-practice statements covering caries prevention, nonrestorative management of initial lesions, and direct restorations. It recommends biannual fluoride varnish (5% sodium fluoride) and silver diamine fluoride (38%) as population-wide preventive interventions, pit and fissure sealants for high-risk children, and both glass ionomer cements and resin-based composites as restorative materials. Special attention is given to vulnerable populations: the guideline suggests limiting resin-based materials containing bisphenol A derivatives in children, adolescents, and pregnant or breastfeeding women, and exercising caution in individuals with allergic conditions.

Implementation considerations address supply chain strengthening, workforce training, waste management, and environmental sustainability. The guideline supports a transition away from dental amalgam while ensuring equitable access to quality oral health care, particularly in low-resource settings. It integrates clinical effectiveness, cost-effectiveness, toxicity, and environmental impact evidence to guide decision-making aligned with universal health coverage and sustainable development goals.

Key points

For clinicians — doses and thresholds as stated in the guideline

Apply 5% sodium fluoride varnish twice a year as population-wide caries prevention in primary and permanent teeth (strong recommendation, moderate certainty)
Apply 38% silver diamine fluoride twice a year as population-wide caries prevention in primary and permanent teeth (conditional recommendation, low certainty)
Use pit and fissure sealants to prevent caries in first permanent molars of children at high caries risk (strong recommendation, moderate certainty)
Use 5% fluoride varnish as non-invasive treatment for non-cavitated carious lesions in primary and permanent teeth (strong recommendation, moderate certainty)
Use 38% silver diamine fluoride twice a year as non-invasive treatment for cavitated lesions without pulp involvement in primary teeth and root surfaces of permanent teeth (strong recommendation, moderate certainty)
Use glass ionomer cements and resin-based composites as direct restorative materials for dental caries (conditional recommendation, low certainty)
Limit resin-based fissure sealants and composites containing BPA derivatives in children, adolescents, pregnant or breastfeeding women (conditional recommendation, very low certainty)
Exercise caution using resin-based composites in individuals with allergic conditions due to monomer sensitization risk (conditional recommendation, low certainty)

The four GRADE levels of quality of evidence

Table extracted from the guideline

Quality of evidence	Description
High	We are very confident that the true effect is likely to be close to the effect estimate.
Moderate	We are moderately confident that the true effect is likely to be close to the effect estimate, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited: The true effect may be substantially different from the effect estimate.
Very low	We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the effect estimate.

Source: World Health Organization, Guideline on environmentally friendly and less invasive oral health care for preventing and managing dental caries. Reproduced in summary form.

From the guideline

Verbatim

“The best way to minimize the environmental impact of oral health care is to reduce the need for treatment of preventable oral diseases.”

— World Health Organization, Guideline on environmentally friendly and less invasive oral health care for preventing and managing dental caries, Section 3, Guiding principles (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Chair of the Public Health Institute of Georgia and a WHO consultant, I recognize this guideline's strategic importance for our region's transition to sustainable oral health care. The Minamata Convention obligations require Georgia to phase down dental amalgam use, and this evidence base provides the roadmap. I would particularly stress to Georgian clinicians the strong recommendation for biannual silver diamine fluoride application—this simple, low-cost intervention can arrest caries in primary teeth and root surfaces without requiring the infrastructure of conventional restorative dentistry, making it ideal for our rural areas and mobile clinic programmes. The realistic implementation caveat is that Georgia must urgently invest in training our dental workforce on these techniques, update our national essential medicines list to include these products, establish reliable supply chains for mercury-free materials, and develop waste management infrastructure compliant with international standards—none of which currently exists at scale in our country.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus as the region strengthens oral health services within universal health coverage frameworks. Georgia’s national oral health programmes should consider how to integrate preventive fluoride applications and silver diamine fluoride into school-based and community health settings, particularly in rural areas where access to specialized dental care is limited. The emphasis on glass ionomer cements as alternatives requiring less infrastructure aligns well with capacity constraints in remote regions of Georgia, Armenia, and Azerbaijan. National programmes will need to assess current dental amalgam use patterns, update procurement policies for mercury-free materials, establish training programmes for mid-level oral health workers, and develop waste management systems compliant with the Minamata Convention. The guideline’s focus on preventive and minimally invasive approaches supports cost-effective oral health care delivery in resource-constrained settings typical of the region.

Questions this guideline answers

Quick answers

What is the recommended frequency for fluoride varnish application?

Twice a year for both prevention and management of dental caries. This biannual protocol is most commonly used in studies and specified by manufacturers for 5% sodium fluoride varnish.

Why should resin-based composites containing BPA derivatives be limited in children and pregnant women?

BPA is recognized as an endocrine-disrupting substance. Children, adolescents, and pregnant or breastfeeding women are particularly susceptible to potential endocrine effects during vulnerable developmental periods. Although BPA exposure from dental materials is low, the guideline applies the precautionary principle given uncertain long-term health implications.

When should glass ionomer cements be preferred over resin-based composites?

Glass ionomer cements are suitable for non-load-bearing restorations, for children and older adults, and when tooth-coloured appearance is less critical. They are simpler and quicker to apply, do not require specialized equipment or strict moisture control, release fluoride, and are particularly appropriate for patients who have difficulty cooperating during dental procedures or in low-resource settings.

How should silver diamine fluoride staining be managed in clinical practice?

The guideline emphasizes shared decision-making and informed consent. Patients should be informed about the potential for black staining of treated lesions before application. Potassium iodide can be applied immediately after silver diamine fluoride to reduce staining, though its effect on efficacy is uncertain. Studies show staining concerns do not significantly affect quality of life.

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Guideline on environmentally friendly and less invasive oral health care for preventing and managing dental caries

What this guideline says

Key points

The four GRADE levels of quality of evidence

From the guideline