9783131547118_inhaltsverzeichnis

XIIITable of Contents

Table of Contents

Part 1: CariesScience

The Disease

1 Ecology of the Oral CavityKim R. Ekstrand, Domenick T. Zero

Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Tooth Development and Tooth Emergence. . . . . . . 4Macromorphological Terms . . . . . . . . . . . . . . . . 4Occlusal Surfaces . . . . . . . . . . . . . . . . . . . . . . . 4Approximal Surfaces . . . . . . . . . . . . . . . . . . . . . 7The Cervical Enamel Line and the Roots . . . . . . . . 7Enamel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Chemical Composition and Structure ofApatite Crystals . . . . . . . . . . . . . . . . . . . . . . . . 8The DentinPulp Organ . . . . . . . . . . . . . . . . . . . 9The Cementum . . . . . . . . . . . . . . . . . . . . . . . . 10

Saliva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Saliva Production, Salivary Glands . . . . . . . . . . . 10Function of Saliva . . . . . . . . . . . . . . . . . . . . . . 10Pellicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Hyposalivation . . . . . . . . . . . . . . . . . . . . . . . . 13

Changes in Teeth and Saliva with Aging . . . . . . 13Dental Plaque or Dental Biofilm? . . . . . . . . . . . 14Classifying Oral Microorganisms . . . . . . . . . . . . . 14Colonization of the Mouth in the Newborn. . . . . . 15Plaque: Development and Metabolic End Products . 15Plaque Stagnation Areas . . . . . . . . . . . . . . . . . . 16Plaque Composition and Structure inStagnation Areas . . . . . . . . . . . . . . . . . . . . . . . 17

2 Etiology and Pathogenesis of CariesPeter Shellis

Microbiology of Caries . . . . . . . . . . . . . . . . . . . 23Chemistry of Dental Minerals . . . . . . . . . . . . . . 25Solubility, Dissolution, and Crystal Growth . . . . . . 25Minerals of Dental Tissues . . . . . . . . . . . . . . . . . 26Fluoride and Calcium Phosphate Chemistry . . . . . . 27

The Cariogenic Challenge . . . . . . . . . . . . . . . . . 28

Chemistry of Caries . . . . . . . . . . . . . . . . . . . . 33Enamel Lesion Formation . . . . . . . . . . . . . . . . . 33Dentin Lesion Formation. . . . . . . . . . . . . . . . . . 34Fluoride and Lesion Formation . . . . . . . . . . . . . . 34Remineralization and Lesion Arrest . . . . . . . . . . . 34

Dental Erosion . . . . . . . . . . . . . . . . . . . . . . . . 35

3 Histological and Clinical Appearance of CariesWolfgang Buchalla

Enamel Caries . . . . . . . . . . . . . . . . . . . . . . . . . 40Location in the Teeth. . . . . . . . . . . . . . . . . . . . . 40The White Spot Lesion . . . . . . . . . . . . . . . . . . . 42Activity of White and Brown Spot Lesions . . . . . . . 42Transmitted and Polarized Light Microscopy . . . . . 43Transverse Microradiography . . . . . . . . . . . . . . . 46Scanning Electron Microscopy. . . . . . . . . . . . . . . 47Transmission Electron Microscopy . . . . . . . . . . . . 48

Dentin Caries . . . . . . . . . . . . . . . . . . . . . . . . . 48Early Signs of Dentin Reaction . . . . . . . . . . . . . . 50Continuing Caries Progression into Dentin. . . . . . . 51

Spread of Bacteria within Dentin . . . . . . . . . . . . 52Hardness of Carious Dentin . . . . . . . . . . . . . . . . 52Fluorescence Properties of Carious andHealthy Dental Hard Tissue . . . . . . . . . . . . . . . . 54

Caries of the Exposed Root . . . . . . . . . . . . . . . 55Caries Arrest and Remineralization . . . . . . . . . . 57Correlation of Histology with Radiographyand Clinical Appearance of Caries . . . . . . . . . . . 58Erosiona Noncarious Defect . . . . . . . . . . . . . 59

aus: Meyer-Lueckel u. a., Caries Management - Science and Clinical Practice (ISBN 9783131547118) 2013 Georg Thieme Verlag KG

XIV Table of Contents

4 Paradigm Shift in CariologySebastian Paris, Hendrik Meyer-Lueckel

Scientific Paradigms . . . . . . . . . . . . . . . . . . . . 65How Paradigms Influence Our Clinical Approach . 65The Specic Plaque Hypothesis . . . . . . . . . . . . . . 65The Ecological Plaque Hypothesis . . . . . . . . . . . . 66

A Current Model of Caries . . . . . . . . . . . . . . . . 66

Diagnostics and Epidemiology

5 VisualTactile Detection and AssessmentKim R. Ekstrand, Stefania Martignon

General Remarks . . . . . . . . . . . . . . . . . . . . . . . 70Histological and Clinical Features of Caries . . . . . 71Coronal Caries Lesions . . . . . . . . . . . . . . . . . . . . 71Root Caries Lesions . . . . . . . . . . . . . . . . . . . . . . 73Caries Adjacent to Restorations . . . . . . . . . . . . . . 74

Indices for Clinical Recording of Caries Lesions . . 74Historical Perspective . . . . . . . . . . . . . . . . . . . . 74

Correlation between Histology andClinical Severity: the ICDAS System . . . . . . . . . . 76

Coronal Caries Lesions . . . . . . . . . . . . . . . . . . . 76Root Caries Lesions . . . . . . . . . . . . . . . . . . . . . 78Caries Adjacent to Restorations . . . . . . . . . . . . . 78

Caries Activity Assessment . . . . . . . . . . . . . . . 79Coronal Caries Lesions . . . . . . . . . . . . . . . . . . . 79Root Caries Lesions . . . . . . . . . . . . . . . . . . . . . 79Caries Adjacent to Restorations . . . . . . . . . . . . . 80

The Visual Difference between Cariesand other Dental Hard Tissue Defects . . . . . . . . 82

6 Radiographic and Other Additional Diagnostic MethodsRainer Haak, Michael J. Wicht

Radiographic Caries Diagnostics . . . . . . . . . . . . 87Context of Radiographic CariesDetection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Validity and Reliability of RadiographicCaries Detection . . . . . . . . . . . . . . . . . . . . . . . . 88

Which Gold Standard? . . . . . . . . . . . . . . . . . 88Sensitivity and Specicity . . . . . . . . . . . . . . . 89Reproducibility . . . . . . . . . . . . . . . . . . . . . . 89

Conventional and Digital Bitewing X-ray Imaging . . 89Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Advantages of Digital Technologies . . . . . . . . . 89

Tuned-Aperture Computed Radiography andDigital Volume Tomography . . . . . . . . . . . . . . . . 89Bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Preparations . . . . . . . . . . . . . . . . . . . . . . . . 91Taking Bitewing X-ray Photos . . . . . . . . . . . . . 91Reproducible Adjustment. . . . . . . . . . . . . . . . 92

Documenting the Findings of Bitewing Images . . . 93Radiographic Extension and Clinical Findingsof Approximal Supercial Lesions . . . . . . . . . . 93Evaluating Occlusal Surfaces . . . . . . . . . . . . . 94The Mach Band Eect. . . . . . . . . . . . . . . . . . 95Estimating the Probability of CariesProgression . . . . . . . . . . . . . . . . . . . . . . . . 95

Determining the Radiologic Follow-up Interval . . . 95Relevant Factors . . . . . . . . . . . . . . . . . . . . . 95Special Considerations for Children andAdolescents . . . . . . . . . . . . . . . . . . . . . . . . 96

Other Caries Diagnostic Methods . . . . . . . . . . . 97Fiber-optic Transillumination . . . . . . . . . . . . . . . 97Methods Based on Fluorescence . . . . . . . . . . . . . 97Electrical Conductivity . . . . . . . . . . . . . . . . . . . 98

7 Caries Risk Assessment and PredictionCornelis van Loveren

The Dentists Clinical Judgment. . . . . . . . . . . . . 103Crude Hit Rate of a Predictor . . . . . . . . . . . . . . 103Utilities of Predictors . . . . . . . . . . . . . . . . . . . . 105Objective Predictors . . . . . . . . . . . . . . . . . . . . 108ROC curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Cariogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Signs of Past Caries Experience . . . . . . . . . . . . . 113Too Young to Have Past CariesExperience . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Active versus Nonactive Lesions . . . . . . . . . . . . . 115

The Nex Model. . . . . . . . . . . . . . . . . . . . . . . 116


XVTable of Contents

8 Epidemiology of Caries and Noncarious DefectsUlrich Schiffner

General Relevance ofEpidemiology . . . . . . . . . . . . . . . . . . . . . . . . . 119Study Types . . . . . . . . . . . . . . . . . . . . . . . . . . 119Descriptive Epidemiology of Caries andNoncarious Defects . . . . . . . . . . . . . . . . . . . . . 120Epidemiological Identication of Caries. . . . . . . . . 120Indices for Coronal Caries. . . . . . . . . . . . . . . . . . 121Indices for Root Caries . . . . . . . . . . . . . . . . . . . . 123Other Indices for Public Health Needs. . . . . . . . . . 124Indices for Noncarious Defects . . . . . . . . . . . . . . 124

Developmental Defects of the DentalHard Tissues . . . . . . . . . . . . . . . . . . . . . . . . 124Acquired Defects of the Dental Hard Tissues . . . 125

Occurrence and Distribution of Caries . . . . . . . . 125Trends in Caries Epidemiology . . . . . . . . . . . . . 126Global Considerations . . . . . . . . . . . . . . . . . . . 126Children and Adolescents . . . . . . . . . . . . . . . . . 126

Association of Caries and Social Status . . . . . . . 128Adults and Seniors. . . . . . . . . . . . . . . . . . . . . . 128Root Caries. . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Occurrence and Distribution of NoncariousDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Developmental Defects . . . . . . . . . . . . . . . . . . . 129Acquired Defects of Enamel and Dentin . . . . . . . . 130

9 From Diagnostics to TherapySebastian Paris, Kim R. Ekstrand, Hendrik Meyer-Lueckel

From Diagnostics... . . . . . . . . . . . . . . . . . . . . . 134Diagnostics at the Individual Level . . . . . . . . . . . . 134Diagnostics at the Tooth Level. . . . . . . . . . . . . . . 134

How is Caries Diagnosed? . . . . . . . . . . . . . . . 134The Truth About Caries . . . . . . . . . . . . . . . . . 135Diagnostic Errors and Their Consequences. . . . . 136The Diagnostic Process . . . . . . . . . . . . . . . . . 137Categories and Thresholds . . . . . . . . . . . . . . . 138

...to Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 139Aim of Treatment . . . . . . . . . . . . . . . . . . . . . . . 139Treatment Approaches . . . . . . . . . . . . . . . . . . . 140Noninvasive Measures . . . . . . . . . . . . . . . . . . . . 140

Inuencing the Biolm . . . . . . . . . . . . . . . . . 140Inuencing Diet . . . . . . . . . . . . . . . . . . . . . . 140Inuencing Mineralization . . . . . . . . . . . . . . . 141

Microinvasive Measures . . . . . . . . . . . . . . . . . . 141Sealants. . . . . . . . . . . . . . . . . . . . . . . . . . . 141Inltration . . . . . . . . . . . . . . . . . . . . . . . . . 141

(Minimally) Invasive Measures. . . . . . . . . . . . . . 142Restoration . . . . . . . . . . . . . . . . . . . . . . . . 142Additional Measures . . . . . . . . . . . . . . . . . . 142

Which Measures are Indicated at What Time? . . 142Individual Level . . . . . . . . . . . . . . . . . . . . . . . 142Tooth Level . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Therapeutic Options for Occlusal Caries . . . . . . 143Therapeutic Options for Approximal Caries. . . . 143Therapeutic Options for Caries in AccessibleSmooth Surfaces . . . . . . . . . . . . . . . . . . . . . 143Therapeutic Options for Root Caries . . . . . . . . 144

Noninvasive Therapy

10 Caries Management by Modifying the BiolmSebastian Paris, Christof Doerfer, Hendrik Meyer-Lueckel

Dental Plaque as a Biofilm . . . . . . . . . . . . . . . . 147Mechanical Biofilm Control. . . . . . . . . . . . . . . . 148Correlation between Oral Hygiene and Caries . . . . 148Self-Applied Mechanical Biolm Control . . . . . . . . 148

Tooth Brushing . . . . . . . . . . . . . . . . . . . . . . 148Interdental Hygiene . . . . . . . . . . . . . . . . . . . 153

Professional Tooth Cleaning . . . . . . . . . . . . . . . . 154

Chemical Biofilm Control . . . . . . . . . . . . . . . . . 154Chlorhexidine . . . . . . . . . . . . . . . . . . . . . . . . . 155Xylitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Triclosan/Copolymer . . . . . . . . . . . . . . . . . . . . 155Essential Oil (Listerine) . . . . . . . . . . . . . . . . . . . 156Sodium Lauryl Sulfate . . . . . . . . . . . . . . . . . . . 156Metal Ions . . . . . . . . . . . . . . . . . . . . . . . . . . . 156General Considerations. . . . . . . . . . . . . . . . . . . 156

Biological Biofilm Control . . . . . . . . . . . . . . . . 156Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . 157Probiotic Therapy . . . . . . . . . . . . . . . . . . . . . . 157


XVI Table of Contents

11 Caries Management by Modifying DietBennett T. Amaechi

Carbohydrates (Sugars) in the Caries Process . . . 162Conventional Sugars . . . . . . . . . . . . . . . . . . . . . 162Sugar Metabolism and Acid Production byCariogenic Microorganisms . . . . . . . . . . . . . . . . 163

Intracellular Pathway . . . . . . . . . . . . . . . . . . 163Extracellular Pathway . . . . . . . . . . . . . . . . . . 164

Factors Modifying the Role of Sugars inCaries Development . . . . . . . . . . . . . . . . . . . . . 165

Frequency of Sugar Intake . . . . . . . . . . . . . . . 165Consistency of the Sugary Food . . . . . . . . . . . . 165Amount of Sugar Intake . . . . . . . . . . . . . . . . . 166Thickness and Age of the Plaque . . . . . . . . . . . 166

Sugar Alcohols . . . . . . . . . . . . . . . . . . . . . . . . 167Xylitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Sorbitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Maltitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Intense Sweeteners . . . . . . . . . . . . . . . . . . . . . 168

Other Food Components . . . . . . . . . . . . . . . . . 169Proteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169Food Preservatives. . . . . . . . . . . . . . . . . . . . . . 169Fresh Fruits, Vegetables,and Other Dietary Components . . . . . . . . . . . . . 170Inuence of Nutritional Deciencies in theCaries Process . . . . . . . . . . . . . . . . . . . . . . . . . 170

Population Groups with Raised Caries RiskDue to Dietary Pattern . . . . . . . . . . . . . . . . . . 170Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Dietary Guidance for Prevention ofDental Caries . . . . . . . . . . . . . . . . . . . . . . . . . 171Snacking Habit . . . . . . . . . . . . . . . . . . . . . . . . 172

Diet and Erosion . . . . . . . . . . . . . . . . . . . . . . 172

12 Caries Management by Inuencing MineralizationSvante Twetman, Kim R. Ekstrand

What is Fluorine/Fluoride? . . . . . . . . . . . . . . . . 177Units of Measure . . . . . . . . . . . . . . . . . . . . . . . 177

Fluoride in Our Surroundings . . . . . . . . . . . . . . 177Fluoride in Humans . . . . . . . . . . . . . . . . . . . . . 177Acute Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . 177Fluoride Absorption and Distribution . . . . . . . . . . 178Fluoride in Teeth . . . . . . . . . . . . . . . . . . . . . . . 179Fluoride in Saliva and in Plaque. . . . . . . . . . . . . . 179

From Mottled Enamel (Colorado Stained Teeth)to Dental Fluorosis . . . . . . . . . . . . . . . . . . . . . 180Prevalence of Dental Fluorosis . . . . . . . . . . . . . . 180

Effects of Water Fluoridation on Caries andDental Fluorosis: Pre- or Posteruption? . . . . . . . 182How Fluoride Interacts with the Caries Process. . 183Formation of Calcium Fluoride . . . . . . . . . . . . . . 183Inuence of Fluoride on Microbial Metabolism . . . . 184Discussion of Classical Data . . . . . . . . . . . . . . . . 184

Clinical Effectiveness of Fluoride . . . . . . . . . . . . 185Systemic and Topical Fluorides . . . . . . . . . . . . . . 186

Community-Based Fluoride Application . . . . . . . 186Water Fluoridation (After Introduction ofFluoride Toothpaste) . . . . . . . . . . . . . . . . . . . . 186Fluoridated Milk and Salt . . . . . . . . . . . . . . . . . 186

Individual Fluoride Application:Professionally Applied Fluorides . . . . . . . . . . . . 186Fluoride Varnishes . . . . . . . . . . . . . . . . . . . . . . 186Fluoride Solutions . . . . . . . . . . . . . . . . . . . . . . 187Fluoride Gels . . . . . . . . . . . . . . . . . . . . . . . . . 188

Individual Fluoride Application:Self-Applied Fluorides . . . . . . . . . . . . . . . . . . . 188Fluoride Toothpaste . . . . . . . . . . . . . . . . . . . . . 188Fluoride Mouth Rinses . . . . . . . . . . . . . . . . . . . 189Fluoride Tablets and Chewing Gums . . . . . . . . . . 189Other Fluoride-Containing Products and Devices . . 189

Safety of Fluorides . . . . . . . . . . . . . . . . . . . . . 189Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . 190Other Remineralization Agents . . . . . . . . . . . . 190CPP-ACP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

13 Oral Health Promotion: Implementation of Noninvasive Interventionsand Health-Related Behaviors to Control the Caries ProcessHendrik Meyer-Lueckel, Sebastian Paris

Implementing Strategies of Prevention . . . . . . . 195PreventionWhat Does This Mean? . . . . . . . . . . . 195Why Do People Get Sick? . . . . . . . . . . . . . . . . . . 195

A Little More Upstream: Setting-Approaches . . . . 196Most Upstream: the Population-Based CommonRisk Factor Approach . . . . . . . . . . . . . . . . . . . . 197


XVIITable of Contents

Contemporary Strategies to Improve Oral Health 197High-Risk versus Population-Based . . . . . . . . . . . 197Noninvasive Interventions versusBehavioral Change in Caries Prevention . . . . . . . . 199

Is it Possible to Change Oral HealthRelatedBehaviors? . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Denition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

Effectiveness of Contemporary Programs forCaries Prevention . . . . . . . . . . . . . . . . . . . . . . 200Role of Routine Serial Examinations inCommunities . . . . . . . . . . . . . . . . . . . . . . . . . . 200Population-Based Approaches . . . . . . . . . . . . . . . 200

Mass Campaigns to Change Behavior . . . . . . . . 200Fluoridated Water . . . . . . . . . . . . . . . . . . . . 200Fluoridated Salt . . . . . . . . . . . . . . . . . . . . . . 200

Approaches for Communities: Medical Options . . . 201Fluoride Tablets . . . . . . . . . . . . . . . . . . . . . 201Providing Free Fluoride Toothpaste . . . . . . . . . 201Other Methods of Fluoride Application . . . . . . 201

Approaches for Communities:Oral Health Education . . . . . . . . . . . . . . . . . . . 202

Supervised Tooth Brushing . . . . . . . . . . . . . . 202Programs Relying on Oral Health Education . . . 202Setting-Approaches . . . . . . . . . . . . . . . . . . . 203

Approaches for Communities:Combining Medical Options and Oral HealthEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . 203One-to-One Situation in Dental Practice . . . . . . . . 204

Adhesion

14 Basics in Adhesion TechnologyBart Van Meerbeek, Yasuhiro Yoshida

Evolution of Adhesive Technology in Generations 209Early Days. . . . . . . . . . . . . . . . . . . . . . . . . . . . 209Breakthrough in Adhesion Technology . . . . . . . . . 210No Separate Etching? . . . . . . . . . . . . . . . . . . . . 210

Modern Classification of Adhesives . . . . . . . . . . 210Interaction with Hydroxyapatite-Based Tissues . . 212Current Strategies for Bonding to Enamel . . . . . 212Obstacles in Bonding to Dentin . . . . . . . . . . . . . 214Bonding to Dentin through the Etch-and-RinseApproach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214Shortcomings of Etch-and-Rinse Technologyand Potential Solutions . . . . . . . . . . . . . . . . . . 215Wet BondingHow Moist is Wet? . . . . . . . . . . . . 216

Rewetting . . . . . . . . . . . . . . . . . . . . . . . . . . . 216Nanoleakage. . . . . . . . . . . . . . . . . . . . . . . . . . 217Recent Developments. . . . . . . . . . . . . . . . . . . . 217

Bonding to Dentin through the Self-EtchApproach . . . . . . . . . . . . . . . . . . . . . . . . . . . 218Nomenclature. . . . . . . . . . . . . . . . . . . . . . . . . 218Mild Self-Etch Adhesives. . . . . . . . . . . . . . . . . . 218

Mechanisms of Bond Degradation . . . . . . . . . . 219Bonding to Carious Dentin . . . . . . . . . . . . . . . 220Clinical Performance. . . . . . . . . . . . . . . . . . . . 220Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Microinvasive Therapy

15 Fissure SealingHafsteinn Eggertsson

Caries Prevalence on Occlusal Surfaces. . . . . . . . 226The SealantRestoration Spectrum . . . . . . . . . . 226Epidemiological considerations . . . . . . . . . . . . . . 227

Fissure Morphology. . . . . . . . . . . . . . . . . . . . . 228The Fissure as Substrate for Resin Bonding . . . . . 229Cleaning of Fissures Prior to Sealant Placement . 230Should Mechanical Preparation Be Routine? . . . . 230Glass-Ionomer Sealants . . . . . . . . . . . . . . . . . . 231

Preventive versus Therapeutic Sealants . . . . . . . 231Sealing over Caries? . . . . . . . . . . . . . . . . . . . . 232Moisture Control . . . . . . . . . . . . . . . . . . . . . . 233Are Sealants Working Clinically? . . . . . . . . . . . 233Sealant Failures and Maintenance. . . . . . . . . . . 234Cost-Effectiveness of Sealants . . . . . . . . . . . . . 234Widespread Use of Sealants . . . . . . . . . . . . . . 235Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 236


16 Transfer of the Sealing Technique from the Occlusal to the Approximal SurfaceStefania Martignon, Kim R. Ekstrand

Transfer of the Sealing Technique from theOcclusal to the Approximal Surface . . . . . . . . . . 240Clinical Procedure . . . . . . . . . . . . . . . . . . . . . . 240Which Approximal Lesions Should Be Sealed? . . . . 240Techniques for Approximal Sealing . . . . . . . . . . . 241

Sealing Procedure . . . . . . . . . . . . . . . . . . . . 241Patch Technique . . . . . . . . . . . . . . . . . . . . . 241

Clinical Evidence . . . . . . . . . . . . . . . . . . . . . . 242

17 Caries InltrationHendrik Meyer-Lueckel, Sebastian Paris

Development of Caries Infiltration . . . . . . . . . . . 246Biological Principles . . . . . . . . . . . . . . . . . . . . . 246Principle of Caries Inltration . . . . . . . . . . . . . . . 248

Infiltration to Prevent Caries Progression . . . . . . 249Clinical Ecacy of InltratingApproximal Surfaces . . . . . . . . . . . . . . . . . . . . . 250Indications for Approximal Caries Inltration . . . . . 250

Clinical Use of Approximal Caries Inltration . . . . 253Follow-up for Approximal Caries . . . . . . . . . . . . 253

Infiltration for PrimarilyEsthetic Reasons . . . . . . . . . . . . . . . . . . . . . . 253Scientic Studies . . . . . . . . . . . . . . . . . . . . . . . 253Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . 254Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Invasive Therapy

18 How Much Caries Do We Have to Remove?David D. J. Ricketts

Historical Perspective . . . . . . . . . . . . . . . . . . . 260When to Remove Caries? . . . . . . . . . . . . . . . . . 261Enamel Lesion . . . . . . . . . . . . . . . . . . . . . . . . . 261EnamelDentin Junction . . . . . . . . . . . . . . . . . . 261Cavitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Microbial Invasion of Dentin . . . . . . . . . . . . . . . . 262

Dentin Caries . . . . . . . . . . . . . . . . . . . . . . . . . 263Conventional Caries Removal . . . . . . . . . . . . . . 264

Caries Removal at the EnamelDentin Junction . 264Contemporary Caries Removal . . . . . . . . . . . . . 265PulpDentin Complex . . . . . . . . . . . . . . . . . . . 265Deep Caries . . . . . . . . . . . . . . . . . . . . . . . . . . 265Fissure Sealant Studies . . . . . . . . . . . . . . . . . . . 266Stepwise Excavation Studies . . . . . . . . . . . . . . . 266Systematic Review of the Literature . . . . . . . . . . 268

Is There a Need for Cavity Disinfection? . . . . . . 268

19 Minimally Invasive Therapy with Tooth-Colored Direct Restorative MaterialsRoland Frankenberger, Uwe Blunck

Indications for Restorative Therapy . . . . . . . . . . 272Posterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . 272Anterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . 272Cervical Area . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Manifestations and Causes . . . . . . . . . . . . . . . 273Technical Limits to Direct Restorative Materials . . . 273

Materials for Tooth-coloredDirect Restorative Therapy . . . . . . . . . . . . . . . . 275Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Glass-Ionomer Cements . . . . . . . . . . . . . . . . . . . 275Composites . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Resin-Modied Glass-Ionomer Cements . . . . . . . . 276Compomers. . . . . . . . . . . . . . . . . . . . . . . . . . . 276Choosing Materials for Dierent Indications . . . . . 277

Posterior Region. . . . . . . . . . . . . . . . . . . . . . 277Anterior Region . . . . . . . . . . . . . . . . . . . . . . 277Cervical Defects . . . . . . . . . . . . . . . . . . . . . . 277

Preparation Instruments . . . . . . . . . . . . . . . . . 277Excavation . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Rotating Preparation . . . . . . . . . . . . . . . . . . . . 277Oscillating Preparation . . . . . . . . . . . . . . . . . . . 277

Rules for Minimally Invasive Preparation . . . . . . 278General Preparation Rules . . . . . . . . . . . . . . . . . 278Access Forms . . . . . . . . . . . . . . . . . . . . . . . . . 278

Anterior Region. . . . . . . . . . . . . . . . . . . . . . 278Posterior Region . . . . . . . . . . . . . . . . . . . . . 278

Class I (Fissures and Grooves) . . . . . . . . . . . . . . 278Class II (Approximal-Occlusal) . . . . . . . . . . . . . . 279Class III and Class IV (Anterior Tooth) . . . . . . . . . 279Class V (Cervical Area) . . . . . . . . . . . . . . . . . . . 279

Problems in the Treatment of Cervical Defects . 279

Damage to the Neighboring Tooth inApproximal Preparations. . . . . . . . . . . . . . . . . 280

XVIII Table of Contents


XIXTable of Contents

Clinical Experience with Minimally InvasiveRestorative Therapy . . . . . . . . . . . . . . . . . . . . 280Posterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . 280Anterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . 281Cervical Area . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Repairing Restorations . . . . . . . . . . . . . . . . . . 282

Treatment Decision

20 Decision-Making in Managing the Caries ProcessHendrik Meyer-Lueckel, Martin J. Tyas, Michael J. Wicht, Sebastian Paris

Fundamentals of Evidence-Based Dentistry . . . . . 287Treatment Recommendations . . . . . . . . . . . . . . . 288Study Types . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Shared Decision-Making . . . . . . . . . . . . . . . . . . 289The DoctorPatient Relationship . . . . . . . . . . . . . 290

Including the Patient in the Decision-MakingProcess. . . . . . . . . . . . . . . . . . . . . . . . . . . . 290Implementing Shared Decision-Makingin Practice. . . . . . . . . . . . . . . . . . . . . . . . . . 291

The Nine Steps of SharedDecision-Making . . . . . . . . . . . . . . . . . . . . . . . 291

Decisions, Decisions: Noninvasive, Microinvasive,or (Minimally) Invasive? . . . . . . . . . . . . . . . . . . 292When in Rome, Do as the Romans Do. . . . . . . . . . 292Economic Consequences of the Time of Therapy . . . 293

Consequences on Therapy of Philosophyin Cariology . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Philosophy Drill and Fill . . . . . . . . . . . . . . . . . 293A New Philosophy: Heal and Seal . . . . . . . . . . . 293

Limits to Noninvasive Therapies . . . . . . . . . . . . 294Micromorphological Aspects . . . . . . . . . . . . . . . 294Clinical Considerations . . . . . . . . . . . . . . . . . . . 294

Radiographic ExtensionCavitation of theSurface . . . . . . . . . . . . . . . . . . . . . . . . . . . 294CavitationBiolm . . . . . . . . . . . . . . . . . . . 295BiolmCaries Progression . . . . . . . . . . . . . . 295Speed of Caries Progression . . . . . . . . . . . . . . 295

Limits to Microinvasive Therapies. . . . . . . . . . . 296Avoidance of Overtreatment . . . . . . . . . . . . . . . 297The Problem of Undertreatment . . . . . . . . . . . . . 297

Dentin Involvement . . . . . . . . . . . . . . . . . . . 297Residual Microorganisms . . . . . . . . . . . . . . . 297

Limits to Invasive Therapies. . . . . . . . . . . . . . . 297Decision Trees and Choice of Therapy . . . . . . . . 299

Special Aspects in Children and the Young

21 How to Maintain Sound Teeth: an Individualized Population Strategy for Children andAdolescentsKim R. Ekstrand

The Multifactorial Concept of Caries . . . . . . . . . 306Relevant Epidemiology . . . . . . . . . . . . . . . . . . 307Caries in the Primary Dentition . . . . . . . . . . . . . . 307Caries in the Permanent Dentition . . . . . . . . . . . . 307Caries Progression Rate through the Enamel . . . . . 308

Eruption Time for Teeth in the Two Dentitions . . . 308Diagnostics of Caries in the Child Population . . . . 308

Individualized Population Strategy . . . . . . . . . . 308Documentation of caries experience . . . . . . . . . 310

22 Individualized Caries Management in Pediatric DentistryChristian H. Splieth, Mohammad Alkilzy

Deciduous versus Permanent Teeth . . . . . . . . . . 314Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . 314Function and Longevity . . . . . . . . . . . . . . . . . . . 314Erupting Permanent Teeth . . . . . . . . . . . . . . . . . 315

Treatment Concepts in Deciduous Teeth. . . . . . . 315Buccal Surfaces . . . . . . . . . . . . . . . . . . . . . . . . 315Occlusal Surfaces . . . . . . . . . . . . . . . . . . . . . . . 316Approximal Surfaces . . . . . . . . . . . . . . . . . . . . . 316

Minimum Intervention in Permanent Teethin Children and Adolescents . . . . . . . . . . . . . . 316Occlusal Surfaces . . . . . . . . . . . . . . . . . . . . . . . 317

Sealants for Individuals at High Risk of Caries . . 318Approximal Surfaces . . . . . . . . . . . . . . . . . . . . 318


XX Table of Contents

A Glimpse into the Future

23 Future Trends in Caries ResearchBrian H. Clarkson, Agata Czajka-Jakubowska

Genetic Approaches. . . . . . . . . . . . . . . . . . . . . 321GenomicsCaries Susceptibility . . . . . . . . . . . . . 321ProbioticsReplacement Therapy with non-Acid-Producing Bacteria . . . . . . . . . . . . . . . . . . . . . . 321Gene TherapyRepairing Salivary Glands . . . . . . . 321

Proteomics. . . . . . . . . . . . . . . . . . . . . . . . . . . 322Antibody EngineeringBacterial Adherence. . . . . . 322Enzyme RecognitionCaries Activity Assessment . . 322

Tissue Engineering . . . . . . . . . . . . . . . . . . . . . 322The DentinPulpal Complex . . . . . . . . . . . . . . . 322

Nanotechnology . . . . . . . . . . . . . . . . . . . . . . 323DendrimersAntimicrobials/Antiadherents . . . . . 323Antibacterial Nanoemulsions . . . . . . . . . . . . . . . 323Degradable MicrospheresRemineralizing Agents . 323Smart MaterialsResponding to Physiologicaland Nonphysiological Changes in the Oral Cavity . . 324Synthetic Enamel . . . . . . . . . . . . . . . . . . . . . . 324

Part 2: CariesClinical Practice24 Diagnostics, Treatment Decision, and Documentation

Sebastian Paris, Rainer Haak, Hendrik Meyer-Lueckel

Caries Diagnostics at the Patient Level . . . . . . . . 330Determining the Risk Factors . . . . . . . . . . . . . . . 331

Caries Experience . . . . . . . . . . . . . . . . . . . . . 331Sugar Consumption . . . . . . . . . . . . . . . . . . . 331Frequency of Food Consumption . . . . . . . . . . . 331Oral Hygiene . . . . . . . . . . . . . . . . . . . . . . . . 331Fluoride Sources. . . . . . . . . . . . . . . . . . . . . . 331Salivary Flow . . . . . . . . . . . . . . . . . . . . . . . . 331

Calculating the Caries Risk and Consequences . . . . 331

Caries Diagnostics at the Tooth Level. . . . . . . . . 333

VisualTactile Examination . . . . . . . . . . . . . . . . 333Primary Caries . . . . . . . . . . . . . . . . . . . . . . 333Caries Adjacent to Restorations . . . . . . . . . . . 333

Additional Diagnostic Tools . . . . . . . . . . . . . . . . 335Bitewing Radiographs and FiberopticTransillumination . . . . . . . . . . . . . . . . . . . . 335Laser Fluorescence. . . . . . . . . . . . . . . . . . . . 336Endodontic Findings . . . . . . . . . . . . . . . . . . 336

Additional Diagnostics . . . . . . . . . . . . . . . . . . . 336

Diagnosis and Planning a Therapy . . . . . . . . . . 337

25 Minimal Interventional Treatment of Caries in the Permanent Dentition: Clinical CasesHendrik Meyer-Lueckel, Sebastian Paris, Christian A. Schneider, Leandro A. Hilgert, Soraya Coelho Leal

Case 1: A 30-year-old Woman withLow-to-Medium Caries Risk. . . . . . . . . . . . . . . . 339Hendrik Meyer-Lueckel, Sebastian ParisAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 339Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 339Caries Risk Assessment (Individual Level) . . . . . . . 341Diagnoses and Treatment Plan . . . . . . . . . . . . . . 342

Individual Level . . . . . . . . . . . . . . . . . . . . . . 342Tooth Level . . . . . . . . . . . . . . . . . . . . . . . . . 342

Clinical Aspect at the End of the Treatment . . . . . . 348Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348

Case 2: A 22-year-old Man withMedium Caries Risk . . . . . . . . . . . . . . . . . . . . . 351Hendrik Meyer-Lueckel, Sebastian ParisAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 351Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 351Caries Risk Assessment (Individual Level) . . . . . . . 352Diagnosis and Treatment Plan . . . . . . . . . . . . . . . 353


Clinical Aspect at the End of the Treatment . . . . . . 360Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360

Case 3: Minimally InterventionalAnterior Restorations . . . . . . . . . . . . . . . . . . . 361Christian A. Schneider, Hendrik Meyer-LueckelAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . 361Caries Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Diagnosis and Treatment Plan . . . . . . . . . . . . . . 362

Individual Level . . . . . . . . . . . . . . . . . . . . . 362Tooth Level . . . . . . . . . . . . . . . . . . . . . . . . 362

Case 4: Infiltration to Mask Caries Lesions . . . . . 367Leandro A. Hilgert, Soraya Coelho LealAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . 367Caries Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . 368Diagnosis and Treatment Plan . . . . . . . . . . . . . . 368


Clinical Aspect at the End of the Treatment . . . . . 370

Case 5: Stepwise Caries Excavation. . . . . . . . . . 371Hendrik Meyer-Lueckel, Sebastian Paris


XXITable of Contents

26 Minimal Interventional Treatment of Caries in Young Children: Clinical CasesVera Mendes Soviero, Soraya Coelho Leal, Christian Splieth, Mohammad Alkilzy

Case 1: A 6-Year-Old Boy with High Caries Risk . . 374Mohammad Alkilzy, Christian SpliethAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 374Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 374Caries Risk Assessment (Individual Level) . . . . . . . 375Diagnosis and Treatment Plan . . . . . . . . . . . . . . . 376


Clinical Aspect at the End of the Treatment . . . . . . 380Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . 380

Case 2: A 7-Year-Old Girl withMedium Caries Risk . . . . . . . . . . . . . . . . . . . . . 381Vera Mendes Soviero, Soraya Coelho LealAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 381Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 381Caries Risk Assessment (Individual Level) . . . . . . . 381Diagnosis and Treatment Plan . . . . . . . . . . . . . . . 383


Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

Case 3: A 6-Year-Old Girl withVery High Caries Risk . . . . . . . . . . . . . . . . . . . 385Vera Mendes Soviero, Soraya Coelho LealAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 385Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 385Caries Risk Assessment (Individual Level) . . . . . . . 386Diagnosis and Treatment Plan . . . . . . . . . . . . . . 388

Individual Level . . . . . . . . . . . . . . . . . . . . . 388Tooth level . . . . . . . . . . . . . . . . . . . . . . . . . 389

Clinical Aspect at the End of the Treatment . . . . . 393Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . 393

Case 4: An 8-Year-Old Boy withMedium Caries Risk . . . . . . . . . . . . . . . . . . . . 394Vera Mendes Soviero, Soraya Coelho LealAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 394General Findings . . . . . . . . . . . . . . . . . . . . . . . 394Oral Health Indices . . . . . . . . . . . . . . . . . . . . . 394Clinical Findings (Tooth Level) . . . . . . . . . . . . . . 394Caries Risk Assessment (Individual Level) . . . . . . . 397Diagnosis and Treatment Plan . . . . . . . . . . . . . . 397


Monitoring and Recall . . . . . . . . . . . . . . . . . . . 39927 Appendix

Dental examination form . . . . . . . . . . . . . . . . . 401Caries risk analysis . . . . . . . . . . . . . . . . . . . . . 402Treatment plan . . . . . . . . . . . . . . . . . . . . . . . . 403

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405


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