Barriers and enablers influencing the implementation of minimally invasive caries management: a systematic review and behavioural analysis.

INTRODUCTION

Minimally Invasive Dentistry (MID) aims to preserve tooth structure and maintain pulp vitality. Despite MID being incorporated into clinical guidelines, an evidence-practice gap persists. This systematic review aimed to synthesise the barriers and enablers influencing the implementation of MID for the management of carious lesions.

METHOD: This PROSPERO registered mixed methods systematic review (CRD42022342877) followed PRISMA guidelines. MEDLINE, EMBASE, Scopus, CENTRAL, the Cochrane Library, JBI, and ProQuest were searched from 01/01/1970 to 18/05/2025. Eligible studies were primary quantitative, qualitative, or mixed methods studies examining barriers and enablers to MID implementation, with no restrictions on language, participants, or setting. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT), with moderate or high-quality studies included. A narrative synthesis was undertaken with findings mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF). No funding sought.

RESULTS

From 13,086 records, 87 studies from 26 countries were included, comprising 5,100 child patients, 934 adult patients, 1,131 parents, 159 mixed patient groups, 15,145 practitioners, 172 educators, and 1,644 students. Perspectives were reported from practitioners (n=34), patients (n=49), and the education sector (n=6). The most frequently studied approaches were atraumatic restorative treatment (n=23), silver diamine fluoride (n=23) and the Hall Technique (n=18). Eight themes were identified: practitioner-related, patient-related, evidence, outcomes, financial, social, procedural, and organisational factors. These were sub-categorised into 27 subthemes representing key barriers and enablers, many of which operated as both depending on context. All COM-B components and TDF domains were represented with beliefs about consequences (n=26), environmental context and resources (n=19), social influences (n=17), reinforcement (n=14), and knowledge (n=11) being the most common. One study evaluated an intervention to support MID implementation, targeting practitioner knowledge. A limitation of this review is that it reports frequencies of barriers and enablers without assessing their relative importance.

CONCLUSION

Implementation of MID is influenced by multiple interacting behavioural determinants spanning all COM-B factors and TDF domains, with substantial overlap across MID approaches, suggesting that unified, multifaceted implementation strategies may be appropriate. The limited evidence on how best to support MID implementation highlights an important priority for future research.