Dental Caries: The Disease and its Clinical Management

Contributors xi

Part I Dental caries: what is it and how widespread is it globally?

Chapter 1 Prologue 3
O. Fejerskov, B. Nyvad, and E.A.M. Kidd

Introduction 3

The role of cariology in restorative dentistry 3

The content of this textbook 4

Chapter 2 Dental caries: what is it? 7
O. Fejerskov, B. Nyvad, and E.A.M. Kidd

The disease 7

Terminology 9

Background literature 9

References 10

Chapter 3 Clinical features of caries lesions 11
O. Fejerskov and B. Nyvad

What do caries lesions look like clinically? 11

The deciduous dentition 12

The permanent dentition 13

Chapter 4 How big is the problem? Epidemiological features of dental caries 21
V. Baelum and O. Fejerskov

Introduction 21

What? Defining the health issue at hand 21

Who? The distribution of caries in populations 28

Where? The geography of caries 35

When? Trends in caries 37

Why? The causes of caries 37

References 41

Part II The caries lesion and its biological determinants

Chapter 5 Pathology of dental caries 49
O. Fejerskov

Introduction 49

Human dental enamel at time of eruption 51

Enamel changes during early caries lesion development 55

The approximal white spot lesion 58

Progression of the enamel lesion 63

Arrest of the caries lesion 63

Occlusal caries 66

Dentin reactions to caries progression 71

Pulpo-dentinal reactions 71

Root-surface caries 77

Background literature 80

References 80

Chapter 6 Saliva and caries development 83
A. Bardow and A. Vissink

Introduction 83

Saliva and salivary glands 84

Saliva and caries development: biological aspects 87

Saliva and caries development: clinical aspects 98

Evaluation of salivary gland function 101

Management of salivary gland hypofunction 104

Concluding remarks 105

Background literature 105

References 105

Chapter 7 Biofilms in caries development 107
P.D. Marsh, N. Takahashi, and B. Nyvad

Introduction 107

The resident microflora 108

Dental biofilms: development, structure, composition, and properties 111

Caries microbiology: a brief historical perspective 121

Methodological problems in microbiological studies of dental caries 121

Microbiology of caries 122

Cariogenic features of dental biofilm bacteria 125

The ‘ecological plaque hypothesis’ to explain the role of dental biofilm bacteria in the etiology of dental caries 125

Concluding remarks 129

Background literature 129

References 129

Chapter 8 Diet and dental caries 133
C. van Loveren and P. Lingström

History 133

Early ecological studies 134

Experimental human studies 134

Influence of fluoride on the diet–caries relationship 135

Measuring cariogenicity 136

Sweeteners 141

Protective factors in foods 149

Diet and dental erosion 150

Conclusion 151

References 151

Chapter 9 Demineralization and remineralization: the key to understanding clinical manifestations of dental caries 155
O. Fejerskov and M.J. Larsen

Introduction 155

Enamel mineral 156

Stability of calcium phosphates 156

Crystal dissolution 157

Why is apatite solubility increased by acid? 158

Effect of carbonate and fluoride on apatite dissolution and growth 159

Demineralization and remineralization of the dental hard tissues 160

Caries demineralization 162

Remineralization of enamel 164

Remineralization of dentin 166

Background literature 169

References 170

Part III Diagnosis

Chapter 10 The foundations of good diagnostic practice 173
V. Baelum, B. Nyvad, H.-G. Gröndahl, and O. Fejerskov

Introduction 173

The making of a dentist 174

The dental examination: in the best interest of our patients 175

What are we looking for? What is caries? 176

The wealth of caries diagnostic methods and criteria 178

The evolution in caries diagnostic methods 178

Diagnostic test assessment in the essentialistic gold-standard paradigm 179

Evaluating caries diagnostic methods 180

Leaps in the essentialistic gold-standard reasoning 181

Diagnostic test evaluation in the nominalistic caries paradigm 183

Inter- and intra-examiner errors in caries diagnosis 184

How do we deal with the unavoidable diagnostic uncertainty? 185

The additional diagnostic yield argument 186

Concluding remarks 187

References 188

Chapter 11 Visual–tactile caries diagnosis 191
B. Nyvad, V. Machiulskiene, V.M. Soviero, and V. Baelum

Introduction 191

The diagnostic process 192

Why do we diagnose caries? 193

Diagnosis from a dental caries perspective 193

How early should caries lesions be detected? 194

What are the best visual–tactile caries diagnostic criteria? 195

Commonly used visual–tactile criteria 197

Differential diagnosis 201

Visual–tactile caries examination: a systematic clinical approach 205

Additional aids in visual–tactile caries diagnosis 207

Benefits and limitations of visual–tactile caries diagnosis 208

References 209

Chapter 12 Additional caries detection methods 211
H. Hintze, A. Lussi, F. Cuisinier, and B. Nyvad

Introduction 211

Radiography 211

Methods based on light and electrical current 223

Are the additional methods suitable for use in clinical practice? 229

Can the methods serve as adjuncts to a visual–tactile caries examination? 229

References 229

Part IV Controlling dental caries

Chapter 13 The caries control concept 235
B. Nyvad and O. Fejerskov

Why the caries control concept should replace caries prevention 235

How caries control was managed in the past 236

Arrest of active enamel caries 237

Arrest of active root caries 238

Arrest of active cavitated caries 239

Role of fluoride in lesion arrest 242

Benefits and limitations of the caries control approach – and some recommendations 242

References 242

Chapter 14 Fluorides in caries control 245
O. Fejerskov, J.A. Cury, L.M. Tenuta, and V.C. Marinho

Introduction 245

Fluoride in caries prevention and control 246

Cariostatic mechanisms of fluoride 250

Dental fluorosis and metabolism of fluoride 253

The effectiveness of fluorides in the control of dental caries: evidence from systematic reviews 263

Rational use of fluorides in caries control in different parts of the world: recommendations 271

Background literature 272

References 272

Chapter 15 The role of oral hygiene 277
B. Nyvad

Introduction 277

Some theoretical considerations 277

The biological effect of tooth cleaning 278

The clinical effect of tooth cleaning 278

The effect of professional tooth cleaning 282

The effect of dental flossing 283

Concluding remarks 283

References 284

Chapter 16 Are antibacterials necessary in caries prophylaxis? 287
A.A. Scheie, H.V. Rukke, and F.C. Petersen

The biofilm lifestyle and the rationale for antibacterial intervention 287

Biological activity and mode of action 288

Vehicles for caries prophylactic agents 292

Specific agents 292

Other agents proposed for caries prophylaxis, but without documented anticaries effects 296

Risk of antibacterial resistance development? 298

Concluding remarks and future approaches 299

Background literature 299

References 299

Chapter 17 The principles of caries control for the individual patient 303
B. Nyvad and E.A.M. Kidd

Introduction 303

How are current caries activity and risk of future caries progression assessed? 304

How is the information used to categorize patients into risk groups? 307

What nonoperative treatments are available? 308

How is the individual helped to control disease progression? 312

When should the patient be recalled? 312

Caries control in children and adolescents 314

Patients with a dry mouth 317

Failure 318

References 319

Chapter 18 Caries control for frail elders 321
M.I. MacEntee, S.R. Bryant, H. Keller, C.T. Nguyen, and C.S. Yao

Introduction 321

A conceptual model of oral health 321

Frailty 322

Physical characteristics of caries in elderly mouths 323

Incidence of caries in frail adults 323

Recognizing the risk of caries 324

Impact of caries in frailty 326

Management of caries in frailty 327

Summary 329

References 330

Part V Operative intervention

Chapter 19 Classical restorative or the minimally invasive concept? 335
E.A.M. Kidd, J. Frencken, B. Nyvad, C.H. Splieth, and N.J.M. Opdam

Operative dentistry and caries control 335

Sealants 339

Atraumatic restorative treatment 345

Conventional minimal intervention methods 353

Minimal intervention and the deciduous dentition 365

References 370

Chapter 20 Caries ‘removal’ and the pulpo-dentinal complex 375
E.A.M. Kidd, L. Bjorndal, and O. Fejerskov

Introduction 375

The pulpo-dentinal complex and caries 376

Pulpitis and its clinical diagnosis 376

Why are pulpo-dentinal reactions important to the choice of operative management? 376

The infected dentin concept and its clinical consequence 377

Studies placing fissure sealants over carious dentin 379

Stepwise excavation studies 380

Randomized controlled clinical trials on stepwise excavation outcome 382

Do we need to reenter? 382

What happens if we do not remove caries at all but seal it in the tooth permanently? 384

Further consideration of deciduous teeth 384

Conclusion on caries removal and the pulpo-dentinal complex 385

References 385

Chapter 21 Longevity of restorations: ‘the death spiral’ 387
V. Qvist

Introduction 387

Clinical assessment of restorations 388

Assessment of restoration longevity 388

The amalgam debate and its consequences for restoration longevity 391

Longevity of restorations in the primary dentition 391

Longevity of restorations in the permanent dentition 394

Longevity of fissure sealants 395

Longevity of atraumatic restorative treatment restorations 396

Factors influencing restoration longevity 397

Consequences of restoration longevity for dental health and cost 398

Concluding remarks 399

References 400

Part VI From chair-side to population caries control

Chapter 22 Caries prevention and control in low- and middle-income countries 405
W. van Palenstein Helderman, C. Holmgren, B. Monse, and H. Benzian

Introduction 405

Caries: a public health problem in low- and middle-income countries 406

Health and oral health systems in low- and middle-income countries 408

Public health approaches to address caries in low- and middle-income countries 411

Conclusions and recommendations 417

References 420

Chapter 23 How accurately can we assess the risk for developing caries lesions? 423
H. Hausen and V. Baelum

Introduction 423

The risk of developing caries lesions cannot be observed directly for an individual patient 424

The course of a typical study for evaluating the accuracy of a prediction 425

A real-life example of using a single, dichotomous predictor 427

Interpretation and use of the measures of prediction accuracy 427

What level of accuracy would be sufficient in everyday practice? 432

What level of accuracy can be achieved? 433

Clinical caries risk assessment: is it possible? 435

How valuable are the proposed measures? 436

Concluding remarks 436

Background literature 436

References 436

Chapter 24 Caries control in low-caries populations 439
H. Hausen, M. Jossing, and O. Fejerskov

Introduction 439

A low caries frequency entails the polarization of the caries problem 439

Are effective and feasible measures available for protecting the high-risk individuals from dental decay? 440

Noninvasive treatment of early caries lesions among teenagers exposed to community-wide oral health promotion 441

A model for controlling caries in low-caries child populations 442

A demonstration case in 0–18-year-old Danes 443

Concluding remarks 446

References 447

Chapter 25 Epilogue. Controlling the global burden of dental caries: the evidence calls for a reorganization of the oral health-care system 449
O. Fejerskov, V. Baelum, B. Nyvad, and E.A.M. Kidd

Index 453