Dental Caries: The Disease and its Clinical Management

Contributors xi

Preface xiii

Part I Dental caries: What is it and what is the magnitude of the problem?

Chapter 1 Dental caries – definitions and clinical features 3
Ole Fejerskov and Bente Nyvad

The editors’ view on dental caries and introduction to the book 3

Terminology 5

Examples of dental caries 6

Background literature 15

Chapter 2 Strategic public health considerations for caries control in populations 17
Anja Heilmann and Richard G. Watt

Introduction 17

The global burden of dental caries 18

The role of sugar in the etiology of dental caries 18

Public health principles for preventive action 21

Overview of upstream, midstream, and downstream strategies to prevent dental caries 27

Implications for the dental profession and oral health care systems 30

Conclusion 30

References 31

Chapter 3 Dental caries epidemiology 35
Firoze Manji and Ole Fejerskov

Introduction 35

Probability of an outcome 36

Some standard terms used in epidemiology 40

Measures of central tendency: Mean, median, mode 42

Types of investigation 43

Problems of determining the role of specific factors 44

Analysis and interpretation of data 45

Drawing inferences about associations 51

Age and dental caries 54

International comparisons of occurrence of dental caries 54

Background literature 56

References 56

Part II Diagnosis and detection

Chapter 4 Visual–tactile caries diagnosis and the role of bitewing radiography 61
Bente Nyvad, Vita Machiulskiene, and Vibeke Baelum

Introduction 62

The diagnostic process 62

Two differing perspectives on caries detection 63

Achieving the best health outcome for the patient by classifying caries lesions according to the best management options for each lesion type 63

How early should caries lesions be detected? 65

What are the best visual–tactile caries diagnostic criteria? 65

Commonly used visual–tactile criteria 68

Differential diagnosis 74

Visual–tactile caries examination: A systematic clinical approach 76

Benefits and limitations of visual–tactile caries diagnosis 78

Do we need radiographs for caries detection? 79

Conclusion 82

References 83

Chapter 5 The foundations of good diagnostic practice 85
Vibeke Baelum

Introduction 85

The making of a dentist 86

The dental examination: In the best interest of our patients 87

What are we looking for? What is caries? 88

The wealth of caries diagnostic methods and criteria 90

The evolution in caries diagnostic methods 90

Diagnostic test assessment in the essentialistic gold-standard paradigm 91

Evaluating caries diagnostic methods 92

Leaps in the essentialistic gold-standard reasoning 93

Diagnostic test evaluation in the nominalistic caries paradigm 95

Inter- and intra-examiner errors in caries diagnosis 96

How do we deal with the unavoidable diagnostic uncertainty? 97

The additional diagnostic yield argument 98

Concluding remarks 99

References 100

Part III The oral environment and dental caries

Chapter 6 The oral microbiome – composition, acquisition, establishment, and maturation 105
Gunnar Dahlén

The microbiome 105

The composition of the oral microbiome 107

The composition and structure of oral mucosal and tongue microbiome 116

Dental plaque microbiome 117

The oral microbiome and immunity 120

Acquisition of the oral microbiome 123

Establishment of the oral microbiome 125

Maturation of the oral microbiome 125

Conclusions 129

Background literature 129

References 129

Chapter 7 Functions of the oral microbiome in caries and how they can be controlled 133
Nobuhiro Takahashi and Bente Nyvad

Introduction 133

Bacterial metabolism and ecological factors affecting the cariogenic features of dental biofilm 134

The ‘ecological plaque hypothesis’ to explain the role of dental biofilm bacteria in the etiology of dental caries 135

How to control a cariogenic drift of the oral microbiome 141

Clinical approaches to caries control by interference with microbial metabolism 144

Prebiotics, probiotics, and synbiotics 146

Concluding remarks 148

References 149

Chapter 8 The essential role of saliva in dental caries and erosion 153
Anne Marie Lynge Pedersen

Introduction 153

The salivary glands and their secretion 154

Neuronal regulation of salivary secretion 155

Formation of saliva 157

Saliva and its role in maintaining dental health 159

The functions of saliva flow and its inorganic and organic electrolytes 164

Saliva gland hypofunction and dental caries and erosion 170

Evaluation of salivary gland function 172

Management of salivary gland hypofunction 175

Concluding remarks 175

Background literature 176

References 176

Part IV What happens in the dental hard tissues and key determinants of caries

Chapter 9 The process of de- and remineralization – the key to understanding clinical manifestations of dental caries 181
Ole Fejerskov and Mogens Joost Larsen

Introduction 181

Enamel mineral 182

Stability of calcium phosphates 183

Crystal dissolution 183

Why is apatite solubility increased by acid? 184

Effect of carbonate and fluoride on apatite dissolution and growth 185

Demineralization and remineralization of the dental hard tissues 186

Caries demineralization 188

Remineralization of enamel 190

Remineralization of dentin 192

Background literature 196

References 196

Chapter 10 Initiation and progression of dental caries in dental hard tissues 199
Ole Fejerskov

Introduction 199

Human dental enamel at the time of eruption 201

Enamel changes during early caries lesion development 205

The approximal white spot lesion 209

Progression of the enamel lesion 213

Arrest of the caries lesion 215

Occlusal caries 216

Dentin reactions to caries progression 221

Pulpo-dentinal reactions 221

Root surface caries 227

Background literature 230

References 230

Chapter 11 Erosion of the teeth 233
Mogens Joost Larsen

Introduction 233

Clinical manifestations and diagnosis 233

Histological and chemical features 236

Classification by depth of the lesion 237

Classification by etiology 237

Erosion caused by food and drinks 237

Erosion caused by stomach contents 242

Erosion caused by airborne acids 243

Idiopathic erosion 243

Prophylaxis and treatment of erosion 244

Conclusion 246

Background literature 246

References 246

Chapter 12 Sugar, diet, and dental caries 247
Cor van Loveren, Peter Lingström, and Bente Nyvad

Introduction 247

History 248

Early ecological studies 248

Experimental human studies 249

Influence of fluoride on the diet – caries relationship 250

Which is of more importance – amount or frequency of sugar consumption? 251

Measuring cariogenicity 251

Sweeteners 256

Protective factors in foods 265

Diet and dental erosion 266

Dietary advice for dental health promotion 266

References 267

Chapter 13 Oral hygiene – does it matter? 273
Bente Nyvad

Introduction 273

Some theoretical considerations 273

The biological effect of tooth cleaning 274

The clinical effect of tooth cleaning 274

The effect of professional tooth cleaning 278

The effect of dental flossing 279

Does tooth cleaning matter? 279

References 280

Chapter 14 Fluorides in caries control 283
Ole Fejerskov, Jaime A. Cury, Livia M. A. Tenuta, and Firoze Manji

Introduction 283

Fluoride in caries control 284

Anticaries mechanisms of fluoride 288

Dental fluorosis and metabolism of fluoride 292

Fluoride dose and dental fluorosis 296

Where is fluoride found in nature? 300

Fluoride absorption, distribution, and elimination 300

Fluoride concentration in teeth 301

Pathogenesis of dental fluorosis 303

The efficacy and effectiveness of fluorides in the control of dental caries: Systematic review 303

Rational use of fluorides in caries control 309

Background literature 310

References 310

Part V Caries Control in Children, Adults and Elderly

Chapter 15 The caries control concept 317
Bente Nyvad and Ole Fejerskov

Why the caries control concept should replace caries prevention 317

How caries control was managed in the past 318

Arrest of active enamel caries 319

Arrest of active root caries 320

Arrest of active cavitated caries 321

Role of fluoride in lesion arrest 324

Benefits and limitations of the caries control approach – and some recommendations 324
References 324

Chapter 16 Caries control for the individual patient in all age groups 327
Bente Nyvad and Edwina A.M. Kidd

Introduction 327

How are current caries activity and risk of future caries progression assessed? 328

The ‘dental traffic light’ 331

What non-operative, treatments are available? 332

How is the individual helped to control disease progression? 337

When should the patient be recalled? 337

Caries control in children and adolescents 339

Caries control in the frail elderly 343

Failure 345

References 346

Part VI Intervention and treatment

Chapter 17 Carious cavities – how to manage the ‘infected’ dentin and the pulpal response 351
Bente Nyvad, Edwina A.M. Kidd, and Ole Fejerskov

Introduction 351

The caries process in dentin 352

Mineral distribution in dentin caries 352

Inflammatory reactions to caries in the dental pulp 354

How to manage the carious dentin 355

How much carious dentin needs to be removed? 355

Excavation techniques 356

Excavation protocols 356

Excavation of deep dentin lesions 358

Concluding remarks 360

References 360

Chapter 18 Control of dental caries by minimally invasive restorative intervention 363
Sebastian Schlafer, Irene Dige, and Bente Nyvad

Introduction 363

The strategy for minimally invasive restorative intervention of caries 364

Micro-invasive treatments 364

Minimally invasive operative treatment 369

Defective restorations: replacement or repair? 376

A final word of caution 377

References 377

Part VII The Implication of Caries Control for the Dental profession

Chapter 19 How accurately can we assess the risk of developing caries lesions? 383
Hannu Hausen

Introduction 383

The risk of developing caries lesions cannot be observed directly for an individual patient 384

The course of a typical study for evaluating the accuracy of a prediction 385

A real-life example of using a single, dichotomous predictor 387

Interpretation and use of the measures of prediction accuracy 387

What level of accuracy would be sufficient in everyday practice? 393

What level of accuracy can be achieved? 393

Social factors 395

Clinical caries risk assessment: is it possible? 396

How valuable are the proposed measures? 396

Concluding remarks 397

Background literature 397

References 397

Chapter 20 Oral health care – past, present, and future perspectives 401
Ole Fejerskov and Firoze Manji

A brief history of the emergence of dentistry 401

How many dentists are needed? 402

Caries research in the last 50 years 403

A possible future for oral health care in the times of COVID-19 404

References 405

Index 407