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Minimal intervention dentistry: part 1. From ‘compulsive’ restorative dentistry to rational therapeutic strategiesJ. D. B. Featherstone1 and S. Doméjean2

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of its pathogenesis, its transmission, the demineralisation and remineralisation con-tinuum, the mode of action of fluoride, but also with respect to the great technologi-cal developments in biomaterials, equip-ment for the detection of caries lesions and methods for cavity preparation. This new scientific knowledge combined with developments both technological and tech-nique related, impose that both medically and ethically, the sole pertinent therapeutic model that is relevant is one that is based on prevention and treatment using the least invasive of approaches. This ‘rational’ model of care is known as minimal inter-vention dentistry and is applicable not only to cariology but to periodontology and all other areas of dentistry.1-3

Studies conducted in France in the early 2000s indicated that dental practitioners had not yet integrated this concept of cariology into practise4-7 even though, since the 1990s, Elderton had already denounced traditional approaches to con-servative dentistry when considered in isolation.8-10 Indeed, traditional oral care, which comprises largely conservative/operative dentistry, including scaling and polishing, has very little impact on the oral health of patients both in children and adults because the patient finds himself/herself caught in a repeat restoration spi-ral of care, where successive replacement

INTRODUCTION

Cariology has advanced over the past 30 years with scientific advances in the knowledge of the caries process in terms

The concept of minimal intervention dentistry is based on all the factors that affect the onset and progression of disease and therefore integrates concepts of prevention, control and treatment. The field of minimal intervention dentistry is wide, including the detection of lesions as early as possible, the identification of risk factors (risk assessment) and the implemen‑tation of preventive strategies and health education for the patient. When the effects of the disease are present, in the form of a carious lesion, other therapeutic strategies are required, but in this case the least invasive solutions should be chosen, for example remineralisation, therapeutic sealants and restorative care aimed at conserving the maximum amount of sound tissue. This article aims to enlighten dental practitioners as to the foundations of minimal intervention dentistry in order to help them in the implementation of modern concepts into everyday clinical practice.

of restorations results in the restoration increasing in size each time the restoration is renewed, leading to eventual loss of the tooth.2,8,11,12 Figure 1 illustrates a patient, aged 33 at the time of the photograph, who has, judging by the number of endo-dontic treatments present, been obliged to visit the dentist on numerous occasions in the past. The problem of oral hygiene has not been resolved and, the caries process, which is very aggressive, has not been halted. Restorative and endodontic treat-ment do not in themselves solve the prob-lems of oral health. The reasons for the

1*Office of the Dean, Box 0430, 513 Parnassus Ave, University of California at San Francisco, San Francisco CA 94143‑0430, USA; 2CHU Clermont‑Ferrand, Service d’Odontologie, Hôtel‑Dieu, F‑63001 Clermont‑Ferrand, France *Correspondence to: Professor John D. B. Featherstone Email: [email protected]; Tel: +01 415 476 1323

Accepted 21 June 2012 DOI: 10.1038/sj.bdj.2012.1007 ©British Dental Journal 2012; 213: 441-445

• Explains the differences between minimal intervention dentistry, minimally invasive dentistry, micro-dentistry, atraumatic restorative treatment and selective tissue excavation.

• Examines the foundations of minimal intervention dentistry.

• Considers the implementation of modern concepts into everyday clinical practice.

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Fig. 1 The limitations of traditional dental treatment

1. From ‘compulsive’ restorative dentistry to rational therapeutic strategies

2. Caries risk assessment in adults

3. Paediatric dental care – prevention and management protocols using caries risk assessment for infants and young children

4. Detection and diagnosis of initial caries lesions

5. Atraumatic restorative treatment (ART) – a minimum intervention and minimally invasive approach for the management of dental caries

6. Caries inhibition by resin infiltration

7. Minimally invasive operative caries management - rationale and techniques

This paper is adapted from: Featherstone J D B, Doméjean S. Le concept d’intervention minimale en cariologie. De la dentisterie restauratrice ‘compulsive’ aux stratégies thérapeutiques raisonnées. Réalités Cliniques 2011; 22: 207–212.

MINIMAL INTERVENTION DENTISTRY

BRITISH DENTAL JOURNAL VOLUME 213 NO. 9 NOV 10 2012 441

© 2012 Macmillan Publishers Limited. All rights reserved.

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delay in adopting minimal intervention in routine dental practice are certainly many, including lack of initial training and con-tinuous education of practitioners in this subject area, lack of time and personnel for its easy implementation in general prac-tice, lack of knowledge and appreciation of preventive and non-invasive therapeu-tic strategies by the public authorities and their lack of incorporation into financial reimbursement schemes. Adapted from a series first published in French in Réalités Cliniques, the BDJ offers a series of arti-cles on the general topic of minimal inter-vention dentistry written by international authors to help the dental practitioner integrate this concept into daily clinical practice.

WHAT ARE THE DIFFERENCES BETWEEN MINIMAL INTERVENTION DENTISTRY, MINIMALLY INVASIVE DENTISTRY, MICRO-DENTISTRY, ATRAUMATIC RESTORATIVE TREATMENT AND SELECTIVE TISSUE EXCAVATION AND HOW SHOULD EACH BE DEFINED?

A primary source of confusion for practi-tioners concerns the terminology used since ‘minimally invasive dentistry’ and ‘minimal intervention dentistry’ are often used inter-changeably although they describe different concepts. This first section aims to define the terms most commonly used that are associated with minimal intervention.

Minimal intervention dentistryMinimal intervention dentistry is a concept of patient care that deals with the causes of dental disease and not just the symp-toms.1,13,14 Based on biological solutions rather than purely restorative, minimal intervention is based entirely on preven-tion and control of oral disease.

Primary prevention focuses on prevent-ing new cases of oral diseases. It uses collec-tive prevention measures such as artificial fluoridation of water or school oral health programmes. At the individual level, pri-mary prevention aims to prevent the early colonisation of childrens’ teeth by cario-genic bacteria (for example, Streptococcus mutans, one of the species associated with the initiation of the caries process). Prevention also includes the management of other factors such as a cariogenic diet

rich in fermentable carbohydrates, coupled with poor oral hygiene habits.

Secondary prevention aims at prevent-ing the disease from becoming established and progressing. This includes screening to detect carious lesions at the earliest pos-sible stage so that appropriate treatment can be delivered.

Tertiary prevention, for its part, aims to prevent recurrence of disease as well as the failure of preventive and restorative care initially implemented.

The concept of minimal intervention is based on all the factors that affect the onset and progression of disease and therefore integrates concepts of prevention, control and treatment. The field of minimal inter-vention dentistry is wide, including the detection of lesions as early as possible, the identification of risk factors (risk assess-ment) and the implementation of preven-tive/control strategies and health education for the patient. When the effects of the disease are present, in the form of a cari-ous lesion, other therapeutic strategies are required, but in this case the least invasive solutions should be chosen for example, remineralisation, therapeutic sealants and restorative care aimed at conserving the maximum amount of dental tissue.

Minimally invasive dentistry, ultra-conservative and micro-dentistry

Minimally invasive dentistry, ultraconser-vative and micro-dentistry are terms that embrace operative restorative approaches that respect both the dental tissues and patient’s comfort. The excavation of den-tine caries is performed with the objective of preserving not only sound tooth tissue but also that tissue which has the poten-tial to remineralise. The use of adhesive biomaterials is preferred, for example, resin composite of different viscosities selected according to the clinical situation and glass-ionomer cements, particularly those of high viscosity.15 One should not confuse minimal intervention dentistry and minimally invasive dentistry since the latter is merely a component of the minimal intervention treatment (care) plan (Fig. 2). In traditional dentistry the prepa-ration and restoration of cavities are the only and systematic response to the pres-ence of carious lesions. With a minimal intervention approach, the placement of restorations is an ancillary phase of the

overall management of patient care where restorations are indicated only when the lesion has advanced to frank cavitation and where remineralisation techniques have reached their limits. Micro-dentistry is performed preferably using optical aids (magnification, microscopes, intra-oral cameras) and can also make use of more

Minimalintervention

Minimallyinvasive dentistry

Micro-dentistry

Fig. 2 Diagram illustrating how minimal intervention dentistry and minimal invasion (minimally invasive dentistry) are two terms that are not interchangeable. Minimally invasive dentistry is actually a phase of minimal intervention

Figs 3a and b Photographs of multiple caries lesions and ART – prophylactic phase in the management of the caries process

a

b

Fig. 3c Photograph taken after first session of ART

442 BRITISH DENTAL JOURNAL VOLUME 213 NO. 9 NOV 10 2012


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sophisticated devices other than traditional rotary instruments mounted on a contra-angle handpiece or air-turbine, such as chemo-mechanical, air-abrasion, sono-abrasion and laser systems.

Atraumatic restorative treatment (ART)

The atraumatic restorative treatment (ART) approach is part of the therapeutic armamentarium of minimal intervention dentistry and is minimally invasive. The manual selective excavation of tissues destroyed by the caries process, involv-ing excavation of the infected dentine while conserving the affected dentine, is described in a separate article later in this series. A sealant restoration is then placed, which comprises a conventional adhesive restoration combined with the

sealing of adjacent pits and fissures. In the case of ART, the restoration and seal-ant are placed simultaneously using high-viscosity glass-ionomer cement. Initially, this approach was proposed for the man-agement of patients in developing coun-tries because it can be performed using only manual instruments. The excellent results from clinical studies suggest that it also has its applications in industrial-ised countries especially for patients with multiple caries lesions during the stabi-lisation and motivation phase. Figure 3 illustrates the prophylactic phase in the management of the caries process. This patient consulted the dental department of the University Hospital of Clermont-Ferrand for restoration of his teeth. Many open lesions can be observed as well as the presence of abundant plaque. Brushing

was impossible because the many open dentine caries lesions made it very pain-ful. ART was performed in quadrants. This not only improved the aesthetics but more importantly oral hygiene recommenda-tions could then be implemented by the patient.

MINIMAL INTERVENTION DENTISTRY: BUILDING THE TREATMENT (CARE) PLAN?

‘Rational’ clinical practice is based on four key elements: 1. Control of the disease by identifying

and managing the risk factors2. The detection and remineralisation of

early lesions3. Minimally invasive surgical

intervention4. Where possible the repair rather

than replacement of defective restorations.15,16

Clinically, a cariology-based care plan comprises three main phases: the diagnos-tic phase, the prophylactic phase and the (recall) monitoring phase (Fig. 4).

The diagnostic phaseThe diagnostic phase allows one to under-stand why the disease (caries) has occurred and is used to evaluate the severity of the damage caused. It includes the determina-tion of the individual caries risk factors and detection of carious lesions (pres-ence and activity) for the application during the next phase, of non-invasive therapeutic solutions.

The determination of caries risk of indi-vidual patients is based on the identification of the presence of pathological and protec-tive factors that affect the demineralisation and remineralisation process respectively but also on the identification of risk pre-dictors.17-19 Within the term ‘risk predictors’ are grouped all those factors which, while being not directly related to the caries pro-cess itself, have been shown in longitudinal studies to be correlated with the appearance of new lesions. The main risk predictors are past exposure to caries, the presence of cav-itated caries lesions or recent restorations placed due to caries, as well as demographic factors relating to the patient in terms of age, level of education and disabilities that potentially expose the patient to risk habits – a teenager with uncontrolled eat-ing habits, the elderly where oral hygiene

Minimalintervention

Prophylaxisphase

Restorativephase

Diagnosticphase

Recall

Protectivefactors

Pathologicalfactors

Riskpredictors

Fig. 4 The minimal intervention treatment (care) plan

Fig. 5 Diagram of imbalance between protective factors, pathological factors and risk predictors existing in the case of high caries risk. Concept developed by J. D. B. Featherstone27-29



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is more difficult to maintain due to loss of motor skills, education associated with the level of care one takes of oneself and harmful lifestyles, which expose people to situations of poor hygiene and failure to seek care.20-26

Figure 5 illustrates the imbalance between protective factors, pathologi-cal factors and risk predictors that exist in the case of high caries risk, a concept developed by Featherstone.27-29 Indeed, the weight of the caries risk predictors is important and entails the need to coun-terbalance them in the implementation of measures tailored to the pathological fac-tors present for each clinical case.

Prophylactic phase The second prophylactic phase aims to readjust the balance between pathological and protective factors. During this phase, measures required to curb the phenomena of demineralisation and to initiate rem-ineralisation are implemented. Emphasis is placed on recommendations relating to hygiene and dietary habits, antibacterial therapy, prescription of appropriate fluo-ride measures and the placement of pre-ventive sealants. In the case of patients with cavitated lesions involving the den-tine, atraumatic restorative care can com-plement the arsenal of prophylactic or partial excavation of caries. ART reduces the bacterial load, places a glass-ionomer cement restoration, eliminates the cavity responsible for retention of the plaque bio-film and protects the dentine allowing the patient to develop efficient oral hygiene.

Follow-up monitoring and maintenance

The third phase includes follow-up moni-toring and maintenance. It concerns the reinforcement of patient education, moni-toring the effectiveness of all preventive and control measures implemented for example, fluoride and preventive sealants, and thera-peutic measures for example, the integrity of therapeutic sealants and restorations. During follow-up visits, potential failures can be intercepted and the recall interval adjusted based on new clinical findings and the behaviour of the patient.30-32

RestorationsThe placement of restorations has long been regarded, incorrectly, as the primary

solution to manage the caries process. The restorative component is of course not excluded, when required, from a minimal intervention care plan, but has no effect on the aetiologic factors and is not an essential component unlike the other three described above. Restorative treatment is therefore still required when the caries process has resulted in significant loss of dental tissue, in order to eliminate the retention of plaque within cavities and restore physiological masticatory function and aesthetics. The restorative phase can fit between control and surveillance. It must follow a minimally invasive approach, where caries removal/cavity preparation is delayed until there are cavitated dentine lesions and through the use of adhesive materials, these cavities can remain minimally invasive.13,15,16,33-37 Such cavities are, by definition, conservative in design and there is no so-called ‘extension for prevention’, although sometimes it might be necessary to remove some sound tissue for example, reducing a weakened cusp or making retentive features. In the case of lesions close to the pulp, the complete removal of all the carious dentine is now called into question since glass-ionomer cements allow ion exchange leading to the remineralisation of demineralised tissue.38-44 Defective restorations are not systematically removed and replaced. These radical solu-tions need to be rethought and nuanced; polishing reduces the indications for the complete replacement of the restoration, the margins of restorations can be sealed and restorations can be repaired.15,45-48

CONCLUSIONSHigh quality modern dentistry based on minimal intervention focuses on preven-tion and control of disease with operative dental interventions that are limited to the absolute minimum.1 Ideally, care strategies must meet certain criteria, namely effec-tiveness, ‘does it work in dental practice?’ and efficiency, ‘is the cost–effectiveness adequate?’ Although there is a growing scientific evidence-base about the effec-tiveness of minimal intervention dentistry, it is nevertheless clear that the problem of efficiency arises in the context of imple-mentation levels within current healthcare systems in different countries.

The authors would like to thank Claudie Damour-Terrasson, publishing director of the Groupe Information Dentaire, Paris France, for the

authorisation of translation and publication of the series in the BDJ, and Christopher Holmgren for his assistance with the translation of the present article.

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2. Elderton R J. Preventive (evidence‑based) approach to quality general dental care. Med Princ Pract 2003; 12(Suppl 1:) 12–21.

3. Bowley J. Minimal intervention prosthodontics: cur‑rent knowledge and societal implications. Med Princ Pract 2002; 11(Suppl 1): 22–31.

4. Doméjean‑Orliaguet S, Tubert‑Jeannin S. La prise en charge des lésions carieuses en France. Clinic 2009; 30: 229–288.

5. Doméjean‑Orliaguet S, Léger S, Auclair C, Gerbaud L, Tubert‑Jeannin S. Caries management decision: influence of dentist and patient factors in the pro‑vision of dental services. J Dent 2009; 37: 827–834.

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P J, Espelid I, Tveit A B. French dentists’ restorative treatment decisions. Oral Health Prev Dent 2004; 2: 125–131.

7. Tubert‑Jeannin, S, Doméjean‑Orliaguet S, Riordan P J, Espelid I, Tveit A B. Restorative treatment strategies reported by French university teachers. J Dent Educ 2004; 68: 1096–1103.

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9. Elderton R J. Overtreatment with restorative dentistry: when to intervene? Int Dent J 1993; 43: 17–24.

10. Elderton R J, Mjör I A. Changing scene in cariology and operative dentistry. Int Dent J 1992; 42: 165–169.

11. Sheiham A. Impact of dental treatment on the incidence of dental caries in children and adults. Community Dent Oral Epidemiol 1997; 25: 104–112.

12. Elderton R J. Clinical studies concerning re‑restoration of teeth. Adv Dent Res 1990; 4: 4–9.

13. Mount G J. A new paradigm for operative dentistry. Aust Dent J 2007; 52: 264–270.

14. Featherstone J D. The science and practice of caries prevention. J Am Dent Assoc 2000; 131: 887–899.

15. Tyas M J, Anusavice K J, Frencken J E, Mount G J. Minimal intervention dentistry ‑ a review. FDI Commission Project 1–97. Int Dent J 2000; 50: 1–12.

16. Mount G J, Ngo H. Minimal intervention: a new concept for operative dentistry. Quintessence Int 2000; 31: 527–533.

17. Beck J D. Risk revisited. Community Dent Oral Epidemiol 1998; 26: 220–225.

18. Stamm J W, Stewart P W, Bohannan H M, Disney J A, Graves R C, Abernathy J R. Risk assessment for oral diseases. Adv Dent Res 1991; 5: 4–17.

19. Bader J D, Perrin N A, Maupomé G, Rush W A, Rindal B D. Exploring the contributions of components of caries risk assessment guidelines. Community Dent Oral Epidemiol 2008; 36: 357–362.

20. Tagliaferro E P, Pereira A C, Meneghim Mde C, Ambrosano G M. Assessment of dental caries pre‑dictors in a seven‑year longitudinal study. J Public Health Dent 2006; 66: 169–173.

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23. Azogui‑Lévy S, Lombrail P, Riordan P J et al. Evaluation of a dental care program for school beginners in a Paris suburb. Community Dent Oral Epidemiol 2003; 31: 285–291.

24. de Saint Pol T. La santé des plus pauvres. Insee Premiere 2007; 1161.

25. Haut Comité de la santé publique. La progression de la précarité en France et ses effets sur la santé. Rennes: Haut Comité de la santé publique, 1998.

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31: 129–133.28. Featherstone J D. The caries balance: the basis for

caries management by risk assessment. Oral Health Prev Dent 2004; 2(Suppl 1): 259–264.

29. Featherstone J D, Doméjean‑Orliaguet S, Jenson L, Wolff M, Young D A. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007; 35: 703–707, 710–713.

30. National Institute for Clinical Excellence. Dental recall - recall interval between routine dental exami-nations. London: NICE, 2004.

31. Beirne P, Clarkson J E, Worthington H V. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev 2007; 4: CD004346.

32. Beirne P, Forgie A, Clarkson J, Worthington H V. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev 2005; 18: CD004346.

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34. Mount G J, Ngo H. Minimal intervention: advanced lesions. Quintessence Int 2000; 31: 621–629.

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lesions. Quintessence Int 2000; 31: 535–546.36. Peters M C, McLean M E. Minimally invasive opera‑

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38. Ngo H. Glass‑ionomer cements as restorative and preventive materials. Dent Clin North Am 2010; 54: 551–563.

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2006; 3: CD003808.43. Bjørndal L. Indirect pulp therapy and stepwise

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45. Criteria for placement and replacement of dental restorations: an international concensus report. Int Dent J 1988; 38: 193–194.

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Minimal intervention dentistry: part 2. Caries risk assessment in adultsM. Fontana1 and C. Gonzalez-Cabezas2

and efforts to remineralise non-cavitated lesions with the prompt provision of pre-ventive care in order to minimise operative intervention. When operative interven-tion is required unequivocally, typically for an active cavitated lesion, the proce-dure used should be as minimally inva-sive as possible.4,5 This risk-based clinical decision-making for caries management in everyday clinical practice should be based on the best available evidence whilst tak-ing into account the dentist’s knowledge and expertise and focusing on the needs and desires of the patient.6

Opponents of this strategy maintain that it is difficult to identify such patients accurately, and that even if we could, the evidence for preventive measures on high-risk individuals is still not very strong. All of this is in part true; however, we contend that when the wellbeing of the patient is considered, it is more important to carry out a risk assessment incorporating the best available evidence than just doing nothing due to lack of strong evidence. Others allege that similar preventive meas-ures should be administered to the whole population, regardless of the risk. However, for the current environment of increasing healthcare costs and resource constraints, targeted healthcare delivery has become paramount, depending profoundly on risk assessment. If a clinician practices in an environment in which all patients have a similar risk of caries, then we agree that doing individual risk assessments would

INTRODUCTION

Risk-based prevention and disease man-agement have been recognised as the cornerstones of modern caries manage-ment1-3 and are essential components of the minimal (minimum) intervention (MI) approach. MI stresses a preventive philoso-phy with individualised risk assessment, accurate and early detection of lesions

Risk-based, patient-centred decision-making, supported by best available evidence is an essential component for the cor-rect prevention, control and management of dental caries. This article reviews the importance of caries risk assessment in adults as a prerequisite for appropriate caries preventive and treatment intervention decisions. A clinical case will be used to demonstrate how risk assessment can be easily incorporated in everyday clinical practice, using information readily available in the dental-medical history and clinical examination.

add no value to the clinician or the patient. However, dental caries is unequally dis-tributed in most populations around the world, with a small percentage of individu-als carrying the heavier burden of caries disease.7 For most dentists in private prac-tice, it becomes imperative to be able to identify a patient’s risk status in order to be able to develop the most cost-effective treatment strategy for that individual. Due to the multifactorial nature of the caries process, and the fact that the disease is dynamic (for example, lesions can progress and/or regress), studies on risk assessment tend to be complex, with a multitude of variables challenging the prediction at different times during the life of an indi-vidual.8 Most studies on risk assessment have been conducted in children (see later article in this BDJ series) and there is very little evidence from adults or the elderly to help guide practitioners on how to apply risk assessment models to adult populations.2,9

Therefore, caries risk assessment should be useful in the clinical management of dental caries by helping to:•Determine lesion activity•Estimate the degree of risk so the

intensity of the treatment (for example, fluoride concentration and delivery method) and frequency of appointments can be customised

• Identify the main aetiological agents contributing to the current disease that might be targeted in the management

1*-2Associate Professor, Department of Cariology, Re-storative Sciences and Endodontics at the University of Michigan School of Dentistry, Michigan 48109, USA *Correspondence to: Margherita Fontana Email: [email protected]; Tel: +1 734 647 1225


• Reviews the importance of caries risk assessment in adults.

• Demonstrates how risk assessment can be incorporated in everyday clinical practice.

• Presents a clinical case report of a patient with a moderate to high risk of dental caries.

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2. Caries risk assessment in adults3. Paediatric dental care: prevention and

management protocols using caries risk assessment for infants and young children




7. Minimally invasive operative caries management: rationale and techniques

This paper is adapted from: Featherstone J D B, Doméjean S. Le concept d’Intervention minimale en cariologie. De la dentisterie restauratrice ‘compulsive’ aux stratégies thérapeutiques raisonnées. Réalités Cliniques 2011; 22: 207-12.




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of the disease (for example, diet control)•Establish the need for additional

diagnostic procedures (for example, salivary flow rate/buffering measurements)

•Formulate the best restorative treatment (care) plan for this patient (for example, dental material selection)

•Enhance the overall prognosis of the patient

•Appraise the efficacy of the caries management plan established at recall visits.

This paper reviews the importance of caries risk assessment in adults as a pre-requisite for appropriate caries preventive and treatment intervention decisions.

RISK INDICATORSTraditionally, caries disease indicators have been defined as clinical observa-tions that tell about the past caries history and activity. They are indicators or clini-cal signs that there is disease present or that there has been recent disease.1 These indicators also include variables that say nothing about what caused the disease or how to treat it, but that are related to disease experience (for example, socioeco-nomic status, education). Caries experience is an illustration of an indicator that shows how the host copes with the biological activity.10 However, as before, others have defined risk indicators as factors estab-lished only in cross-sectional studies as being associated with the disease without any longitudinal validation.11

Caries experienceThe strongest risk indicator is past caries experience and current lesion activity.8,12,13 As a predictor it is simple, inexpensive and fast, as it requires a dental examination only. If approximal lesions are included in the risk analysis, then radiographs, espe-cially radiographic follow-up of existing lesions, would enhance the diagnosis. Past caries experience summarises the cumula-tive effect of all risk factors and protective factors to which an individual has been exposed over a lifetime. However, exposure to risk factors may change over a lifetime, and this affects the predictive power of this indicator making it less than 100% accu-rate. Risk factors that lead to the patient’s past caries experience might have changed

over their lifetime and sometimes we are simply seeing the consequences of the dis-ease that occurred years ago. Nevertheless, as mentioned earlier, epidemiological stud-ies have shown a positive strong correla-tion between past caries experience and future caries development, which is why all available risk tools include this indicator very prominently. In adults, there is also a clear association between coronal caries and the risk of developing root caries 14,15

It is important to assess not only cavi-tated lesions, but non-cavitated lesions also. If lesions are present it is imperative to decide whether they are likely active or arrested, as this will influence the analysis of future risk. Presence of current activ-ity would indicate a high likelihood that if conditions do not change, activity will continue in the future.

Another important aspect to take into consideration is the site specificity of the disease. Caries lesions develop in areas where dental plaque is stagnant for long periods of time. For younger individuals, the occlusal surfaces of posterior teeth are by far the areas more frequently affected by the disease, but for older patients, however, this might not be the case. Frequently, older adults have very few or no fissures without restorations in pos-terior teeth reducing the risk of caries in those high risk surfaces when restorations in good condition are present. However, restorations with significant defects will accumulate significant amounts of plaque biofilm, increasing the risk at that specific site. In these people, newly exposed root surfaces and defective restorations need to be carefully examined and have their risk for caries determined.

Socio-demographic indicatorsAlthough socioeconomic status is a stronger predictor of caries risk in chil-dren than in adults, it is still important in adults 13,16 However, because dental caries generally is more prevalent in lower than higher socioeconomic classes, the dentist should consider the social environment of the patient (for example, education, income, occupation etc) as available to him/her through the medical history, in the analysis of caries risk.

Notes•The best indicators of caries risk can

be attained easily from data obtained at periodic dental examinations and do not require additional testing routinely. This is, of course, very encouraging for every day clinical practice

•The fact that previous caries experience is such a strong predictor is, from a disease management perspective, a less than desirable outcome, considering the fact that the disease is actually manifest before it can be accurately predicted, and the ultimate goal of caries management is to prevent disease in the first case

•The fact that the existence of recent restorations is one of the greatest indicators of risk for the development of new caries lesions only proves that the act of treating the caries lesion surgically does little to reduce the risk of developing the next lesion9,13,17

• In a systematic review, Zero et al. concluded that for caries prediction in permanent teeth in adults, past caries experience was the best predictor, followed by education and marital status, probably because these factors influenced attitudes towards oral health9

• It is very important to realise that the assessment of all risk factors not only allows a more complete assessment of future risk of disease, but most importantly identifies the aetiological factors responsible for the disease in a particular patient.2

RISK FACTORSTraditionally, a risk factor plays an essen-tial role in the aetiology of the disease, while a risk indicator is indirectly associ-ated with the disease. In other words, car-ies risk factors are the biologic reasons, or factors, that have caused or contributed to the disease, or will contribute to its future manifestation on the tooth (for example, bacteria, diet etc).8

GeneticsAlthough this is the only factor that can-not be measured currently in clinical prac-tice, it is important to highlight that even when there is still much to learn about the genetic-environmental relationships in dental caries aetiology and risk assess-ment, the amount of evidence relating to genes and caries experience has increased



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significantly in the last decade. As reviewed recently by Wright, genes have been identified linking tooth development, salivary function and diet/taste to caries risk or protection.18 This is very important because as the understanding of genet-ics associated with caries risk increase, so does the future possibility of using sali-vary diagnostics based on genetic scans to develop either better risk assessment tools or to better target specific interventions that would improve the oral and general health of at-risk populations.

SalivaIt is well established that saliva plays an important role in the health of soft and hard tissues in the oral cavity. Dentists can assess several salivary parameters as related to caries risk, but the most common ones include salivary flow rate, buffering capacity and pH. Chronically low salivary flow rate (that is, true hypo-salivation) has been found to be one of the strongest salivary indicators for an increased risk of dental caries.19 Apart from this scenario, the caries prediction of saliva parameters is modest to low, and thus hard to justify rou-tinely in dental practice for every patient.

Oral complications as a result of sali-vary gland hypofunction include altered oral sensations, taste dysfunction, mucosal dryness resulting in infection and tooth wear due to abrasion, among other factors.

Pain and diminished quality of life are also common complaints associated with sali-vary hypofunction.20 Many dentists tend to rely on the complaint of dry mouth or xerostomia to diagnose hyposalivation. Unfortunately, subjective complaint of xerostomia often does not correlate with objective findings of reduced salivary flow rate. Fox et al.21 recommended that den-tal care professionals ask their patients the following questions: does your mouth feel dry when eating a meal? Do you sip liquids to aid swallowing dry foods? Do you have difficulty swallowing any foods? Does the amount of saliva in your mouth seem to be too little, too much or do you not notice it? A positive answer to any of these questions should prompt considera-tion as to how long the patient has expe-rienced the problem, whether or not an increased caries experience has resulted and lead to an objective measurement of salivary flow rate. Other questions, such as

‘is your mouth dry?’ are not predictive at all, since most people have dry mouths in the mornings due to the normal decrease in salivary flow rate which occurs during sleep.

Many current medications (for example, psycho-pharmaceutical products) reduce the flow rate of saliva in a percentage of the population using them, and there-fore may affect their caries risk. Also, certain diseases, especially those related to decreases in salivary flow rate, such as Sjögren’s syndrome and uncontrolled diabetes, can increase the risk of caries.

BacteriaDental caries is a microbial disease in which the aetiological agents are normal constituents of the dental plaque bio-film that cause problems only when their pathogenicity and proportions change in response to environmental conditions.

It is clear that without any plaque bio-film there would be no caries. However, most patients do not remove plaque effec-tively from areas at high risk. The principle of microbial testing in clinical practice is the thought that people with high numbers of cariogenic bacteria are at higher risk for developing future lesions and, as such, should be treated, however:•Most plaque indices are ineffective

predictors of future caries because dental caries typically develops in fissures and interproximal areas, while most plaque indices were developed to evaluate periodontal disease or gingivitis based on smooth surface scores

•To solely evaluate the effectiveness of mechanical cleaning is difficult because tooth brushing usually involves a dentifrice with fluoride. However, it is known that any conditions that compromise the long-term maintenance of good oral hygiene, and for which the patient has not been able to show the ability to maintain plaque-free, are positively associated with caries risk

•Salivary bacterial tests have existed for several years and are based on the premise that saliva levels represent levels in the oral biofilm. As one of the primary aetiologic agents of dental caries, mutans streptococci and lactobacilli historically have

captured the greatest interest among researchers and clinicians. There is great controversy in the literature regarding the accuracy of salivary tests for mutans streptococci and lactobacilli in predicting future caries in adults.13 Several tests exist in the market to measure salivary bacteria based on culturing. These tests have disadvantages because they require incubators, many enumerate bacteria in saliva only (not in plaque), and in general they correlate poorly in adults with future caries risk. However, they may be useful to motivate and monitor oral hygiene, assess the effectiveness of oral antimicrobials and monitor dietary changes.

Newer tests are available that measure site-specific plaque pH, or measure bacte-rial load using either monoclonal antibod-ies, or responses to ATP bioluminescence and although useful for patient education, many of these have not been validated longitudinally yet for risk assessment.

DietSugar exposure is an important aetiologi-cal factor in caries development. Due to the wide use of fluoride and its effect in lowering the incidence and rate of caries, it is difficult to show a strong, clear-cut, positive association between a person’s total sugar consumption and his/her car-ies development. Thus, for example, self-reported sugar intake seems to have little value at identifying, by itself, patients at risk. However, diet is one of the main driv-ers of caries activity, and recognising the behaviours that are placing the patient at risk may be very important for caries pre-vention and management.22

Other dietary considerations include the retentiveness of the food, frequency of con-sumption (this being the most important), consumption between meals, the presence of protective factors in foods (for example, calcium, fluoride) and the type of carbohy-drate. Although sugar in liquid form (for example, soft drinks) is less cariogenic than sugar in solid form (for example, sweets), excessive frequent consumption of soft drinks remains a major risk factor that may be partly responsible for the high rate of caries in teenagers and young adults in many parts of the world. As a reminder,



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starches are considered less cariogenic than the simple sugars sucrose, glucose and fruc-tose, with sucrose possibly being the most cariogenic due to its unique role in the pro-duction of extracellular polysaccharides.

OthersMental and/or physical disabilities that affect regular oral hygiene or which require a more frequent carbohydrate-enriched diet also may affect the individu-al’s risk. Additionally, enamel defects, such as hypoplasia, have also been related to increase caries risk, especially in children.

PROTECTIVE FACTORSCaries protective factors are biologic or therapeutic factors/measures that can col-lectively offset the challenge presented by caries risk factors. The more severe the risk factors, the higher the protective factors need to be to keep the patient in balance or to reverse the caries process.

We recommend that risk assessment in adults include an analysis of risk indica-tors, risk factors and protective factors. To determine the risk status of a patient we must balance the presence of risk fac-tors that the patient currently has, plus risk indicators of past and current disease history and weigh that against the protec-tive factors that the patient is exposed to.1 Although the clinician should analyse all protective factors the patient is exposed to, of great importance is the exposure to fluorides. The widespread use of fluoride has reduced dramatically the prevalence of dental caries and the rate of the progression of carious lesions.23 Its use, which should be considered one of the most important pro-tective factors when assessing a patient’s caries risk, allows more conservative man-agement strategies for the prevention and treatment of dental caries. The frequency of fluoride exposure is one of the most impor-tant considerations when considering its use as a management and preventive strat-egy to control dental caries. This is because the main mechanism by which fluoride prevents against caries is by enhancing remineralisation. When does remineralisa-tion need to happen? Every time there is demineralisation. The dental care profes-sional should consider all fluoride sources to which the patient is exposed, for exam-ple, fluoridated drinking water, foods/drinks, home topical fluoride products and

periodic professional fluoride exposures. The dentist should then determine if this history/pattern of fluoride exposure has arrested the appearance or progression of carious lesions (incipient or cavitated) over time. If new lesions have appeared or existing lesions have progressed, then the patient’s fluoride exposure is inadequate. As the risk is increased, so should be the level of fluoride exposure, both at home and in office.2,24 In addition, fluoride use should be individually determined for each patient based on age, physical abilities, health awareness and attitude.

CASE REPORTFor the patient presented in the following case report (Figs 1-3) it is not necessary to complete a complicated and long risk assessment form or to measure risk factors using chair-side bacterial or salivary tests available in the market to determine that the patient is at elevated risk for dental car-ies. The presence of clear clinical signs of disease activity (presence of active caries lesions) can be used to help predict a higher risk of future disease progression. But, what if there had not been any signs of active dis-ease? Does this mean the risk of developing caries lesions in the next few years is low?

Risk indicators

Caries experience

Caries experience has been high and there are numerous lesions present that appear active; therefore, we should classify this patient, as explained later on, as moderate to high risk. Although this information is helpful, we still do not know the specific reasons behind the caries experience of this patient.

Socio-demographic indicatorsThe patient is female, 63 years old, of lower middle class, divorced, living independently for the last seven years, but under a lot of financial stress. Although none of these fac-tors are a strong predictor of her future risk, they point to an environment which may be conducive, for example, to difficulty accessing care as frequently as needed.

Risk factors

Saliva

In the present case, there were no signs or

symptoms of salivary dysfunction. None of the conditions, which could affect the salivary flow rate, such as Sjögren’s syn-drome, uncontrolled diabetes or medica-tions, were present in the patient described.

BacteriaThis patient presented mature, stagnant plaque around most cervical and inter-proximal areas, with gingivitis associated with it. This clinical observation suggests these are risk areas for caries development in this patient.

DietWhen initially questioned, the patient did not think she had a high sugar-rich diet. However, her active lesions suggested there must be a current dietary factor in play. Upon closer examination, she admit-ted to drink very frequently throughout the day coffee with sugar, usually with a cookie or two. Although not an unusual behaviour for some people, the combina-tion of this habit with presence of stagnant mature plaque and lack of protective fac-tors (discussed next) increases the risk of the patient.

Protective factorsThe patient used to brush twice a day with a dentifrice with fluoride; however, since

Figs 1-3 Clinical photographs presenting patient with a moderate to high risk of dental caries



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her divorce seven years ago she is brushing less than once a day. In addition, she has received no in-office fluoride treatments over the last two decades. Even though she may have had an appropriate level of fluoride exposure at one time, currently this level is not enough to balance out the plaque and dietary factors she is being challenged with.

Re-evaluationIn order to provide frequent counselling and exposure to in–office fluoride, the recall interval was set at four months.

CONCLUSIONSConsidering the current understanding of the caries disease process, we propose the following factors, whether appearing singly or in combination, would yield a moderate to high risk assessment of caries (as in the case presented in this paper): the develop-ment of new caries lesions, the presence of active lesions and the placement of res-torations due to active disease since the patient’s last examination (assuming a one to two-year lapse between the previous and current appointment). Finally, of greatest importance is that for moderate and high risk individuals; once you have determined they are at risk and have identified the reasons why, the dental team then has to decide what is the simplest and most likely successful strategy, both from the biologi-cal and behavioural perspective, for man-aging the caries disease in that particular patient. This includes a decision of both preventive and restorative approaches.

We also propose that a low caries risk assessment be based on the following fac-tors: no caries lesion development or pro-gression for a period of one to three years; amount of plaque accumulation; frequency of the patient’s sugar intake; presence of salivary problems; behavioural or physi-cal disability changes; history of fluoride exposure and pattern of fluoride usage.

A dentist’s overall subjective impres-sion of the patient has a relatively good predictive value for caries risk,25 but it is unclear how this information is incor-porated into everyday clinical practice. Recent concepts in caries management have not been largely accepted: a recent survey of clinical practices within a U.S. practice-based research network suggests that a significant proportion had yet to

adopt treatments based on assessment of caries-risk.26 Another practice-based study showed that in France decision-making in caries management does not only depend on pathophysiology.27 Thus, a more objec-tive, easy to implement, and validated risk assessment instrument is desirable and this is reflected in the multiple risk assessment tools that have been developed during the last few years. Examples for adults include the American Dental Association’s caries risk tool for adults,28 the caries manage-ment by risk assessment (CAMBRA) tool for adults,29 and the cariogram.30–32

Risk assessment is an essential compo-nent of clinical practice for caries manage-ment. Most of the information needed is readily available in a properly done health/dental history and a clinical examination, with the subjective impression of the clini-cian having been shown to be very use-ful. Most of the risk indicators or factors provide (either by themselves or combined) only a modest possibility of accurately predicting adults at future risk. However, even with these limitations risk assess-ment can enhance patient care. The most important factor in predicting future risk is recent caries experience and current dis-ease activity. However, a careful analysis of all risk and protective factors will allow the dental team and patient to understand the specific reasons for the caries disease and thus will allow them to tailor the treat-ment plan and recall interval specifically to the patient’s needs.

The authors would like to thank Claudie Damour-Terrasson, publishing director of the Groupe Information Dentaire, Paris France, for the autorisa-tion of translation and publication of the series in the BDJ and Dr Sanjay Karunagaran for kindly provid-ing the clinical pictures used in the present article.

1. Featherstone J D. The caries balance: contributing factors and early detection. J Calif Dent Assoc 2003; 31: 129–133.

2. Fontana M, Zero D. Assessing patients’ caries risk. J Am Dent Assoc 2006; 137: 1231–1249.

3. Featherstone J D. The science and practice of caries prevention. J Am Dent Assoc 2000; 131: 887–899.

4. Fontana M, Young D A, Wolff M S, Pitts N B, Longbottom C. Defining dental caries for 2010 and beyond. Dent Clin North Am 2010; 54: 423–440.

5. Reich E, Lussi A, Newbrun E. Caries risk assessment. Int Dent J 1999; 49: 15–26.

6. American Dental Association. Policy of evi-dence based dentistry. USA: ADA, 2008. Online article available at http://www.Ada.Org/1754.Aspx (accessed October 2012).

7. Edelstein B L. The dental caries pandemic and dispari-ties problem. BMC Oral Health 2006; 6(Suppl 1): S2.

8. Twetman S, Fontana M. Patient caries risk assess-ment. Monogr Oral Sci 2009; 21: 91–101.

9. Zero D, Fontana M, Lennon A M. Clinical applica-tions and outcomes of using indicators of risk in caries management. J Dent Educ 2001; 65: 1126–1132.

10. Bratthall D, Hänsel Petersson G. Cariogram – a mul-tifactorial risk assessment model for a multifacto-rial disease. Community Dent Oral Epidemiol 2005; 33: 256–264.

11. Burt B A. Definitions of risk. J Dent Educ 2001; 65: 1007–1008.

12. Powell L V. Caries prediction: A review of the litera-ture. Community Dent Oral Epidemiol 1998; 26: 361–371.

13. National Institutes of Health (US). Diagnosis and management of dental caries throughout life. NIH Consensus Statement 2001; 18: 1–23.

14. Ritter A V, Shugars D A, Bader J D. Root caries risk indicators: a systematic review of risk models. Community Dent Oral Epidemiol 2010; 38: 383–397.

15. Sánchez-García S, Reyes-Morales H, Juárez-Cedillo T, Espinel-Bermúdez C, Solórzano-Santos F, García-Peña C. A prediction model for root caries in an elderly population. Community Dent Oral Epidemiol 2011; 39: 44–52.

16. Jamieson L M, Mejía G C, Slade G D, Roberts-Thomson K F. Predictors of untreated dental decay among 15-34-year-old Australians. Community Dent Oral Epidemiol 2009; 37: 27–34.

17. Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004; 38: 182–191.

18. Wright J T. Defining the contribution of genetics in the etiology of dental caries. J Dent Res 2010; 89: 1173–1174.

19. Leone C W, Oppenheim F G. Physical and chemical aspects of saliva as indicators of risk for dental car-ies in humans. J Dent Educ 2001; 65: 1054–1062.

20. Navazesh M. Salivary gland hypofunction in elderly patients. J Calif Dent Assoc 1994; 22: 62–68.

21. Fox P C, van der Ven P F, Sonies B C, Weiffenbach J M, Baum B J. Xerostomia: evaluation of a symp-tom with increasing significance. J Am Dent Assoc 1985; 110: 519–525.

22. Zero D T. Sugars – the arch criminal? Caries Res 2004; 38: 277–285.

23. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. CDC, 2001. Online article available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm (accessed October 2012).

24. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc 2006; 137: 1151–1159.

25. Disney J A, Graves R C, Stamm J W, Bohannan H M, Abernathy J R, Zack D D. The University of North Carolina Caries Risk Assessment study: further developments in caries risk prediction. Community Dent Oral Epidemiol 1992; 20: 64–75.

26. Riley J L 3rd, Gordan V V, Rindal D B et al. Preferences for caries prevention agents in adult patients: findings from the dental practice–based research network. Community Dent Oral Epidemiol 2010; 38: 360–370.

27. Doméjean-Orliaguet S, Léger S, Auclair C, Gerbaud L, Tubert-Jeannin S. Caries management decision: influence of dentist and patient factors in the pro-vision of dental services. J Dent 2009; 37: 827–834.

28. American Dental Association. Caries risk form: (patients over 6 years). ADA, 2008. Online form available at http://www.ada.org/sections/profes-sionalResources/pdfs/topic_caries_over6.pdf (accessed October 2012).

29. Featherstone J D, Domejean-Orliaguet S, Jenson L, Wolff M, Young D A. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007; 35: 703–707, 710–713.

30. Fure S, Zickert I. Incidence of tooth loss and dental caries in 60-, 70-and 80-year-old Swedish individuals. Community Dent Oral Epidemiol 1997; 25: 137–142.

31. Hänsel Petersson G, Fure S, Bratthall D. Evaluation of a computer-based caries risk assessment program in an elderly group of individuals. Acta Odontol Scand 2003; 61: 164–171.

32. Ruiz Miravet A, Montiel Company J M, Almerich Silla J M. Evaluation of caries risk in a young adult population. Med Oral Patol Oral Cir Bucal. 2007; 12: E412-E418.



http://www.Ada.Org/1754.Aspx

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

Minimal intervention dentistry: part 3. Paediatric dental care – prevention and management protocols using caries risk assessment for infants and young childrenF. J. Ramos-Gomez,1 Y. O. Crystal,2 S. Domejean3 and J. D. B. Featherstone4


INTRODUCTION

Despite progress made in caries control worldwide by the protective effects of fluoride, increased dissemination of oral hygiene information and widespread healthy diet education, dental caries still remains the most common chronic child-hood disease. Consequently, it is a major financial burden on society in many coun-tries throughout the world. In recent years, reports show that caries in the primary dentition has been increasing in the USA, UK, Canada, Australia, the Netherlands and other countries.1-8

Early childhood caries (ECC) is more prevalent among young children from low socioeconomic, ethnic minority popu-lations.9 This uneven distribution occurs in many developed countries with 25% of children bearing 75% of the affected sur-faces. Dental caries is a preventable and transmissible infectious disease; it is well documented that the presence of caries in the primary dentition is one of the best indicators for future caries in the per-manent dentition.10,11 Thus, the early and

Recent increases in caries prevalence in young children throughout the world highlight the need for a simple but effective infant oral care programme. This programme needs to include a medical disease prevention management model with an ear-ly establishment of a dental home and a treatment approach based on individual patient risk. This article presents an updated approach with practical forms and tools based on the principles of caries management by risk assessment, CAMBRA. This method will aid the general practitioner to develop and maintain a comprehensive protocol adequate for infant and young children oral care visits. Perinatal oral health is vitally important in preventing early childhood caries (ECC) in young children. Providing dental treatment to expectant mothers and their young children in a ‘dual parallel track’ is an effective innovative strategy and an efficient practice builder. It promotes prevention rather than intervention, and this may be the best way to achieve long-lasting oral health for young patients. General dental practice can adopt easy protocols that will promote early preventive visits and anticipatory guidance/counselling rather than waiting for the need for restorative treatment.

accurate identification of children at risk is of great importance for cost-effective car-ies control. Signs of ECC can be detected soon after the eruption of the first tooth. If risk indicators are identified early and oral health preventive practices are imple-mented at a young age, the disease can be controlled and its progression slowed.

In the USA, the American Dental Association (ADA), the American Academy of Paediatric Dentistry (AAPD), the American Academy of Paediatrics (AAP), the American Association of Public Health Dentistry (AAPHD) and the Academy of General Dentistry (AGD) all recommend that a child should see a dentist and estab-lish a ‘dental home’ by one year of age or when the first tooth erupts.12-16 A dental home is defined as the ongoing relationship between the dentist and the patient where accessible and coordinated oral healthcare can be delivered comprehensively while actively involving family participation.17 Despite the widespread advocacy of a ‘medical’ and a ‘dental home’ by age one, infant oral health visits have not yet been

1*University of California, Los Angeles, USA; 2New-York University, USA; 3CHU Clermont-Ferrand, Service d’Odontologie, Hôtel-Dieu, F-63,001 Clermont-Ferrand, France; 4University of California, San Francisco, USA *Correspondence to: Francisco Ramos-Gomez Email: [email protected]; Tel: +1 310 825 9460


• Examines the problem of early childhood caries and how it can be minimised.

• Informs caries is a transmissible, infectious disease, which can be passed from mother to child.

• Stresses the importance of risk assessment and preventive dentistry in paediatric healthcare.

I N B R I E F

PRA

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7. Minimally invasive operative caries management – rationale and techniques

This paper is adapted from: Ramos-Gomez F J, Crystal Y O, Doméjean S, Featherstone J D B. Odontologie pédiatrique. Prévention et prise en charge de la maladie carieuse basées sur l’évaluation du risque pour les jeunes enfants. Réalités Cliniques 2011; 22 (3): 221–232.




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embraced universally by practicing clini-cians. Many paediatricians are unaware of current oral health evidence–based proto-cols and recommendations and refer chil-dren only when there is clinical evidence of established dental disease. Since family physicians and paediatricians often see children up to six times before age two, it is crucial to take these appointments as opportunities to increase awareness of oral health evaluations and screen young children for caries risk and refer for dental care.18 However, general dentists have to be prepared to accept these young children for their first dental visit’s evaluation and treatment. This article presents an updated, simple and systematic six-step protocol for an infant oral examination that will ease implementation of early visits into dental practice.19 Due to the infectious and trans-missible nature of dental caries, the first step in preventing the development of ECC is to provide perinatal oral healthcare to expectant mothers as soon as possible.

PERINATAL ORAL HEALTHCaries is a transmissible, infectious disease. If this disease keeps progressing, surface cavitation and destruction of dental tis-sue worsens over time. The mutans strep-tococci (MS) group of bacteria (primarily streptococcus mutans and streptococcus sobrinus) are key pathogens in the caries process, due to their ability to adhere to smooth tooth surfaces and produce acid.20 Generally, colonisation of MS in the oral cavity of children is the result of transmis-sion of these organisms from the child’s primary caregiver.21 A direct relationship exists between MS levels in adult caregiv-ers and that of caries prevalence in their children.22 Factors influencing colonisa-tion include frequent sugar exposure in the infants and habits that allowed salivary transfer from mother/caregiver to infants. Maternal factors, such as high levels of MS, poor oral hygiene, low socioeconomic sta-tus and frequent snacking increase the risk of bacterial transmission to her infant.23 Infants have been identified with high lev-els of MS in their mouths even before the eruption of the first tooth.19 Therefore, it is critical to consider an infant oral care programme in the context of a participat-ing pair or mother-and-child dyad, which includes comprehensive maternal perinatal oral healthcare, counselling and treatment.

Dental professionals are beginning to recognise the essential role a mother plays in ensuring her child’s oral health. Improving expectant mothers’ oral health by reducing pathogenic bacteria levels in their own mouths, will delay the acqui-sition of oral bacteria and the develop-ment of ECC in their children.20 Restoring carious lesions, by itself, is insufficient to reduce a mother’s risk of transmitting cari-ogenic bacteria to her offspring. An effec-tive perinatal program should institute practices such as therapeutic interventions and lifestyle modification counselling both during pre- and post-partum to reduce maternal MS and lactobacilli levels.24 Unfortunately, pregnant women often do not receive oral healthcare and education in a timely manner. Many women do not know they should seek dental care dur-ing their pregnancy. Of those who do, they often encounter dentists unwilling to pro-vide care to pregnant mothers. New moth-ers are also more likely to be receptive to

ideas that would improve their offspring’s oral health,25 making this the best ‘win-dow of opportunity’ for preventive care. Therefore, dental, medical and obstetric providers have the prime opportunity to educate mothers with positive reinforce-ment and effective behavioural changes that could affect significantly their chil-dren’s future oral health.

INITIAL INFANT ORAL CARE VISITInfants and parents (caregivers) will benefit from an early infant oral health visit and the establishment of a ‘dental home’. An infant oral health visit should include caries risk assessment, individualised preventive strategies and anticipatory guidance.26,27 Establishing periodicity supervision of care intervals and age-appropriate ‘care paths’ is determined based on the risk of disease of each individual patient.28 Infants and toddlers are not expected to be coopera-tive during an oral examination; crying and movement are common responses.

Table 1 CAMBRA for dental providers (0‑5 years) assessment tool**

Biological factors High risk factors

Moderate risk factors

Protective factors

Mother/primary caregiver has active caries Yes

Parent/caregiver has low socioeconomic status Yes

Child has >3 between meal sugar containing snacks or beverages per day Yes

Child is put to bed with a bottle containing any sugar Yes

Child has special health care needs Yes

Child is a recent immigrant Yes

Protective Factors

Child receives optimally fluoridated drinking water or fluoride supplements Yes

Child has teeth brushed daily with fluoridated toothpaste Yes

Child receives topical fluoride from health professional Yes

Child has dental home/regular dental care Yes

Primary caregiver uses xylitol chewing gum/lozenges Yes

Clinical Findings

Child has more than one dmfs Yes

Child has active white spot lesions or enamel defects Yes

Child has elevated mutans streptococci Yes

Child has plaque on teeth Yes

Overall assessment of the child’s dental caries risk: High Moderate Low**Modified from Ramos-Gomez et al. CDA Journal 2007; 35: 687-702; and ADA caries risk assessment forms available at http://www.ada.org/sections/professionalResources/pdfs/topic_caries_over6.pdf (accessed October 2012). Copyright 2007/2010 California Dental Association. Reprinted with permission



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Explaining to the caregivers exactly what to expect during this visit and engaging them to participate may allay some of their fears and concerns.

An infant oral health visit consists of a six-step protocol:1. Caries risk assessment2. Proper positioning of the child

(knee-to-knee exam)3. Age appropriate tooth brushing

prophylaxis4. Clinical examination of the child’s

oral cavity and dentition5. Fluoride varnish treatment6. Assignment of risk, anticipatory

guidance and counselling.

Caries risk assessmentAn individualised risk assessment of an infant or toddler for developing caries serves as the foundation for healthcare providers and parents/caregivers to iden-tify and understand the child’s ECC risk factors. A systematic assessment of car-ies risk serves as a guide for dentists to design treatment and preventive protocols for children already with disease and those deemed at risk. For optimal outcomes, caries risk assessment should be done as early as possible, and preferably before the onset of the disease process. Due to the fact that caries in the primary denti-tion is a strong predictor of caries in the permanent dentition, caries risk assess-ment and management is crucial, as is the subsequent follow-up.29,30 The caries bal-ance concept states that the progression or reversal of dental caries is determined by the balance between pathological factors and caries protective factors.31-33 Risk fac-tors are determined from an interview with the parent and from a clinical assessment of the child (Table 1).

During the interview with the parent/caregiver, the assessment should explore biological and lifestyle risk factors that contribute to the development or progres-sion of caries. Examples of risk factors include recently placed dental restora-tions in the mother, low socioeconomic status of the family, low health literacy of caregiver, the child’s frequent intake of fermentable carbohydrates, sleep-ing with a bottle that contains liquids other than water and prolonged use of a ‘sippy cup’ containing milk, juice or a sweetened beverage.

Clinical disease indicators from oral examinations are used to diagnose car-ies. These include cavitated carious lesions, white spot lesions/decalcifications observed visually or by radiographs and recent restorations. However, these physi-cal manifestations of caries do not tell us why the disease is present (Fig. 1). In the three clinical cases presented in Figure 1, the clinical signs (carious lesions at differ-ent clinical stages) indicate the presence of active carious processes. The caries risk assessment and the determination of the pathological factors, in particular, will guide the decision-making and the cus-tomisation of the therapeutic and the pre-vention strategies, specific to each patient.

Biological risk factors, also known as pathological factors, include presence of plaque, gingival bleeding (an indicator of dense plaque), low pH and dry mouth. Any of these recorded indicators can be then combined with the data from the inter-view to determine the risk for that patient (Fig. 2). In older children, the presence of dental or orthodontic appliances increases plaque retention and the risk for caries.

Protective factors, which are indicators that may reduce a child’s risk for ECC, can also be assessed during the interview with the parent. These factors include optimal exposure to fluoride, access to regular dental care (for example, the presence of a dental home), consistent brushing with fluoride toothpaste, use of fluoridated tap water and xylitol among other combina-tion therapy.

Proper positioningProper positioning of the child is critical to conducting an effective and efficient clini-cal exam in a young child. In general, the knee-to-knee position should be used with children aged six months to three years, or up to age five with children who have spe-cial healthcare needs. Children older than three years may be able to sit forward on their caregiver’s lap or sit alone in a chair. Examiners and caregivers need to work together to transition the child smoothly from the interview to the exam (Fig. 3).

The clinician should explain what will happen (tell, show and do) before starting, and anticipate that young children may cry since crying is developmentally appro-priate for children of this age. Knee-to-knee positioning allows the child to see the

Fig. 1a Carious lesions at different clinical stages: child, 18 months old, with advanced cavitated lesions

Fig. 1b Child, three years old, with cavitated lesions localised on the buccal surfaces of the anterior maxillary teeth

Fig. 1c Child, three years old, with cervical white spot lesions (reversible enamel lesions) localised on the canines and posterior teeth

Fig. 2 Biological risk factors. Three‑year‑old child, with high caries risk. Presence of visible dental plaque, gingival bleeding and cervical white spots lesions on the posterior teeth

Fig. 3 The knee‑to‑knee position



PRACTICE

parent throughout the exam. It also allows the parent/caregiver to observe clini-cal findings and hygiene demonstrations directly, while gently helping to stabilise the child safely for the clinical examina-tion. If the child can perceive a friendly and comfortable interaction between the clinician and caretaker, he or she will be more likely to cooperate and result in a smoother examination.

Toothbrush prophylaxisToothbrush prophylaxis is efficient in removing plaque in most young children. It is non-threatening to young children and serves to demonstrate the proper technique of brushing to the caregiver. The examiner retracts the child’s lips and cheeks and demonstrates brushing along the gingival margins. The spongy handle of an age-appropriate sized toothbrush can be used to prop open the child’s mouth. The handle of a second toothbrush can be used as a mouth prop. During this ‘tell-show-do’ encounter, the caregiver should be encouraged to brush their child’s teeth

at least twice a day, especially before bed-time. The use of fluoride toothpaste should be emphasised since fluoride has been shown to be effective topically to prevent caries. Parents and caregivers should be instructed to use a ‘pea-sized’ amount of fluoride toothpaste for children age two to six and a ‘smear’ for children under age two.34,35

Clinical examinationThe examiner ‘counts’ the child’s teeth aloud, using the toothbrush handle as a mouth prop if necessary. Many providers make a game of this task, singing songs, engaging the child’s attention, and if all else fails, distracting the child with a brightly coloured toothbrush or toy. Praise the child at each step for their cooperation and/or good behaviour. While ‘counting’ the teeth, the examiner also inspects the soft tissues, hard tissues and occlusion, if the child is able to cooperate. Data from the clinical exam results should be com-bined with data from the caregiver inter-view to determine the child’s overall caries

risk and establish an oral diagnosis and formulate an individualised care (treat-ment) plan.

The following information should be documented:•Visible plaque and its location•White spot lesions•Brown spots that on the occlusal

surfaces may indicate caries•Tooth defects, deep pits/fissures,

tooth anomalies•Missing and decayed teeth•Existing restorations•Defective restorations•Gingivitis or other soft

tissue abnormalities•Occlusion• Indications of trauma.

Fluoride treatmentFluoride is an important and cost-effective prevention method to strengthen tooth enamel and prevent caries. The ADA and the UK NHS Department of Health recom-mends that high caries risk children receive a full-mouth topical fluoride varnish (FV)

Table 2 Caries management protocol for 0‑2‑year‑olds

Risk category (ages 0 to 2 years)

Diagnostic

Preventive intervention Restoration

Xylitol Sealants Antibacterials Anticipatory guidance/counselling

Self-management goals White spot/precavitated lesions

Existing lesions

Not required No No Yes No n/a n/a

Child: xylitol wipesCaregiver: two sticks of gum or two mints four times a day

Fluoride releasing sealants recommended on deep pits and fissures

No Yes No Treat w/ fluoride products as indicated to promote remineralisation

n/a



Recommend for caregiver Yes Yes Treat w/ fluoride products as indicated to promote remineralisation

n/a




ITR (interim therapeutic restorations) or conventional restorative treatment as patient cooperation and family circumstances allow




ITR or conventional restorative treatment as patient cooperation and family circumstances allow





Periodic oral exams Radiographs Saliva test Fluoride

Low Annual Posterior bitewings at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe

Optional baseline In office: noHome: brush twice a day w/ smear of F toothpaste

Moderate Every six months Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Recommended In office: F varnish initial visit & recallsHome: Brush twice a day w/smear of F toothpaste Caregiver: OTC sodium fluoride treat-ment rinses

Moderate; non-compliant

Every three to six months Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Required In office: F varnish initial visit & recallsHome: Brush twice a day w/smear of F toothpaste combined w/smear of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses

High Every three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe


High; non-compliant

Every one to three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe


Extreme Every one to three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Required In office: F varnish initial visit and recallsHome: Brush twice a day w/smear of F toothpaste combined w/smear of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses



PRACTICE

application and re-application consistently at three/four-month intervals.36 A minimum of every six months is recommended for chil-dren at moderate caries risk even if the child lives in a community that already receives the benefits of water fluoridation. The pro-vider should reiterate the cumulative benefit of the fluoride varnish, even if it has been mentioned earlier in the visit. After applica-tion, the caregiver should be reminded not to allow the child to brush their teeth or to eat crunchy/sticky foods for the rest of the day to allow fluoride varnish to be effective.

FV is one of the most efficacious and prevalent methods used by modern den-tists to combat early childhood caries. According to the ADA, extensive research has shown FV to be safe and effective for patients of all ages.37 FV is painless, quick to apply, and therefore can be used on very young children.38 There is, how-ever, widespread debate on the results in reference to differing recommendations for the frequency and periodicity of FV application. Some sources advocate FV treatments every six months, citing this

protocol as the most cost-effective method with the best outcome.39 Others argue that three consecutive varnishes over a week’s time-period, once annually, are more effective than semi-annual treatments.40-42 Regardless, all sources agree that FV is useful as a necessary standard of care component for the prevention of dental caries and crucial as a tool in oral health maintenance for all ages.40-42

Assignment of risk, anticipatory guidance and counselling

An individualised care plan for each infant/caregiver is designed based upon the risk determined from the parent interview and the clinical examination of the child (Tables 2 and 3). A dual approach is essential for moderate and high caries risk children and their parent/caregivers. Strategies need to be employed to decrease the maternal or caregiver transmission of cariogenic bacte-ria to infants through the potential use of chlorhexidine rinse and xylitol products for caregivers, and fluoride varnish for both the caregiver and the child.34 Additionally, the

necessary changes in the child’s diet, tooth brushing and fluoride application can be identified from the risk analysis.

The science of caries prevention contin-ues to evolve. Table 2 illustrates how to develop care paths for a practice’s patients. There are many alternative approaches to the prevention and treatment of dental caries, with more emerging continuously. Care paths should remain dynamic and change over time as the effectiveness of new as well as current protocols is vali-dated by scientific evidence.

Parents should be given additional information and anticipatory guidance on oral health prevention that is specific to the needs of their child. Such information includes oral hygiene, growth and devel-opment issues (that is, teething, digit or dummy habits), oral habits, diet and nutri-tion and injury prevention (Tables 2 and 3). The anticipatory guidance approach is designed to take advantage of time-criti-cal opportunities to implement preventive health practices and reduce the child’s risk of preventable oral disease.43-45


Risk category (ages 0 to 2 years)

Diagnostic

Preventive intervention Restoration

Xylitol Sealants Antibacterials Anticipatory guidance/counselling

Self-management goals White spot/precavitated lesions

Existing lesions

Not required No No Yes No n/a n/a



No Yes No Treat w/ fluoride products as indicated to promote remineralisation

n/a




n/a




ITR (interim therapeutic restorations) or conventional restorative treatment as patient cooperation and family circumstances allow











Optional baseline In office: noHome: brush twice a day w/ smear of F toothpaste

Moderate Every six months Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Recommended In office: F varnish initial visit & recallsHome: Brush twice a day w/smear of F toothpaste Caregiver: OTC sodium fluoride treat-ment rinses

Moderate; non-compliant

Every three to six months Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe


High Every three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe


High; non-compliant

Every one to three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe


Extreme Every one to three months Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Required In office: F varnish initial visit and recallsHome: Brush twice a day w/smear of F toothpaste combined w/smear of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses



PRACTICE

An important component of the visit is to counsel the parents to change specific factors which may contribute to active car-ies or to an increased caries risk in their child. Traditionally, generic recommenda-tions, such as ‘brush your teeth twice a day and don’t eat sweets’, have been offered to parents with limited success. Using fam-ily-centred, customised recommendations have been shown to be more promising as parents are more engaged in changing spe-cific practices. Motivational interviewing is a counselling technique that relies on two-way communication between the cli-nician and the patient or parent46 (Fig. 4). This includes establishing a therapeutic alliance (that builds rapport and trust), by asking questions to help parents identify the problem and listening to what they say, encouraging self-motivational statements, preparing for change (discussing the hur-dles that interfere with action), responding to resistance and scheduling follow-up, as well as preparing the parent for the inevi-table bumps in the road.47

Following the brief motivational inter-viewing (counselling), the parent/caregiver is asked to select two self-management goals or recommendations as their assign-ments before the next re-evaluation den-tal visit. The parent/caregiver is asked to commit to the two goals selected and is informed that the oral healthcare providers will follow-up on those goals with them at the next appointment (see Tables 2 and 3 for self-management goals for parent/caregiver).

RECALL VISITS AND RECALL PERIODICITY

The clinician must consider each child’s individual needs to determine the appro-priate interval and frequency for oral examination;48 some infants and tod-dlers with high caries risk should be re-evaluated on a monthly basis (Tables 2 and 3). Most children at high risk need to be seen on a three-month interval for re-evaluation. Those children in the mod-erate risk category need to be placed on a six-month interval and the low risk child at a 6-12 month range interval (Tables 2 and 3).

After the parent has been following the recommendations for three to six months, have them and their child come back for reassessment. Parents need encouragement

early on when new behavioural change is required and time to ask questions regard-ing any difficulties with following the rec-ommendations. They should be aware that changing home practices does not happen overnight. At these infant oral care visits, it is essential to reassess the risk status and monitor improvement on the previ-ously set self-management goals. During these reassessment appointments, changes can be made and prevention protocols reinforced.

CONCLUSIONSPaediatric dentists and general dentists have the most influential role in prevent-ing and reducing the severity of early childhood caries in young children. By embracing the concepts of the ‘dental home’, perinatal and infant oral health, providers can implement preventive and treatment protocols. These care paths are based on individually determined caries risk and utilize an appropriate age-specific caries risk assessment. For example, care for very young children should include preventive interventions such as fluoride varnish applications, sealants and use of xylitol products. When restoration is required but can’t be performed readily for a variety of reasons, practitioners should consider interim therapeutic restorations (ITR), employing the use of hand or slow speed rotary instruments for partial car-ies removal followed by the application of adhesive, fluoride releasing restoratives such as auto-curing resin-modified glass ionomer cement.49 Motivational interview-ing, anticipatory guidance and setting self-management goals increases the prob-ability for better oral health outcomes and behaviour, not just for the child, but for the whole family. Partnerships with other

healthcare professionals with the aim of providing preventive care for our high risk populations is crucial to achieving better oral health outcomes in the future. The overall aim is to lower the risk level over time and eliminate the need for further res-torations by controlling the caries process.

The authors would like to thank Claudie Damour-Terrasson, publishing director of the Groupe Information Dentaire, Paris France, for the authori-sation of translation and publication of the series in the BDJ; Dr Norman Tinanoff, Dr Manwai Ng for contributing their support and knowledge to this project; Ms Debra Tom for her editorial assistance; and the HRSA Oral Health Disparities Collaborative for the implementation of the CAMBRA instrument and the development of the self-management goal instrument through High Plains Health Center. Finally, they wish to acknowledge the AAPD and AAP for their support and leadership on Caries Risk Assessment development.

1. World Health Organization. Oral health country/area profile program (CAPP). Geneva: WHO, 2006. Online programme available at http://www.whocol-lab.od.mah.se/ (accessed October 2012).

2. Dye B A, Tan S, Smith V et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11 2007: 1–92.

3. Pitts N B, Chestnutt I G, Evans D, White D, Chadwick B, Steele J G. The dentinal caries experience of chil-dren in the United Kingdom, 2003. Br Dent J 2006; 200: 313–320.

4. Al-Jewair T S, Leake J L. The prevalence and risks of early childhood caries (ECC) in Toronto, Canada. J Contemp Dent Pract 2010; 11: 1–8.

5. Armfield J M, Spencer A J. Changes in South Australian children’s caries experience: is caries re-surfacing? Aust Dent J 2004; 49: 98–100.

6. Truin G J, van’t Hof M A, Kalsbeek H, Frencken J E, König K G. Secular trends of caries prevalence in 6- and 12-year-old Dutch children. Community Dent Oral Epidemiol 1993; 21: 249–252.

7. Begzati A, Berisha M, Meqa K. Early childhood caries in preschool children of Kosovo - a serious public health problem. BMC Public Health 2010; 10: 788.

8. Ferro R, Besostri A, Meneghetti B et al. Oral Health inequalities in preschool children in North-Eastern Italy as reflected by caries prevalence. Eur J Paedr Dent 2007; 8: 13–18.

9. Vargas C M, Crall J J, Schneider D A. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988–1994. J Am Dent Assoc 1998; 129: 1229–1238.

10. Li Y, Wang W. Predicting caries in permanent teeth from caries in primary teeth: an eight-year cohort study. J Dent Res 2002; 81: 561–566.

11. Alm A, Wendt L K, Koch G, Birkhed D. Prevalence of approximal caries in posterior teeth in 15-year-old Swedish teenagers in relation to their caries

Fig. 4 The motivational interviewing (counselling)



PRACTICE

experience at 3 years of age. Caries Res 2007; 41: 392–398.

12. American Dental Association. Statement on early chidlhood caries. Chicago: ADA, 2007. ADA. Online statement available at http://www.ada.org/2057.aspx (accessed October 2012).

13. American Academy of Pediatric Dentistry reference manual 2010–2011. Pediatr Dent 2010-2011; 32: 1–334.

14. Hale K J, American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment

timing and establishment of the dental home. Pediatrics 2003; 111: 1113–1116.

15. American Association of Public Health Dentistry. First oral health assessment policy. AAPHD, 2004. Online policy available at http://www.aaphd.org/default.asp?page=FirstHealthPolicy.htm (accessed October 2012).

16. Academy of General Dentistry. Policies, guidelines, positions statements and fact sheets. Online infor-mation available at http://www.agd.org/issuesadvo-cacy/policies/dentalcare/ (accessed October 2012).

17. American Academy of Pediatric Dentistry. Definition of dental home. Chicago: AAPD, 2006 http://www.aapd.org/media/policies_guidelines/d_dentalhome.pdf (accessed October 2012).

18. Ismail A I, Nainar S M, Sohn W. Children’s first dental visit: attitudes and practices of US pediatricians and family physicians. Pediatr Dent 2003; 25: 425–430.

19. Ramos-Gomez F, Ng M W. Six step protocol for a successful infant oral care visit. Pediatric dentistry today, 2009. http://www.cdhp.org/resource/six_step_protocol_successful_infant_oral_care_visit (accessed October 2012).

20. Ramos-Gomez F. Bacterial salivary markers’ role in ECC risk assessment in infants. J Dent Res 2006; 85B: poster 0516.

21. Seki M, Yamashita Y, Shibata Y, Torigoe H, Tsuda H, Maeno M. Effect of mixed mutans streptococci colonization on caries development. Oral Microbiol Immunol 2006; 21: 47–52.

22. Douglass J M, Li Y, Tinanoff N. Association of mutans streptococci between caregivers and their children. Pediatr Dent 2008; 30: 375–387.

23. Tinanoff N, Kanellis M J, Vargas C M. Current under-standing of the epidemiology mechanisms, and prevention of dental caries in preschool children. Pediatr Dent 2002; 24: 543–551.

24. California Dental Association Foundation, American College of Obstetricians and Gynecologists, District I X. Oral health during pregnancy and early childhood: evidence-based guidelines for health professionals. J Calif Dent Assoc 2010; 38: 391–403, 405–440.

25. Gajendra S, Kumar J V. Oral health and pregnancy: a review. N Y State Dent J 2004; 70: 40–44.

26. American Academy of Pediatric Dentistry, American Academy of Pediatrics, American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies. Pediatr Dent 2005-2006; 27: 31–33.

27. American Academy of Pediatric Dentistry, American Academy of Pediatrics. Policy on early childhood car-ies (ECC): classifications, consequences, and preven-tive strategies. Pediatr Dent 2008-2009; 30: 40–43.

28. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator of future caries: a longitudinal study. Pediatr Dent 2003; 25: 114–118.

29. Tagliaferro E P, Pereira A C, Meneghim Mde C, Ambrosano G M. Assessment of dental caries pre-dictors in a seven-year longitudinal study. J Public Health Dent 2006; 66: 169–173.

30. Featherstone J D. The caries balance: contributing factors and early detection. J Calif Dent Assoc 2003; 31: 129–133.

31. Featherstone J D, Adair S M, Anderson M H et al. Caries management by risk assessment: consensus statement, April 2002. J Calif Dent Assoc 2003; 31: 257–269.

32. Featherstone J D. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent 2004; 2: 259–264.

33. Featherstone J D. Caries prevention and reversal based on the caries balance. Pediatr Dent 2006; 28: 128–132.

34. Ramos-Gomez F J. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent 2005; 26: 17–23.

35. Recommendations from MCHB Expert Panel. Topical fluoride recommendations for high-risk children - development of decision support matrix. Altarum Institute, Washington: 2007. Online article available at http://www.ncdhhs.gov/dph/oralhealth/library/includes/IMBresources/TopicalFluorideRpt%204-30-09%20edited%20with%20link%201-10.pdf (accessed October 2012).

36. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Dent Educ 2007; 71: 393–402.

37. Autio-Gold J. Recommendations for fluoride var-nish use in caries management. Dent Today 2008; 27: 64–67.

38. Moberg Sköld U, Petersson L G, Lith A, Birkhed D. Effect of school-based fluoride varnish programmes on approximal caries in adolescents from different


Risk category Ages 3 to 6

Diagnostic



Optional Baseline

In office: noHome: Brush twice a day w/ pea size of F toothpaste

Moderate Every 6 months

Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Recommended In office: F varnish initial visit and recallsHome: Brush twice a day w/pea- size of F toothpaste Caregiver: OTC Sodium Fluoride treatment rinses

Moderate; non-Compliant

Every 3-6 months

Posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Required In office: F varnish initial visit and recallsHome: Brush twice a day w/pea- size of F toothpaste combined w/pea-size of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses

High Every 3 months

Anterior (#2 occlusal film) and posterior bitewings at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Required In office: F varnish initial visit and recallsHome: Brush twice a day w/pea-size of F toothpaste combined w/pea-size of 900 ppm calcium-phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses

High; non-Compliant

Every 1-3 months


Required In office: F varnish initial visit and recallsHome: Brush twice a day w/pea-size of F toothpaste combined w/pea-size of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses

Extreme Every 1-3 months


Required In office: F varnish initial visit & recallsHome: Brush twice a day w/pea-size of F toothpaste combined w/pea-size of 900 ppm calcium- phosphate paste leave-on at bedtime Caregiver: OTC sodium fluoride treatment rinses



PRACTICE

caries risk areas. Caries Res 2005; 39: 273–279.39. Irigoyen M E, Luengas I, Zepeda M A, Sánchez-Pérez

L T. Frequency of fluoride varnish application in prevention of dental caries. Xochimilco, Mexico: Universidad Autonoma Metropolitana.

40. Marinho V C, Higgins J P, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2002: CD002279.

41. Marinho V C, Higgins J P, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003: CD002782.

42. Marinho V C, Higgins J P, Sheiham A, Logan S. One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. Cochrane

Database Syst Rev 2004: CD002780.43. American Academy of Pediatric Dentistry Clinical

Affairs Committee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent 2008; 30: 112–118.

44. American Academy of Pediatric Dentistry Clinical Affairs Committee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatr Dent 2005-2006; 27: 84–86.

45. American Academy of Pediatric Dentistry. Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatr Dent 2004;

26: 81–83.46. Weinstein P, Harrison R, Benton T. Motivating parents

to prevent caries in their young children: one-year findings. J Am Dent Assoc 2004; 135: 731–738.

47. Weinstein P. Provider versus patient-centered approaches to health promotion with parents of young children: what works/does not work and why. Pediatr Dent 2006; 28: 172–176.

48. Ramos-Gomez F J, Crall J, Gansky S A, Slayton R L, Featherstone J D. Caries risk assessment appropri-ate for the age 1 visit (infants and toddlers). J Calif Dent Assoc 2007; 35: 687–702.

49. American Academy on Pediatric Dentistry Clinical Affairs Committee- Restorative Dentistry Subcommittee, American Academy on Pediatric Dentistry. Council on Clinical Affairs Guideline on pediatric restorative dentistry. Pediatr Dent 2008-2009; 30: 163–169.

ErratumPractice article (BDJ 2012; 213: 447–451)

‘Minimal intervention dentistry: part 2. Caries risk assessment in adults’In the above practice article, the original article was actually adapted from: Fontana M, Gonzalez-Cabezas C. Evaluation du risque carieux chez l’adulte. Réalités Cliniques 2011; 22: 213–219.We apologise for any confusion caused by this error.



Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesionsA. Guerrieri,1 C. Gaucher,2 E. Bonte3 and J. J. Lasfargues4


being treated by non-invasive procedures including ultra-conservative or minimal intervention dentistry.

The detection of carious lesions at an early stage is necessary in order to imple-ment preventive and interceptive treatment strategies. In daily practice, the diagnosis of initial lesions is not always simple; it is often subjective and based on the clini-cian’s clinical sense. For this reason, the search is on for more specific and sensitive tools, using new technologies, to help the practitioner diagnose initial caries lesions as precisely as possible. The purpose of this paper is to review the recommended clinical methods for diagnosing initial car-ies lesions and to examine recent tools for early detection of these lesions.

BACKGROUNDThe initial enamel lesion results from an imbalance between the processes of dem-ineralisation and remineralisation. The first changes in enamel appear at those sites where there is plaque biofilm reten-tion and stagnation. The demineralisation alters the enamel surface, which becomes micro-porous, and with an opaque and matt appearance, characteristic of a white spot lesion. Acid penetration along the sheath of the enamel prism leads to the dissolution of crystalline spaces adja-cent to the lesion and progressing to the

INTRODUCTION

The initial caries lesion can be defined as a primary lesion which has not reached the stage of an established lesion with cavitation. It is therefore amenable to

The detection of carious lesions is focused on the identification of early mineral changes to allow the demineralisation process to be managed by non-invasive interventions. The methods recommended for clinical diagnosis of initial carious lesions are discussed and illustrated. These include the early detection of lesions, evaluation of the extent of the lesion and its state of activity and the establishment of appropriate monitoring. The place of modern tools, including those based on fluorescence, is discussed. These can help inform patients. They are also potentially useful in regular control visits to monitor the progression or regression of early lesions. A rigorous and systematic approach to caries diagnosis is essential to establish a care plan for the disease and to identify preventive measures based on more precise diagnosis and to reduce reliance on restorative measures.

enamel-dentine junction (EDJ) and, in the absence of treatment, cavitation occurs.1-3

High evidence-level studies are in agreement that the ideal tool for detection of the initial lesion, the ‘gold standard,’ has not yet been identified. Such a tool should have both a high level of sensitiv-ity (the ability to detect disease when it exists) and a high level of specificity (the ability to confirm the absence of disease). The conventional and validated tools for detecting early carious lesions include vis-ual and tactile examination and radiogra-phy (bitewings). These methods have good specificity but only moderate sensitivity and are relatively ‘operator-dependent’.4-6 The combination of clinical examination and bitewing radiographs nevertheless allows diagnoses with improved sensitiv-ity and specificity. Some new technolo-gies are appearing and it is of interest to link them with standard clinical practices, with a view to improving caries detection and diagnosis.3

THE STANDARD CLINICAL APPROACH

Systematised caries diagnostic procedures consist of three stages: the detection of a lesion, evaluation of its severity (depth) and its level of activity.7,8 Before an exam-ination, the practitioner will have noted the general context of caries activity. The

1-4Faculté de Chirurgie Dentaire, Université PARIS DESCARTES (1 rue Maurice Arnoux, 92120 Montrouge) et Service d’Odontologie, Hôpital Bretonneau, APHP (2 rue Carpeaux, 75018 Paris), France. *Correspondence to: Professor Jean-Jacques Lasfargues Email: [email protected]; Tel: +33 1 53 11 14 30

Accepted 21 June DOI: 10.1038/sj.bdj.2012.1087 ©British Dental Journal 2012; 213: 551-557

• Discusses the methods recommended for clinical diagnosis of initial carious lesions.

• Stresses the importance of a systematic approach to caries diagnosis and treatment.

• Presents a clinical case to consolidate diagnostic methods.

I N B R I E F

PRA

CTICE








This paper is adapted from: Guerrieri A, Gaucher C, Bonte E, Lasfargues J J. Détection et diagnostic des lésions carieuses initiales. Réalités Cliniques 2011; 22: 233–244


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principle general risk factors should be noted: age group, health state and use of medications, lifestyle, oral hygiene, nutri-tion and use of fluorides (Figs 1 and 2). Evaluation of individual caries risk cannot be separated from the actual diagnosis of carious lesions. It is essential to categorise a patient as being at low or high risk of caries for the correct choice of preventive, interceptive, or therapeutic care.

INITIAL CLINICAL EXAMINATIONThe purpose of the examination is to detect visually changes of colour, trans-lucency and structure of the enamel. An initial inspection, tooth by tooth, on wet surfaces can spot cavities and brown or white stains. Periodontal status and resto-rations may also be checked initially. At this stage, caries activity must be evaluated by checking the build-up of plaque biofilm and the gingival pathology at suspect sites. A blunt/rounded probe (a periodontal probe is appropriate) may be used, with gentle force (Fig. 3). Clinical parameters that indicate and quantify the activity state of a single carious lesion are, according to Ekstrand:8

•The appearance of the lesion, correlated with its severity (extension, depth)

•The position of the lesion (in an area in favouring plaque build-up or not)

•Tactile perceptions on probing (used to assess the presence of surface deposits and the roughness of the enamel)

•The status of the gingival margin in relation to the areas of interest (assessed by the absence or presence of bleeding caused by a careful probing).

EXTENSIVE CLINICAL OBSERVATION

Observation is used to classify each lesion according to its site and its stage of advancement, with a view to therapy.3 Pre-cleaning is fundamental to the qual-ity of diagnosis, both for the direct visual examination and for the use of comple-mentary diagnostic aids such as fluores-cence-based techniques.9 Undertaken with a rotating brush and prophylactic paste, or by air-polishing, the aim is elimination of the surface biofilm and deposits. Once cleaned, the suspect sites are dried and inspected individually. The use of visual aids (magnifying loupes, minimum × 2.5) greatly improves the detection rate of ini-tial carious lesions.10 The signs to look for

are changes in colour and translucency that indicate the state of demineralisation of surfaces and sub-surface zones com-pared with adjacent healthy areas. These visible signs indicating caries have been rationalised in a classification system, the International Caries Detection and Assessment System (ICDAS).11 The classi-fication includes six codes. Initial lesions are mainly covered by codes 1 and 2.• ICDAS II Code 0: the tooth is healthy• ICDAS II Code 1: the tooth has a lesion

visible only after drying and histology reveals that the lesion is limited to the external half of enamel

• ICDAS II Code 2: the lesion penetrates the full thickness of enamel. Clinically, an opacity or discoloration distinctly visible without air-drying is apparent but without cavitation (Fig. 4).

A statistically significant correlation exists between the anatomical and his-tological stages of lesions and the major

visual signs.12 Carious lesions thus identi-fied are classified on the ICDAS system according to the site: occlusal (site 1),

Radiographic examination(bitewings)

Initial interviewGeneral context of cariesactivity (diet, life-style and habits)

Initial clinical examination

Obvious lesions Suspect sites

Probe collects plaque= active site

Gingival bleeding on probing = active site

Cleaning and drying of tooth surfaces

In-depth clinical examination

Complimentary tools(Diagnodent®, LED camera)

Optical aids

Visual criteria(ICDAS II)

SiSta Classi�cation

Treatment decisionCaries riskLow to moderateHigh

Fig. 1 Flow-chart of the practical approach to assessment of initial carious lesions (from Lasfargues and Colon, 2010)3

Fig. 2a Young patient presenting with a high caries risk, as evidenced by the presence of multiple white-spot demineralisations and severe gingivitis

Fig. 2b Close-up of area of plaque retention, indicating high disease activity

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proximal (site 2), and cervical (site 3), then according to their stage (Table 1).

VISUAL EXAMINATION ASSISTED BY PROBING

Tactile sensation has long been the prin-cipal diagnostic tool in cariology, involv-ing the use of a sharp dental explorer. It has been demonstrated that probing does

not improve the diagnostic sensitivity of visual examination, especially in detect-ing lesions in pits and occlusal fissures. Indeed, the result of this subjective method depends on the size of the probe tip, the resistance of the enamel and the force exerted by the probe. Furthermore, prob-ing can cause iatrogenic damage to enamel (and loss of the possibility of reminerali-sation) so favouring lesion progression.13 Probing with a sharp dental explorer can-not be considered a reliable technique for detection of carious lesions.

RADIOGRAPHIC EVALUATIONBitewing radiographs are the method of choice for early detection of carious lesions, especially on proximal surfaces. Radiographic examination reveals, on average, twice as many proximal lesions extending into dentine as simple visual examination. Radiographic examination also allows the depth of a carious lesion to be estimated, useful for care planning. In the permanent dentition, two bitewing radiographs are recommended to cover directly and tangentially all proximal surfaces of the molar-premolar segment. The technique involves using a specific film holder with a guide rod and a col-limator ring (Rinn angulator). This system allows radiographs to be reproduced at time intervals appropriate for the proper longitudinal follow-up (control) of incipi-ent carious lesions.

NEW DIAGNOSTIC AIDSNone of the new caries detection tech-niques developed in recent years is 100% reliable when used alone. They comple-ment the systematic approach already described, with, for the most validated, an increase in detection sensitivity when combined with conventional tech-niques.14,15 Their development is based on the need for increased detection sen-sitivity to allow lesions to be identified as early as possible (particularly before invasive restoration becomes necessary). Today the treatment of initial lesions is well understood,16 as is the need for early caries lesion detection and diagnosis.

The new diagnostic tools are classified on the basis of the physical principles that underpin them.17 The most prominent include transillumination (Diagno.cam, Kavo®), and fluorescence systems (DIAGNOdent, Kavo®; CS 1600 Kodak; VistaCam iX, DürrDental®; SoproLife, Acteon®).

OPTICAL TECHNIQUES

Optical aids

The visual examination requires optical magnification to be properly conducted. This is not a matter of a microscope for clinical use for the detection of early cari-ous lesions. The use of Galilean loupes (magnification × 2-5) is satisfactory for daily practice. The practitioner may choose the most ergonomically appropriate type

Fig. 3a Detection of a proximal carious lesion. Identification of a suspected site of carious activity distal to 36

Fig. 3b Carious activity confirmed by the presence of bleeding on probing with the periodontal probe, allowing the severity of the lesion to be evaluated

Fig. 3c Bitewing showing SiSta classification Stage 2

Fig. 4 Multiple ICDAS II score initial lesions (breach of any thickness of cervical enamel). Note the white areas, clearly visible without drying

Table 1 Criteria for visual detection of carious lesions (ICDAS) and SiSta classification; from Lasfargues and Colon, 20103

ICDAS Code

Criteria for visual lesion detection

Degree of severity of lesion

SiSta* stage

Therapeutic options

0 Sound surface Not necessary

1 Earliest optical change, visible on drying enamel

Demineralisation in outer third of enamel

0Minimal intervention; non-invasive care, remineralisation or sealant

2 Clear enamel change; white or brown blemishes, visible without drying

Demineralisation reaching the inner third of enamel, possibly the ADJ

3 Localised break in enamel Demineralisation of outer third of dentine

1 and 2Minimal intervention; adhesive ultra conservative restoration

4 Dentine not visible Demineralisation of middle third of dentine, no weaken ing of dental crown structure

5 Enamel opaque or greyish, suggestive of an underlying dentine lesion, with or without enamel cavitation

Demineralisation of middle third of dentine, weakening of dental crown structure

3 and 4

Operative dental care; functional crown restoration with or without cusp coverage

6 Dentine cavity Demineralisation of inner third of dentine, undermining of cusp structure and support

SiSta = Site and Stage



PRACTICE

(glasses, headband, helmet), coupled ideally to an integrated halogen/LED lighting system.

Scanned imagesConventional intraoral cameras allow direct viewing of the captured image and digital archiving is simple. Such images are particularly useful for patient teaching and motivation purposes but their quality is not always satisfactory for diagnosis.17

Fluorescence systemsFluorescence is light emission provoked by excitation of the molecules in a material due to the absorption of high energy light. This phenomenon occurs with all natural materials. In the tooth, natural fluores-cence is attributed to the proteins that make up the enamel and dentine matrices. It may also occur when bacterial metabo-lites from the carious process, plaque, composite resins or prophylactic paste residue absorb high energy light. Before using devices based on fluorescence, it is important to undertake meticulous clean-ing, rinsing and drying of the surfaces to be studied so as to eliminate as much as possible matter which could cause confu-sion (Fig. 5).

Infrared laserThe DIAGNOdent® and DIAGNOdent pen® were developed following the work of Hibst and Paulus on dental fluorescence in response to absorption of red light, in the late 1990s. The red light and the sub-sequent fluorescence emissions are car-ried via optical fibres. The return signal is filtered and modulated to indicate the degree of mineralisation of the examined surface on a scale from 1 to 99, displayed on a screen. Some authors agree that this system has better sensitivity than visual or radiographic examination.18-21 Its spec-ificity is acceptable but its reproducibil-ity remains controversial.22-24 Using the DIAGNOdent pen® is easier than its prede-cessor because the hand piece is no longer connected to a monitor by an optical cord. On the other hand, its use requires some precautions: the tips must be aligned cor-rectly on the test surfaces, thorough clean-ing and drying without dehydration and careful scanning of the entire surface with the repeating beep pulses indicating good signal reception.

Quantitative light fluorescence (QLF)This technique uses an intraoral camera with CCD technology linked with system for emitting light in the blue/blue-green wavelengths. The fluorescence of the teeth is rendered on a screen after the blue light is filtered out, leaving green light for the image. Demineralisation greater than 5% results in a dark spot against the healthy enamel, which is green coloured. This sys-tem has been considered to be superior to visual examination for detection of initial carious lesions but confounding factors must be taken into account. Linking QLF

with visual examination results in signifi-cantly increased detection sensitivity of initial lesions. The extended time required for acquisition of the images makes the use of this technology impractical in daily practice.14,17,25,26

Fig. 5 Use of modern caries diagnosis tools: (a) diagnostic systems such as the SoproLife® camera (Acteon) and the DIAGNODENT® pen (Kavo) should be used with (b) an air-polishing system to pre-clean surfaces

Fig. 5c Clinical examination reveals stained fissures, often considered as affected and treated as carious lesions

Fig. 5d An air-polisher, here the Air Max™ by Satelec. It uses a 250 μm grain powder in a wet environment (it is possible to choose the flavour)

Fig. 5e After cleaning and drying, the DIAGNOdent® does not indicate the presence of a lesion nor does (f) the fluorescence camera used in diagnostic mode with (g) white light or (h) polarised light (SoproLife®, Acteon)

a

b

e

f

g

h



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LED cameras

The newest detection system for carious lesions is the use of intraoral cameras with LED technology. These systems illuminate the tooth, record the fluorescence of the dental tissue and enhance the image using dedicated software. Clinical studies are underway to confirm their usefulness. The Vista Proof® camera is used with DBSWIN software (Dürr Dental AG) which can also analyse digital radiographs. As with QLF systems, the healthy enamel appears green.

Demineralised enamel appears blue and den-tine is yellow to red, depending on the sever-ity of the demineralisation.27 This device was recently improved (VistaCam iX®).

The fluoLED camera Sopro-Life® offers fluorescence images in two modes: a diag-nostic mode and processing mode. Healthy tissues appear green (blue in areas with very thick enamel) and carious tissue is light to very dark red. In diagnostic mode, the distribution of colours is limited to those observed on the tooth while, in processing

mode, the range of red is amplified to guide the practitioner in his elimination of carious tissue (Fig. 6).28 Finally, there is a ‘day light’ mode that allows intraoral photographs and videos to be made.

Research and development of these new technologies should lead to further improvements in their sensitivity, specific-ity and reproducibility to facilitate the reli-able and objective quantitative diagnosis of carious lesions. Beyond the pre- and during-operative diagnostic stages, the

Fig. 6a Using the SoproLife® camera (Acteon) for the diagnosis and treatment of SiSta 1.1 lesions. After cleaning and drying the tooth surfaces, visualisation of the lesion in diagnostic mode with fluorescence

Fig. 7a Facial view of the patient, Mrs A, who attended for a dental assessment before orthodontic treatment

Fig. 6b Visualisation of the lesion in diagnostic mode without fluorescence

Fig. 7b Frontal view of the anterior dentition

Fig. 6c During the removal of carious tissue, observing the cavity in treatment mode allows the ‘red’ caries mark to become more visible. The visual and tactile judgment of the practitioner remains nevertheless the salient factor for assessing the amount of tissue to be removed; the camera does not differentiate between layers of infected or affected carious tissue

Fig. 7c Occlusal view of the maxillary arch

Fig. 7d Occlusal view of the mandibular arch Fig. 7g Clinical details of Quadrant 1

Figs 7e and f Checking the accumulation of plaque and gingival conditions at the 25-26 and 15-16 embrasures

e

f



PRACTICE

main interest in these new technologies for minimum intervention dentistry will be to enable remineralisation of initial lesions to be monitored. It is essential, however, to understand that all detection technologies should be used in combination, without sole reliance on one particular method. This will increase the sensitivity and speci-ficity of caries lesion detection.

CLINICAL CASEMrs A, aged 30 years, consulted for an oral check before commencing orthodontic treatment (angle Class II associated with 21 labially positioned teeth). The patient was cooperative but not easily available for dental appointments (Fig. 7).

During the initial consultation, inspec-tion revealed absence of pain and a healthy lifestyle. A food diary conducted the week following the consultation indicated a high sugar intake. At the preliminary oral exami-nation, oral hygiene appeared less than per-fect (moderate quantities of plaque) despite brushing twice daily. The presence of defec-tive amalgam restorations and noticeable superficial gingivitis was noted.

After air-polishing to eliminate surface discolouration and the biofilm (Fig. 5), a more detailed observation using optical aids was undertaken of suspect sites, particularly in the premolar and molar areas. Gingival condition and the accumulation of plaque were audited at the embrasures with the aid of a periodontal probe. Gingival bleed-ing on probing was noticed in the region of teeth 25-26 (Fig. 7e) and 15-16 (Fig. 7f), raising suspicions of the presence of proxi-mal lesions due to plaque retention in these confined areas. Changed colour in the mesial marginal ridge of 47 (Fig. 7j) indicated a den-tinal lesion with undermined enamel (ICDAS code 4). At this stage, bitewing radiographs in these two regions was deemed necessary to confirm the presence or absence of lesions and, if present, their extent. The radiographs indicated initial caries in the right sector: SiSta 2.0 on 15 D and 14 D as well as 44 D and 45 D, and SiSta 2.2 on 47 M and, in the left sector: SiSta 2.0 on 24 M, 25 D, 26 M and SiSta 2.0 on 36D and 37M.

Ultraconservative minimal intervention dentistry

Analysis of all risk factors and predictors revealed by the dietary diary and the clini-cal examination, indicated a high caries

risk requiring management and follow-up every three months (Table 2). The follow-ing treatment objectives were proposed for this patient:•Control caries disease by lowering

caries risk (plaque control and dietary advice)

•Treatment of non-cavitated lesions using non-operative methods (remineralisation or resin impregnation)

•Treatment of cavitated lesions with adhesive restorations (composite)

•Replacement of defective amalgam restorations by long-lasting provisional adhesive restorations

•Prevention of recurrent caries during

Fig. 7j Clinical details of Quadrant 4; note the lesion on mesial surface of 47

Fig. 7l Bitewing of right molar area

Fig. 7h Clinical details of Quadrant 2

Fig. 7m Bitewing of left premolar area

Fig. 7i Clinical details of Quadrant 3

Fig. 7n Bitewings of left molar area

Fig. 7k Bitewings of right premolar area



PRACTICE

orthodontic treatment by active maintenance.

CONCLUSIONSIn recent years, methods of detection of early carious lesions have evolved consider-ably, moving firstly towards the identifica-tion of the earliest mineral changes and then to controlling the demineralisation process using non-operative procedures. Previously an indiscriminate routine task, caries diag-nosis has become a fully-fledged, codified discipline which demands of the practitioner precise knowledge, rigor and time. In addi-tion to the identification of risk factors and the early detection of lesions, it is essential to evaluate the extent of each lesion (non-cavitated vs cavitated) and its status (active or arrested) so as to establish a monitor-ing procedure and predict the outcome, as for any other disease. Such a systematic approach should lead to a care plan for caries, based on prophylactic measures with minimal use of restorative measures, leading to better patient oral health.

None of the new tools designed to enhance and facilitate caries diagnosis

is yet proven, so there is still no abso-lute substitute for the traditional clinical examination and radiographic bitewing examination. The technologies, particu-larly those based on fluorescence, may nevertheless assist in raising the awareness and motivation of patients; they are also interesting for their monitoring potential and controlling the process of regression/progression over periodic intervals.

The authors would like to thank Claudie Damour — Terrasson, President and publishing director of the Groupe ID Espace — L’Information Dentaire, Paris France, for the authorisation of translation and publication of the series in the BDJ.

1. Haikel Y. Carie dentaire. In Piette E, Goldberg M (eds) La dent normale et pathologique. pp 99–124. Bruxelles: De Boeck Supérieur, 2001.

2. Fejerskov 0, Kidd E A M. Dental caries. The disease and its clinical management. Copenhagen: Blackwell Munksgaard. 2003.

3. Lasfargues J J, Colon P. Odontologie conservatrice et restauratrice. Tome 1: une approche médicale globale. France: Wolters Kluwer, 2010.

4. Bader J D, Shugars D A, Bonito A J. Systematic reviews of selected dental caries diagnostic and management methods. J Dent Educ 2001; 65: 960–968.

5. Selwitz R H, Ismail A I, Pitts N B. Dental caries. Lancet 2007; 369: 51–59.

6. Ewoldsen N, Koka S. There are no clearly superior methods for diagnosing, predicting, and noninva-sively treating dental caries. J Evid Based Dent Pract 2010; 10: 16–17.

7. Pitts N B. Modern concepts of caries measurement. J Dent Res 2004; 83: C43-C47.

8. Ekstrand K R, Martignon S, Ricketts D J, Qvist V. Detection and activity assessment of primary coronal caries lesions: a methodologic study. Oper Dent 2007; 32: 225–235.

9. Lussi A, Longbottom C, Gygax M, Braig F. Influence of professional cleaning and drying of occlusal surfaces on laser fluorescence in vivo. Caries Res 2005; 39: 284–286.

10. Erten H, Uçtasli M B, Akarslan Z Z, Uzun O, Baspinar E. The assessment of unaided visual examination, intra-oral camera and operating microscope for the detection of occlusal caries lesions. Oper Dent 2005; 30: 190–194.

11. Ismail A I, Coordinating ICDAS Committee. Rationale and evidence for the international caries detection and assessment system (ICDAS II). In Stookey G (ed) Proceedings of the 7th Indiana Conference, Indianapolis. pp161–222. Indiana: 2005.

12. Ekstrand K R, Ricketts D N, Kidd E A. Reproducibility and accuracy of three methods for assessment of demineralization depth on the occlusal surface: an in vitro examination. Caries Res 1997; 31: 224–231.

13. Kuhnisch J, Dietz W, Stosser L, Hickel R, Heinrich-Weltzien R. Effects of dental probing on occlusal surfaces - a scanning electron microscopy evalua-tion. Caries Res 2007; 41: 43–48.

14. Ferreira Zandoná A, Santiago E, Eckert G, Fontana M, Ando M, Zero D T. Use of ICDAS combined with quantitative light-induced fluorescence as a caries detection method. Caries Res 2010; 44: 317–322.

15. Banerjee A, Cook R, Kellow S, Shah K, Festy F, Sherriff M, Watson T. A confocal micro-endoscopic investigation of the relationship between the microhardness of carious dentine and its autofluo-rescence. Eur J Oral Sci 2010; 118: 75–79.

16. Doméjean-Orliaguet S, Banerjee A, Gaucher C et al. Minimum Intervention Treatment Plan (MITP) - practical implementation in general dental practice. J Minim Interv Dent 2009; 2: 103–123.

17. Pretty I A. Caries detection and diagnosis: novel technologies. J Dent 2006; 34: 727–739.

18. Lussi A, Francescut P. Performance of conventional and new methods for the detection of occlusal caries in deciduous teeth. Caries Res 2003; 37: 2–7.

19. Lussi A, Hellwig E. Risk assessment and preventive measures. Monogr Oral Sci 2006; 20: 190–199.

20. Shi X, Traneaeus S, Angmar-Månsson B. Fluorescence methods. In Wilson N H F (ed) Minimally invasive dentistry. The management of caries. pp 40–46. UK: Quintessence Books, 2007.

21. Rodrigues J A, Hug I, Diniz M B, Lussi A. Performance of fluorescence methods, radiographic examination and ICDAS II on occlusal surfaces in vitro. Caries Res 2008; 42: 297–304.

22. Lussi A, Hack A, Hug I, Heckenberger H, Megert B, Stich H. Detection of approximal caries with a new laser fluorescence device. Caries Res 2006; 40: 97–103.

23. Spiguel M H, Tovo M F, Kramer P F, Franco K S, Alves K M, Delbem A C. Evaluation of laser fluorescence in the monitoring of the initial stage of the de-/remineralization process: an in vitro and in situ study. Caries Res 2009; 43: 302–307.

24. Ghaname E S, Ritter A V, Heymann H O, Vann W F Jr, Shugars D A, Bader J D. Correlation between laser fluorescence readings and volume of tooth preparation in incipient occlusal caries in vitro. J Esthet Restor Dent 2010; 22: 31–39.

25. Kuhnisch J, Heinrich-Weltzien R. Quantitative light-induced fluorescence (QLF) - a literature review. Int J Comput Dent 2004; 7: 325–338.

26. Kühnisch J, Bücher K, Henschel V, Hickel R. Reproducibility of DIAGNOdent 2095 and DIAGNOdent Pen measurements: results from an in vitro study on occlusal sites. Eur J Oral Sci 2007; 115: 206–211.

27. Eberhart J, Frentzen M, Thoms M et al. New optical techniques for caries detection. Fluorescence-based systems to identify non-cavitated lesions. Paris: Dürr Dental Publication, 2007.

28. Terrer E, Koubi S, Dionne A, Weisrock G, Sarraquigne C, Mazuir A, Tassery H. A new concept in restorative dentistry: light-induced fluorescence evaluator for diagnosis and treatment. Part 1: diagnosis and treatment of initial occlusal caries. J Contemp Dent Pract 2009; 10: E086–E094.

Table 2 Evaluation of caries risk of Mrs A

Risk factors and predictors Present Absent

New carious lesions

New active lesions in the past 3 years 9 lesions

Restorations placed in the past 3 years X

Oral factors (hygiene, plaque, saliva)

Twice daily toothbrushing X

Topical fluoride (toothpaste, mouth rinse) X

Dental plaque accumulation X

Gingival bleeding (on probing, spontaneous) X

Salivary pH and stimulated salivary flow X

Increased counts, Lactobacillus and S. mutans Not done

General factors (age, nutrition, health)

Risk age group (child, adolescent, senior (reduced autonomy) X

Sugar consumption, snacking, frequent sugary drinks X

Boulimia, obesity, diabetes X

Pregnancy X

Dry mouth due to medication; addiction X

Sjögren’s syndrome X

Chemotherapy, radiotherapy of head and neck region X

Behavioural factors

Risk occupation; injurious cultural habits X

Low socio-economic status, unemployed X

Caries risk High

Frequency of caries check-up 3 months



Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART) – a minimum intervention and minimally invasive approach for the management of dental cariesC. J. Holmgren,1 D. Roux2 and S. Doméjean3


INTRODUCTION

Atraumatic restorative treatment (ART) was developed in the 1980s but embodies all the principles of an alternative philoso-phy of dental care that was ultimately to become known as minimal (or minimum) intervention dentistry.1,2 Minimal inter-vention management of caries attaches importance to the diagnosis and evalua-tion of caries risk and includes prevention, stabilisation and healing (remineralisation) of early lesions and minimally invasive restorative treatment for cavitated den-tine lesions with selective excavation of destroyed tissue combined with maximal preservation of healthy tissues. While developed originally in response to a need to provide effective restorative and preventive treatment in underserved com-munities, over the past two decades the ART approach has become a worldwide phenomenon. ART can be considered to be a cornerstone of minimal intervention caries management in combining preven-tion and minimal invasion.

The objectives of this paper are to:1. Describe the philosophy of the ART

approach within the overall concept of minimal intervention and minimal invasion for the management of dental caries

While originally developed in response to a need to provide effective restorative and preventive treatment in underserved communities where running water and electricity might not always be available, over the past two decades, the atraumatic restorative treatment (ART) approach has become a worldwide phenomenon; used not only in some of the poorest de-veloping countries but also in some of the most wealthy. The ART approach involves the removal of infected dentine with hand-instruments followed by the placement of a restoration where the adjacent pits and fissures are sealed simultane-ously using high viscosity glass-ionomer inserted under finger pressure. Reliable results can only be obtained if the treat-ment protocol, as described in this article, is closely followed. ART should be considered as a therapeutic option especially in children, anxious patients and those with special needs.

2. Describe the clinical aspects of ART3. Review the evidence base for

supporting the use of ART4. Describe the indications for ART.

WHAT ARE ART SEALANTS AND RESTORATIONS?

Over the past 20 years some confusion has arisen as to what constitutes the atrau-matic restorative treatment (ART) approach since a number of authors use the term to describe procedures that are not considered to be ART. To avoid confusion a recent def-inition by Frencken and van Amerongen should be adopted as follows: ‘ART is a minimally invasive approach to both pre-vent dental caries and to stop its further progression. It consists of two components: sealing caries prone pits and fissures and restoring cavitated dentin lesions with seal-ant-restorations. The placement of an ART sealant involves the application of a high-viscosity glass-ionomer that is pushed into the pits and fissures under finger pressure. An ART restoration involves the removal of soft, completely demineralised carious tooth tissue with hand instruments. This is followed by restoration of the cavity with an adhesive dental material that simultane-ously seals any remaining pits and fissures that remain at risk’.3

1*Aide Odontologique Internationale, Paris, France; 2Senior lecturer, Hospital consultant, CHU Clermont-Ferrand, Service d’Odontologie, Hôtel-Dieu, F-63001 Clermont-Ferrand, France and Univ Clermont 1, UFR d’Odontologie, F-63000 Clermont-Ferrand, France; 3Professor, Hospital consultant, Centre de Recherche en Odontologie Clinique, EA4847; CHU Clermont-Ferrand, Service d’Odontologie, Hôtel-Dieu, F-63001 Clermont-Ferrand, France and Univ Clermont1, UFR d’Odontologie, F-63000 Clermont-Ferrand, France *Correspondence to: Dr Christopher Jonathan Holmgren Email: [email protected]; Tel: +33 254 371951


• Describes the clinical aspects of the atraumatic restorative treatment (ART) approach.

• Stresses the importance of following the treatment protocol to ensure reliable results and reviews the evidence base supporting its use.

• Suggests ART should be considered as a therapeutic option especially in children, anxious patients and those with special needs.

I N B R I E F

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This paper is adapted from: Holmgren CJ, Roux D, Doméjean S. Traitement restaurateur atraumatique (ART). Une approche a minima de la prise en charge des lésions carieuses. Réalités Cliniques 2011; 22: 245–256.


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This definition implies that if any other method is used to prepare the cavity, for example, use of rotating instruments to open a cavity or the use of non-adhesive restorative material this cannot be consid-ered as ART nor should the term ‘modi-fied ART’ be used since this may lead to confusion.4

The philosophy and science behind the ART approach

The sealing of fissures with sealants has been shown to be an effective approach both for the prevention of fissure caries lesions de novo and for the prevention of the progression of early lesions in this site.5-8 As such, sealants, including ART sealants that use a high-viscosity glass-ionomer cement (GIC), play an essential role in a minimal intervention and non-invasive approach.9

The principle by which preventive and therapeutic sealants function is by pro-viding a physical barrier that excludes bacteria and their nutrients from pits and fissures that cannot be cleaned and that have minimal access to saliva and fluo-ride. There is no reason why this principle shouldn’t be extrapolated to situations where the caries process has extended into the dentine resulting in frank cavi-tation but without pulpal involvement. Here, the major constraint of a cavitated caries lesion is that in order to achieve a seal to the cavity and to render the exter-nal surface cleansable, there is a need to place a restoration, preferably with an adhesive material.10,11

If a restoration is required for caries control in cavitated lesions then the next question is how best to restore the cavity. Ideally the objectives should be to retain a maximum amount of sound tooth tissue for strength, make the restoration as small as possible so it is long lasting and to seal the adjacent pits and fissures that are of high caries risk (placement of a sealant res-toration). Adhesive restorative materials, namely composites and GIC, have revolu-tionised cavity restoration since the need to destroy sound tooth tissue to achieve mechanical retention, as was the case for amalgam, has been greatly reduced. Furthermore, a better understanding of the histopathology of the dentine caries lesion means that a minimally invasive cavity preparation can safely be used. The

term ‘cavity preparation’ is better named ‘cavity cleaning’ since it emphasises the more biological approach that ART and other minimal invasive approaches adopt over purely mechanistic approaches.

Over 50 years ago, Fusayama and Massler independently showed that the dentine caries lesion could be divided into two layers.12–14 The layer closest to the opening into the cavity defined as ‘outer carious dentine’ or ‘infected den-tine’ is a soft, infected biomass that has no sensation and is largely incapable of being remineralised. As such it is of no further structural use to the tooth and therefore should be removed (Fig. 1). The deeper part of the dentine caries lesion, that which is more distant from the opening of the cav-ity, is harder since the mineral content is higher. This is called ‘inner carious dentine’ or preferably ‘affected dentine’. This often darker and stained layer is vital, minimally affected with bacteria and has the potential to remineralise. It is therefore logical to retain this layer. If rotary instrumentation is used to clean (prepare) the cavity, tac-tile feedback that enables the distinction between the softer infected dentine and the harder affective dentine is compromised. This often leads to excessive cavity prepa-ration and unnecessary removal of sound tooth tissue or that which has the poten-tial to remineralise.15,16 While a number of alternatives to rotary instrumentation for cavity cleaning exist, the best com-promise between effectiveness of caries removal and efficiency has been shown to be the use of hand-excavators.15,16 These are used for cavity cleaning in the ART approach since they are readily available and, as they do not rely on electricity or running water, can be used both in the traditional dental clinic environment and for outreach situations where dental facili-ties do not exist.

It is important to emphasise that the ART approach to manage cavitated car-ies lesions does not intentionally leave soft, infected dentine behind in the cavity. The sole exception might be in deep car-ies lesions where there is a risk of pulpal exposure. As is now becoming common practice, in such cases soft dentine is retained deliberately and the cavity filled and sealed with a sealant restoration. The deliberate leaving of soft dentine car-ies in a cavity is contrary to traditional

Inner “affected” dentine• few bacteria • remineralisable • vital• sensitive• useful

Outer “infected” dentine • bacterial invasion• unmineralisable • dead• without sensation• not useful

Fig. 1 Layers of a dentine caries lesion. The ‘outer carious dentine’ or ‘infected dentine’ is soft and infected and should be removed. The ‘inner carious dentine’ or ‘affected dentine’ can remineralise and should be retained

Fig. 2 A small enamel hatchet used to open access to underlying softened dentine

Fig. 3 Two spoon-shaped excavators, one small with a spoon approximately 1 mm across, another slightly larger are used to excavate soft dentine

Fig. 4 A small flat plastic instrument is used for applying the GIC and for shaping the restoration. An ‘Ash 6 special’ is shown here

12 BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013


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dictum but there is little evidence that infected dentine must be removed before sealing the tooth with a restoration.17–19 Conversely, there is now a substantial evi-dence base from long-term studies that caries lesions that are sealed in place do not progress and might even regress.11,20–22 This is consistent with the principles of therapeutic sealing since if cariogenic bacteria are isolated from their source of nutrition they either die or remain dor-mant and therefore cannot result in caries lesion progression.23–27

While the notion of intentionally leav-ing a limited amount of soft, infected dentine behind in a cavity to be restored might be totally contrary to what has been taught in dental schools over the years, the unsubstantiated dangers of such an approach must be balanced against the

real dangers of complete removal of all soft infected dentine in deep lesions, which have been shown to lead to an increased number of pulpal exposures.19,28 It is there-fore not only logical but also good practice to retain some soft caries on the pulpal floor of deep caries lesions when there is a likelihood of causing a pulpal exposure in a vital and otherwise symptomless tooth, irrespective of the restoration method used.

PRACTICAL CONSIDERATIONS WHEN USING ART

Instruments required

Under normal situations no special instru-ments are needed to perform ART since most can be found in a normal den-tal clinic. The instruments required are as follows:•Mirror, probe and tweezers•A small enamel hatchet to open access

to underlying softened dentine (Fig. 2)•Two spoon-shaped excavators,

one small with a spoon approximately 1 mm across, another slightly larger (Fig. 3). These are used for the removal of soft dentine. The larger excavator can also be used for packing filling material under enamel and for the removal of excess filling material

•A small flat plastic instrument for applying the GIC and for removing excess filling material and for shaping the restoration. An ‘Ash 6 special’ is ideally suited to this purpose (Fig. 4).

In addition to this basic set of instru-ments, a special instrument might be nec-essary. The ‘Enamel Access Cutter’ (EAC) has been developed to access smaller cavi-ties where the blade of the enamel hatchet might be too large (Fig. 5). To reduce hand fatigue it is recommended that the instru-ments have a wide handle.

Materials requiredIn addition to the normal consumable materials that are found in a dental prac-tice, for example, cotton wool rolls, petro-leum jelly (Vaseline) etc, the only other requirement is a high-viscosity, high-strength GIC. Encapsulated GIC gener-ally produce a more consistent mix but are usually more expensive than hand-mixed GIC. Furthermore, if an encapsu-lated GIC is to be used then a separate

dentine conditioner will be required. Fuji IX™ (GC International), Ketac™ Molar (3M ESPE) and Chemflex™ (Dentsply) have been validated for use for ART. Other GIC that purport to be suitable for ART should only be used if there is evidence that they are effective.

ART RESTORATIONS STEP-BY-STEPFor experienced dentists the ART approach might at first appear simple and straight-forward. However, reliable outcomes can only be achieved if the following steps are rigorously adhered to.

Step 1. Preparation of the ART instruments and materials before the clinical procedure

Before starting the clinical procedure ensure that all the instruments and con-sumable materials are laid out in a logi-cal and ordered manner. They should be arranged in the sequence that they are going to be used (Fig. 6). Since cotton wool pellets are used for many steps in the ART approach, it saves time to separate an adequate number of these into individual pellets of suitable size beforehand.

Step 2. Isolation of the operating site

As for all restorations, isolation is impor-tant since contamination of the operating site with saliva or blood will affect bond-ing of the GIC to the tooth surface. For ART, a rubber dam is not necessary since isolation with cotton rolls is adequate. These must be changed as soon as they are saturated with saliva.

Step 3. Examining the cavitated tooth

Once the operating site has been correctly isolated, the tooth and the extent of car-ies lesion can be examined more easily. To assist in this task, carefully remove any plaque or food debris from the pits and fissures with a dental explorer, tak-ing care not to create additional cavita-tion. The tooth surface is then cleaned by rubbing with a damp cotton wool pellet, followed by drying the surface with a dry pellet or gently with a triple syringe (Fig. 7). Discoloured or translu-cent enamel usually indicates deminerali-sation where the enamel might be weak and where the caries process might have

Fig. 5 An Enamel Access Cutter (EAC) can be used to access the cavity when the enamel hatchet is too large

Fig. 6 The instruments are laid out in the sequence that they are going to be used

Fig. 7 The tooth surface is cleaned by rubbing with a damp cotton wool pellet and then dried with a dry pellet or a triple syringe



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spread laterally along the enamel-dentine junction (EDJ).

Note: unlike for conventional restora-tions, a local anaesthetic is very rarely required since only necrotic tooth tissue is being removed during cavity cleaning. However, an anaesthetic can be given at the request of the patient.

Step 4. Gaining adequate access to the caries lesion

In small caries lesions, where the opening into the cavity is small, it is often neces-sary to widen the access. A dental hatchet is used ensuring that the instrument is correctly stabilised using an appropriate finger rest. The corner of the hatchet is placed in the entrance of the cavity, usu-ally in the deepest part of the pit or fissure for the occlusal surface, and the instru-ment tip rotated backwards and forwards while maintaining slight pressure (Fig. 8). This fractures off the weak demineralised enamel surrounding the cavity entrance, permitting adequate access to the dentine caries for the smallest excavator. As men-tioned above, an EAC can also be used to improve access to a caries lesion. This instrument is placed in the cavity opening and rotated in a similar way as the hatchet to fracture off weak demineralised enamel. The EAC has two pyramidal shaped work-ing tips, one large and one small. The largest tip can be used when the cavity opening is relatively wide, but needs to be opened further; the smaller tip being used in small openings where there might be difficulty in using the hatchet.

Note: the EAC should not be used for creating cavities where they do not exist. If in doubt about the presence of a pos-sible lesion it is better to place a thera-peutic sealant without any mechanical preparation.

Step 5. Cavity cleaningHand excavators are used to remove soft, infected dentine. Cavity cleaning starts with the removal of soft dentine from the EDJ. Here the smallest excavator is used making circular scooping move-ments under the enamel (Fig. 9). This so called ‘unsupported’ enamel only needs to be removed if it is thin and weak or if additional access is required to complete removal of soft dentine at the EDJ. Here, some of the enamel can be gently fractured

off with the blade of the hatchet along the line of the enamel prisms (Fig. 10).

Note: there is no danger in leaving sound, ‘unsupported’ enamel since it effec-tively becomes ‘supported’ when the cavity is restored with GIC.

Soft dentine from the rest of the cavity is now removed with the larger excava-tor as access permits. Care must be taken in deep cavities where there is danger of exposing the pulp. It is advisable not to exert excessive pressure on the pulpal floor with a small excavator since this increases the likelihood of exposure. For deep cavi-ties close to the pulp it is better to leave some soft dentine on the pulpal floor than risk exposing the pulp. The resultant cavity is then washed and gently dried. In out-reach situations a wet cotton wool pellet is used and the cavity dried with a dry pellet. Note, that since a local anaesthetic is not routinely used, luke-warm water for rinsing is preferable to reduce tooth sensi-tivity during this stage. The use of a triple syringe is not recommended. The cavity is then examined carefully and additional cavity cleaning is undertaken if necessary. It is important that stained or discoloured dentine that is hard should be retained.

There is normally no indication to use a lining material for an ART restoration except in the deepest of cavities. Here a setting calcium hydroxide liner can be used but only at the spot closest to the pulp. Excessive use of lining material will reduce the surface area available for bond-ing of the GIC.

Step 6. Conditioning the cavity and adjacent pits and fissures

The use of hand instruments on the dentine surface results in a smear layer. In order to improve the chemical and mechanical bonding of the GIC to the tooth tissues this smear layer must be removed by the use of a dentine conditioner. When using encapsulated GIC it will be necessary to use a separate dentine conditioner spe-cially developed for this purpose. This differs from the liquid used for acid-etching for composites since a dentine conditioner usually contains a solution of between 10-40% polyacrylic, tartaric and/or maleic acid. Because of the differ-ence in dentine conditioners available, it is important to carefully follow the man-ufacturer’s instructions. If a hand-mixed

powder-liquid GIC is used the liquid com-ponent of the GIC can be used as the con-ditioner. The concentration is often too high and needs to be reduced. This can be achieved easily by dipping a cotton wool pellet in water, removing excess on a paper towel and then dipping this moist cotton wool pellet in a drop of the liquid compo-nent of the hand-mixed GIC.

Note: the liquid component of GIC can only be used for conditioning if it contains the acid component of the GIC. There are some brands of GIC where the liquid com-ponent consists of demineralised water only, the acid being in the powder in a freeze-dried form. Under such circumstances a

Fig. 8 The corner of the hatchet is placed in the entrance of cavity, usually in the deepest part of the pit or fissure for the occlusal surface and the instrument tip rotated backwards and forwards while maintaining slight pressure

Fig. 9 The smallest excavator is used to remove soft dentine from the enamel dentine junction by making circular scooping movements under the enamel

Fig. 10 Where more access is required, some of the enamel can be gently fractured off with the blade of the hatchet along the line of the enamel prisms



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separate dentine conditioner must be used.The conditioner is applied to the cavity

and pits and fissures using a cotton wool pellet for 15-20 seconds or for the period of time specified by the manufacturer. Bond strength is affected if insufficient or too long a time is allowed for conditioning. Wash the cavity and pits and fissures with pellets dipped in clean, luke-warm water and then dry carefully. If a triple-syringe is used, take care not to over-dry the cavity since this will tend to reduce the chemical bonding of the GIC to the dentine.

Note: At this stage proper isolation is essential. Contamination of the conditioned tooth surface with saliva or blood will have

a negative effect on the bonding of the GIC to dentine and enamel. Therefore, if the conditioned tooth surface becomes con-taminated it is essential to wash and dry it, recondition, wash and dry it again.

Step 7. Mixing GICA consistent and correct mix of GIC is essen-tial for reliable results. Always follow the manufacturers’ instructions. This involves following recommendations for mixing time and finishing the restoration within the specified working time. For hand-mix GIC, the correct powder to liquid ratio must be maintained since too much powder or too much liquid can result in a weaker restora-tion.29 If a hand-mix GIC is used, those for ART have a high powder-to-liquid ratio and are usually more difficult to mix than other GICs, thus special care needs to be taken. The consistency of the final mix does, how-ever, vary between different manufacturers.

Step 8. Restoring the cavity and filling the pits and fissures

The mixed GIC must be used promptly since any delay will compromise bonding to the tooth surface. The GIC is inserted into the cavity in small increments using the rounded end of the applier/carver

instrument. Where possible, pack the GIC around the margins of the cavity, par-ticularly under any overhanging enamel, before filling the central portion of the cavity (Fig. 11). This helps to prevent air bubbles from being incorporated into the restoration. Overfill the cavity slightly and then place additional GIC in any pits and fissures adjoining the cavity (Fig. 12).

Rub a small amount of petroleum jelly on the gloved index finger. Spread the petroleum jelly thinly over the tip of the gloved index finger with the thumb. Then, place the index finger on the occlusal surface and press the GIC firmly into the cavity, pit and fissures (Fig. 13). Roll the ball of the finger slightly bucco-lingually and then mesio-distally so that material is spread over the whole occlusal surface. This is called ‘the press-finger technique’. After at least ten seconds, slide the finger sideways to prevent the restorative mate-rial from lifting out of the cavity or pits and fissures. The press-finger technique results in excess GIC being displaced to the outer margins of the occlusal surface. Remove this excess as soon as possible with either the carver instrument or the large excavator, taking care not to dislodge the restoration (Fig. 14). Ensure that the proximal areas are clear of excess GIC.

Note: in the event that insufficient GIC has been mixed to ensure the cavity and fissures are completely filled, pack this first mix into the cavity with the applier but DO NOT use the press-finger technique at this stage. While maintaining good moisture control, a second batch of GIC is mixed that can then be used to completely fill the cavity and pits and fissures.

Step 9. Finishing the ART restoration

Before the GIC becomes too hard, the occlusion is checked with articulating paper. Any parts of the restoration that are too high can be adjusted using the carver instrument or the large excavator. The finished restoration is then covered with petroleum jelly or varnish (Fig. 15). Ask the patient to avoid eating for at least an hour.

Note: the dentist can adapt the clinical procedures according to the equipment available and his normal working practice. For example, a local anaesthetic can be used, a rubber dam can be placed, and a

Fig. 11 The GIC is inserted into the cavity in small increments using the rounded end of the applier/carver instrument. Where possible, pack the GIC under any overhanging enamel first, before filling the central portion of the cavity

Fig. 12 Slightly overfill the cavity and then place additional GIC in any pits and fissures adjoining the cavity

Fig. 15 The finished restoration is then covered with petroleum jelly or varnish and the patient advised not to eat for at least one hour

Fig. 13 The tip of the index finger is then placed onto the central part of the restorations to enable the GIC to be pressed firmly into the cavity, pit and fissures

Fig. 14 The excess GIC is displaced to the outer margins of the occlusal surface and will need to be removed as soon as possible with the carver or large excavator taking care not to dislodge the restoration



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rotary instrument instead of a hatchet can be used to gain minimal access to the body of the lesion. The use of rotary instruments is, however, specifically not part of the clas-sic ART approach. Since the ART approach, as has been described above, provides sat-isfactory clinical results (see our section on the evidence base), there is no need to overload the clinical procedures with meth-ods or equipment that may raise anxiety in patients (eg rotary instruments are often not accepted by children and dental phobics).

ART SEALANTS STEP-BY-STEPThe only difference between placing an ART restoration and an ART sealant is that with the latter there is no cavity to clean and restore. Otherwise all the other steps and materials remain identical.

The same high-viscosity GIC is used but cavity preparation is not undertaken. Thus, techniques of isolation, cleaning, condi-tioning and filling of the pits and fissures remain identical. The steps are therefore summarised as:•Step 1. Preparation of the ART

instruments and materials before the clinical procedure

•Step 2. Isolation of the operating site•Step 3. Cleaning the pits and fissures

and examination of the tooth•Step 4. Conditioning the pits and fissures•Step 5. Mixing the GIC•Step 6. Filling the pits and fissure•Step 7. Press-Finger•Step 8. Finishing the ART sealant

(Fig. 16).

THE EFFECTIVENESS OF ART – WHAT IS THE EVIDENCE BASE?

Ideally all dental care decisions and treat-ments should be based on a sound research evidence base, this being the basis of evi-dence-based dentistry. This helps to ensure that dental care is both safe and effective. Unfortunately, the evidence base to sup-port the effectiveness of many of the com-monly performed treatments in dentistry is limited both in quantity and quality.30,31 Gradually, properly conducted systemic reviews of dental treatment approaches are appearing in the literature and there are attempts by a number of organisations to sensitise and educate the dental pro-fession (Cochrane, NICE, American Dental Association, etc). Despite initiatives by organisations such as the Centre Français

d’Evidence Based Dentistry, which has started to make some Cochrane reviews available in French, there remains a dearth of information in the French language.

Since its early development, ART has constantly been subject to research evalua-tion and remains one of the most researched minimal intervention approaches with currently over 200 publications on the subject. With respect to the effectiveness of the approach a number of systematic reviews and meta-analyses have been undertaken. The first meta-analysis of the effectiveness of single-surface ART res-torations in the permanent dentition was published by Frencken et al. in 2004.32 This study, based on an analysis of five studies reported no difference in survival results over three years between single-surface ART restorations and amalgam restora-tions. It also indicated that results were better from the then more recent studies as the ART approach evolved and better restorative materials became available.

The interest in the ART approach led to a substantial number of research pub-lications on the subject during this time that permitted a second more compre-hensive meta-analysis to be undertaken in 2006.33 Here, 28 studies were included in the analysis. The high mean survival rates for single-surface ART restorations using high-viscosity GIC in permanent dentitions found in the previous meta-analysis was confirmed and a survival rate of 72% over a period of six years was reported.32 Similarly, in primary teeth single-surface ART restorations using high-viscosity GIC had a high mean sur-vival rate of 95% after one year and 86% after three years. The survival rates of multiple-surface ART restorations in the primary dentition were low with a mean annual failure rate of 17%.

The most recent meta-analysis of ART survival based on 29 publications reported that for single-surface ART restorations in permanent teeth over the first three and five years the mean survival rates were 85% and 80% respectively and 86% for multi-ple-surface ART restorations in permanent teeth over one year.34 The survival rates of single and multiple-surface ART restora-tions in primary teeth over two years were 93% and 62% respectively. A systematic review comparing the longevity of ART and amalgam restorations concluded that,

in the permanent dentition, the survival of ART restorations is equal to or greater than that of equivalent amalgam restorations for up to 6.3 years and is site-dependent.35 In primary teeth no difference in survival outcomes between the two types of resto-ration was observed.

ART has also been used in institutional-ised elderly populations for treating root surface caries where short-term results suggest that ART restorations compare favourably with traditional approaches to treat such lesions.36 In this context, an earlier study where ART restorations were provided for housebound Finnish elderly also showed high success rates.37

With respect to the evidence base for ART sealants, the meta-analysis of van’t Hoff et al. in 2006 found that the number of studies reporting on the retention and caries preventive effect of ART sealants was low but based on available evidence the mean survival rate for partially and fully retained ART sealants in permanent denti-tions using a high-viscosity GIC was of the order of 72% after three years.33 In terms of effectiveness in preventing caries over this time period, 97% of sealed teeth remained sound. The more recent meta-analysis by de Amorim et al.34 showed that the caries prevention effect of ART sealants was high.

A summary of the evidence base for ART is that:•Single-surface ART restorations using

high-viscosity GIC in both primary and permanent teeth show high survival rates and can therefore be safely used

•The survival rate for multiple surface ART restorations in primary teeth is rather low

•ART restorations have the ability to

Fig. 16 A completed ART sealant



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outperform amalgam restorations in terms of survival

•ART sealants have a high caries preventive effect.

INDICATIONS FOR THE ART APPROACH

As with all preventive and restorative approaches ART must not be considered a panacea and therefore careful case selec-tion is essential. The indications for ART are based on the strengths of the approach for certain situations combined with the evidence base for its effectiveness. Thus, the indications can largely be divided into two levels, the patient and the tooth.

Indications at the patient levelAt the patient level, one of the major strengths of the ART approach is that it is well accepted by patients. The high accept-ance is because, unlike most traditional restorative treatment of vital teeth, ART rarely requires a local anaesthetic. This is largely because of the minimally invasive nature of the approach where only necrotic tissue is removed and where remaining sound tissue is retained. Moreover, since rotary instrumentation is not used with ART, the threatening sound from this and the necessary high-volume suction is absent. In this respect, a recent review on dental anxi-ety and pain relating to the ART approach concluded that the ART approach has been shown to cause less discomfort than other conventional approaches and is, therefore, considered a very promising ‘atraumatic’ management approach for use in carious lesions in children, anxious adults and pos-sibly dental-phobic patients.38

The other major strength of the ART approach is that it can be used equally well in a dental practice setting as in an out-reach environment such as in schools or in old people’s homes. The concept of deliver-ing care outside the dental practice setting is largely alien to the dental profession. In France, as in many developed countries, little dental care is delivered outside the traditional dental clinic environment. This does, however, limit the coverage of dental care to those persons who can easily access a dental clinic or are adequately motivated to do so. As an example, in France for children at age six, two thirds of dental cavities in primary teeth are not treated. Similarly, in 12-years olds, only half the

decayed teeth are restored.39 The reasons for this lack of care is obviously multifac-torial but demands the question whether other models of delivery of oral care using approaches such as ART could be explored in France, for instance providing preven-tion and caries management within the schools as is done in other countries.40

Likewise, non-mobile elderly or physi-cally and mentally handicapped peo-ple might not easily be able to access the dental clinic. Although oral health data for the elderly in France is limited, a report by the Haute Autorité de Santé (HAS) showed that elderly people have lit-tle access to dental care and that between 30-60% require restorative treatment.41,42 Here some extractions and restorative care using the ART approach could be delivered in their homes without resort to expensive portable dental equipment.36,37

Indications at the tooth levelThe indications at the tooth level are based on the best evidence from clinical studies. There is now evidence to show that ART single-surface restorations using high-viscosity GIC have a high survival rate in both primary and permanent teeth that is comparable to, if not better than, traditional amalgam restorations.34,35 Taken that ART restorations are both minimally invasive and caries protective when compared to other traditional restorative methods, ART restorations might therefore be considered a treatment of choice for single-surface car-ies lesions. The evidence suggests that ART restorations can be used for multiple surface caries lesions in primary teeth but that, as for other multiple-surface restorations in primary teeth, the survival rates are lower than those for single-surface restorations. There are limited data on the use of ART restorations for multiple-surface lesions in permanent teeth and therefore additional research is required on this aspect.

With respect to the use of sealants generally, their use should be targeted to individuals and teeth that are at high risk of developing caries and to teeth that are already exhibiting early caries lesions. This means that instead of adopting an invasive approach for initial or incipi-ent caries lesions, the placement of seal-ant can effectively halt the progression of these lesions. Such an approach can potentially preserve tooth structure and

lower the likelihood of future complex restorations.8,43 ART sealants made using a high-strength high-viscosity GIC have the advantage over resin-based sealants in that they can be used where moisture control is less than optimal, for instance, in erupting teeth in high caries risk indi-viduals or in younger children.

Irrespective of the type of sealant used, be it ART or resin-based, its placement is non-invasive. Therapeutic sealants can effectively halt the progression of initial or incipient caries lesions. Conversely, even if a minimal invasive approach is used to treat such a lesion, the tooth is condemned for life to the repeat restoration cycle.43 Thus, therapeutic sealants using resins or ART can preserve tooth structure and lower the likelihood of future complex restorations.8

REPAIR OF ART RESTORATIONSAn important element of the minimal inter-vention approach is the repair of defective restorations rather than their total replace-ment.9 Replacement of defective restora-tions is accompanied by a risk of increasing the size of the cavity thereby weakening the tooth if the defective restoration is removed in its entirety. Tyas et al.9 discuss at length the decision-making process as to whether to leave, repair or replace what is deemed to be a defective restoration. Alternative treatments to replacement of both defective amalgam and resin-based composite resto-rations using refinishing, sealing of defec-tive margins or repair, show the viability of this approach in the long term.44,45 These principles can also be applied to ART resto-rations and sealants made with GIC. Indeed Christensen positively encourages the use of GIC for the repair of defective restorations.46

CONCLUSIONSOver the past two decades ART, as a mini-mal intervention and minimal invasion approach for the management of den-tal caries, has proven to be a success in both developed and developing countries. There is now a strong evidence base to show that ART is a quality approach to control caries that is reliable and effec-tive. As with many developments in oral health, but especially minimal interven-tion and minimal invasion approaches, the dental profession and the dental education system has been very slow to take these on board even though there is a strong



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evidence base for these approaches. Thus the concepts that are described in this arti-cle might be alien and hard to accept by many dental practitioners who have had a traditional, rhetorical-based dental educa-tion. This is consistent with what is known as the research-application gap. In France, it appears that very few practicing dentists or dental academics are aware of the ART approach or other minimal intervention and minimal invasion approaches and the opportunities they can afford. Failure of the dental profession and the dental edu-cation system to embrace these approaches results in the oral health of our patients being placed at a disadvantage.

ADDITIONAL NOTEThe indications for ART at the patient level mentioned in this article relate to the situa-tion in France with country-specific exam-ples given. For example, while in France for children at age six, two-thirds of primary teeth with cavities are not restored, this fig-ure is even worse in the United Kingdom where, according to the 2003 survey of chil-dren’s dental health in the United Kingdom, for children age five, only one eighth of decayed teeth are restored on average. This does not imply that the authors advocate that all decayed primary teeth be restored.47,48 With respect to 12-year-old children the sit-uation appears better in the United Kingdom than in France since over half the decayed permanent teeth are filled.47,48 In common with France, access to oral dental care in the United Kingdom is difficult for the elderly or handicapped.49 For example, in one survey of nursing home residents in Avon, 63% were found to have root caries.50 The commonal-ity of untreated dental caries in both France and the United Kingdom points to the need to explore new approaches to the delivery of oral care. Atraumatic restorative treatment might be one of a number of approaches that could lead to an improvement of oral health in our populations.

The authors would like to thank Dr Jo Frencken for reviewing the manuscript and for kindly providing Figures 6 to 15 and Claudie Damour-Terrasson, publishing director of the Groupe Information Dentaire, Paris, France, for authorising the transla-tion and publication of the series in the BDJ.

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2. Dawson A S, Makinson O F. Dental treatment and dental health. Part 2. An alternative philosophy and some new treatment modalities in operative

dentistry. Aust Dent J 1992; 37: 205–210.3. Frencken J E, van Amerongen W E. The Atraumatic

Restorative Treatment approach. In Fejerskov O, Kidd E (eds) Dental caries: the disease and its clinical management. 2nd ed. pp 427–442. Oxford: Blackwell Munksgaard, 2008.

4. Frencken J E, Leal S C. The correct use of the ART approach. J Appl Oral Sci 2010; 18: 1–4.

5. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington H V. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2008; 4: CD001830.

6. Beauchamp J, Caufield P W, Crall J J et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2008; 139: 257–268.

7. Gooch B F, Griffin S O, Gray S K et al. Preventing dental caries through school-based sealant pro-grams: updated recommendations and reviews of evidence. J Am Dent Assoc 2009; 140: 1356–1365.

8. Griffin S O, Oong E, Kohn W et al. The effectiveness of sealants in managing caries lesions. J Dent Res 2008; 87: 169–174.

9. Tyas M J, Anusavice K J, Frencken J E, Mount G J. Minimal intervention dentistry - a review. FDI Commission Project 1–97. Int Dent J 2000; 50: 1–12.

10. Fejerskov O, Kidd E, Bente N. Dental caries: the dis-ease and its clinical management. 2nd ed. Oxford: Blackwell Munksgaard, 2008.

11. Alves L S, Fontanella V, Damo A C, Ferreira de Oliveira E, Maltz M. Qualitative and quantitative radiographic assessment of sealed carious dentin: a 10-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109: 135–141.

12. Fusayama T, Okuse K, Hosoda H. Relationship between hardness, discoloration, and microbial invasion in carious dentin. J Dent Res 1966; 45: 1033–1046.

13. Massler M. Pulpal reactions to dental caries. Int Dent J 1967; 17: 441–460.

14. Fusayama T, Terachima S. Differentiation of two layers of carious dentin by staining. J Dent Res 1972; 51: 866.

15. Banerjee A, Kidd E A, Watson T F. In vitro evaluation of five alternative methods of carious dentine excavation. Caries Res 2000; 34: 144–150.

16. Celiberti P, Francescut P, Lussi A. Performance of four dentine excavation methods in deciduous teeth. Caries Res 2006; 40: 117–123.

17. Kidd E A. How ‘clean’ must a cavity be before restoration? Caries Res 2004; 38: 305–313.

18. Ricketts D N, Kidd E A, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006; 3: CD003808.

19. Thompson V, Craig R G, Curro F A, Green W S, Ship J A. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc 2008; 139: 705–712.

20. Handelman S L, Leverett D H, Espeland M A, Curzon J A. Clinical radiographic evaluation of sealed carious and sound tooth surfaces. J Am Dent Assoc 1986; 113: 751–754.

21. Mertz-Fairhurst E J, Curtis J W Jr, Ergle J W, Rueggeberg F A, Adair S M. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998; 129: 55–66.

22. Massara M L, Alves J B, Brandão P R. Atraumatic restorative treatment: clinical, ultrastructural and chemical analysis. Caries Res 2002; 36: 430–436.

23. Jeronimus D J Jr, Till M J, Sveen O B. Reduced viabil-ity of microorganisms under dental sealants. ASDC J Dent Child 1975; 42: 275–280.

24. Jensen O E, Handelman S L. Effect of an autopolym-erizing sealant on viability of microflora in occlusal dental caries. Scand J Dent Res 1980; 88: 382–388.

25. Wambier D S, dos Santos F A, Guedes-Pinto A C, Jaeger R G, Simionato M R. Ultrastructural and microbiological analysis of the dentin layers affected by caries lesions in primary molars treated by mini-mal intervention. Pediatr Dent 2007; 29: 228–234.

26. Oong E M, Griffin S O, Kohn W G, Gooch B F, Caufield P W. The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence. J Am Dent Assoc 2008; 139: 271–278.

27. Gruythuysen R J, van Strijp A J, Wu M K. Long-term survival of indirect pulp treatment performed in pri-mary and permanent teeth with clinically diagnosed deep carious lesions. J Endod 2010; 36: 1490–1493.

28. Bjørndal L, Reit C, Bruun G et al. Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010; 118: 290–297.

29. Dowling A H, Fleming G J. Is encapsulation of posterior glass-ionomer restoratives the solution to clinically induced variability introduced on mixing? Dent Mater 2008; 24: 957–966.

30. Butani Y, Levy S M, Nowak A J et al. Overview of the evidence for clinical interventions in pediatric dentistry. Pediatr Dent 2005; 27: 6–11.

31. Glick M, Meyer D M. Evidence or science based? There is a time for every purpose. J Am Dent Assoc 2011; 142: 12–14.

32. Frencken J E, Van’t Hof M A, Van Amerongen W E, Holmgren C J. Effectiveness of single-surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res 2004; 83: 120–123.

33. Van’t Hof M A, Frencken J E, van Palenstein Helderman W H, Holmgren C J. The atraumatic restorative treat-ment (ART) approach for managing dental caries: a meta-analysis. Int Dent J 2006; 56: 345–351.

34. de Amorim R G, Leal S C, Frencken J E. Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig 2012; 16: 429–441.

35. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clinical Oral Investig 2010; 14: 233–240.

36. Lo E C, Luo Y, Tan H P, Dyson J E, Corbet E F. ART and conventional root restorations in elders after 12 months. J Dent Res 2006; 85: 929–932.

37. Honkala S, Honkala E. Atraumatic dental treatment among Finnish elderly persons. J Oral Rehabil 2002; 29: 435–440.

38. Leal S C, Abreu D M, Frencken J E. Dental anxiety and pain related to ART. J Appl Oral Sci 2009; 17: 84–88.

39. Hescot P, Rolland E. La santé dentaire en France. Paris, France: UFSBD, 2006.

40. Hermosillo V H, Quintero L E, Guerrero N D, Suárez D D, Hernández M J, Holmgren C J. The imple-mentation and preliminary evaluation of an ART strategy in Mexico: a country example. J Appl Oral Sci 2009; 17: 114–121.

41. Haute Autorite de Sante. Strategies de prevention de la carie dentaire. HAS, 2010. Online informa-tion available at http://www.has-sante.fr (accessed November 2012).

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45. Gordan V V, Garvan C W, Blaser P K, Mondragon E, Mjör I A. A long-term evaluation of alternative treatments to replacement of resin-based compos-ite restorations: results of a seven-year study. J Am Dent Assoc 2009; 140: 1476–1484.

46. Christensen G J. Restorative dentistry for times of eco-nomic distress. J Am Dent Assoc 2009; 140: 239–242.

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50. Frenkel H, Harvey I, Newcombe R G. Oral health care among nursing home residents in Avon. Gerodontology 2000; 17: 33–38.



http://www.has-sante.fr

Minimal intervention dentistry: part 6. Caries inhibition by resin infiltrationJ. J. Lasfargues,*1,2 E. Bonte,1,2 A. Guerrieri1,2 and L. Fezzani1,2

invasive restoration.1 In this context a new technique to stop the progression of initial caries without the use of drilling has been proposed: the inhibition of caries by resin infiltration, that is, stopping the active carious process at its site without any invasive procedure.2

Remineralisation of enamel deminer-alised by acids from the cariogenic bio-film can be achieved principally through the application of topical fluorides and remineralising agents3,4 by the use of fis-sure sealants or by repair of the lesion using bioactive materials.5 In all cases the goal is to stop lesion progression. Remineralisation by topical application of fluoride requires multiple treatment sessions and strict long-term follow-up, which implies strong cooperation from the patient and is often difficult to obtain. In addition, monitoring systems for assessing the status of the lesions over time are still being studied and are difficult to apply in every-day clinical practice.6 Sealing techniques using resin or glass-ionomer cements are primarily intended for initial carious lesions in the pits and fissures on occlusal surfaces of erupting posterior teeth. They have been proven to prevent tooth decay7 but their effectiveness in the sealing of carious lesions in site 1 (occlusal surfaces) to prevent the need for a restora-tion of stages 0 and 1 (SiSta classification)8 remains controversial. Thus, hitherto there

INTRODUCTION

In recent decades, the management of carious lesions has shifted the paradigm of drilling and filling into the paradigm of prevention, control and minimally

Resin infiltration has made possible an innovative way of treating initial carious lesions that fits perfectly with the concept of minimal intervention dentistry. Infiltration of carious lesions represents a new approach to the treatment of non-cav-itated lesions of proximal and smooth surfaces of deciduous and permanent teeth. The major advantage of this method is that it is a non-invasive treatment, preserving tooth structure and that it can be achieved in a single visit. While this therapy can rightly be categorised as minimum intervention dentistry, clinical experience is limited and further controlled clinical trials are required to assess its long-term results. The inhibition of caries progression by resin infiltration should now be considered an alternative to invasive restorations, but involves early detection of lesions and does not allow for appropriate monitoring of the caries risk.

has been a lack of effective procedures for stopping initial lesions in one ses-sion. This applies particularly to proximal carious lesions and the buccal and lingual smooth surfaces.

Resin infiltration of carious lesions rep-resents an approach to the treatment of non-cavitated lesions on proximal and smooth surfaces of primary and perma-nent teeth. The principal feature of this technique is that it is non-invasive, pre-serves tooth structure and can be com-pleted in a single visit. The concept was first developed in Germany, at the Charité University Hospital in Berlin, from in vitro studies on the penetration of resin into caries9-11 and marketed under the brand name of Icon® (DMG America Company, Englewood, NJ).

PRINCIPLE OF RESIN INFILTRATION OF CARIOUS LESIONS

The principle of resin infiltration is to per-fuse porous enamel with resin by capillary action, thereby stopping the process of demineralisation and stabilising the carious lesion. The principle can be compared with the saturation of a sugar cube or sponge with a liquid (Fig. 1). The infiltration takes place within the enamel, in contrast to pit and fissure sealants, which forms a superfi-cial mechanical barrier on the outer surface of the initial lesion, depriving the bacteria that colonise the surface of the lesion of

1Faculté de Chirurgie Dentaire, Université Paris Descartes, 1 rue Maurice Arnoux, 92120 Montrouge, France; 2Service d’Odontologie – Hôpital Bretonneau – APHP, 23 rue Joseph de Maistre, 75018 Paris, France *Correspondence to: Professor Jean-Jacques Lasfargues Email: [email protected]; Telephone: +33 1 53 11 14 30

Accepted 21 June 2012 DOI: 10.1038/sj.bdj.2013.54 ©British Dental Journal 2013; 214: 53–59

• Suggests the inhibition of caries progression by resin infiltration should now be considered an alternative to invasive restorations.

• Describes the principle and protocol of resin infiltration of carious lesions.

I N B R I E F

PRA

CTICE






6. Caries inhibition by resin infiltration7. Minimally invasive operative caries

management – rationale and techniquesThis paper is adapted from: Lasfargues JJ, Bonte E, Guerrieri A, Fezzani L. Inhibition carieuse par infiltration résineuse. Réalités Cliniques 2011; 22: 257–267.




PRACTICE

nutrients from the biofilm (Fig. 2). Bacteria that have penetrated the demineralised enamel are trapped in the infiltrating resin once it has been cured.

It has been shown that bacteria can physically cross the outer, macroscopi-cally intact or slightly damaged enamel of non-cavitated lesions.12 The presence of these trapped bacteria does not pre-vent the resin infiltrating and does not warrant operative treatment by surgical tissue removal and restoration.13 To pen-etrate the entire thickness of the enamel, to seal its pores, to block the diffusion of nutrients and to stop caries progression it is essential that the infiltrating agent has a high penetrative ability. Despite the novelty of this technique several research studies both in vitro and in vivo14-18 have tested the:•Erosive potential of different etching

agents, including hydrochloric acid, on the ‘compact’ layer and the ‘pseudo-intact’ enamel surface to permit resin impregnation of the enamel

•Ability of different adhesive systems and low viscosity resin fluids to penetrate the enamel subsurface

and their capacity to obstruct caries progression.The results indicate that the inhibition

of caries progression is achieved by the sequential effects of 15% hydrochloric acid gel applied for two minutes, followed by the application of a low viscosity resin of type TEGDMA (tri-ethylene glycol dimeth-acrylate) with a sufficiently high (>200 cm/sec) penetration coefficient. Studies by confocal laser microscopy19 have produced images demonstrating the penetration of the resin, thus allowing the depth of the lesion and its non-progression after resin infiltration to be checked (Fig. 3).

INDICATIONS FOR RESIN INFILTRA-TION OF CARIOUS LESIONS

The erosion/infiltration technique has been proposed for hiding white spots associated with non-carious conditions such as fluo-rosis20,21 and it appears to give satisfactory aesthetic results in patients (Fig. 4). This use of the technique will not be discussed further in this article.

Infiltration of carious lesions may be indicated in all age groups- children, ado-lescents and adults, for all initial lesions

Fig. 1 Illustration of the concept of infiltration by a low viscosity resin: coffee plays the role of ‘infiltrating’ the sugar cube, analogous to porous enamel (a); Clinical application of the concept: the infiltration by resin is achieved by depositing the liquid resin on the demineralised enamel using a specially developed method (b) and then the resin in the saturated area (c) is light-cured

Fig. 2 Sealing and infiltration of initial caries lesions at Site 1 and Site 2 (a) are two different therapeutic concepts; (b) at Site 1, the sealant forms a physical surface barrier which deprives bacteria of nutrients. At Site 2, infiltrating the enamel with resin traps the bacteria that have penetrated the body of the lesion and the outcome is a hybrid resin enamel

Fig. 3 Microscopic appearance of resin infiltration illustrated using lesions coloured by a direct staining technique (a-d) and an indirect technique (e-h), observed by confocal microscopy (CLSM) in dual fluorescence (DF) and combined transparent fluorescence (CTF) modes, and by transversal microradiographs (TMR) and scanning electron microscopy (SEM). With the direct technique, areas infiltrated by the resin are not all identified by red fluorescence. With the indirect technique, the images obtained by CLSM infiltration DF are a good fit with the different reference methods. (Figure reproduced courtesy of the Journal of Microscopy Research and Technique, John Wiley Publishing)18

a

b

a

b

c



PRACTICE

where the depth does not exceed the outer third of dentine, that is, SiSta stages 0 and 1 (Fig. 5). The technique is aimed primarily at initial proximal lesions. Below a thresh-old depth estimated at 800 microns2 the tissue lost by demineralisation is replaced by infiltrated resin, creating an internal barrier to the diffusion of sugars and organic acids which would otherwise colo-nise the proximal embrasure. This barrier stabilises and freezes the lesion without affecting the anatomical shape of the tooth since the surface is not directly concerned. Thus, the interproximal physiology is not disturbed, provided that the excess resin is carefully removed in accordance with the application procedure (see protocol).

The second indication for the technique is for carious lesions on non-proximal smooth surfaces, such as opaque white lesions around orthodontic devices used

in a high caries risk oral environment, pro-vided that they are not cavitated and are surrounded by intact enamel. In addition to stabilising the lesion, the appearance of the tooth is generally improved by the technique (Fig. 6).

OPERATING PROTOCOLAll the necessary elements are included in the proximal treatment kit, including syringes with special tips for delivering in situ the acid gel and infiltration resin

(Fig 7). The nozzle itself consists of a dou-ble film of superfine transparent plastic, perforated on one side for the delivery of the agents and simultaneously protecting the neighbouring surface from them. These tips can be rotated 360°, which facilitates application from all angles. Two screw syringes are used to control extrusion of acid gel and the infiltration resin respec-tively. Interdental wedges can be used to separate the surface to be treated and the contiguous surface.

Fig. 4a Preoperative situation showing non-carious white spot on 11 and 21, in an 18-year-old patient

Fig. 4b Situation during the procedure: application of infiltrating resin after etching with hydrochloric acid

Fig. 4c Result three months after treatment; the aesthetic result obtained after the infiltration procedure is maintained and continues to satisfy the patient

Fluoridation In�ltration In�ltration?

Prevention(No invasive care)

Restoration(Invasive care)

Resin in�ltration(Micro-invasive care)

DIEI EII

Fig. 5 Schematic representation of comparative indications for remineralisation by fluoride, by resin infiltration and minimal intervention dentistry. These treatment options are offered for guidance, given the difficulty of creating a categorical decision based on the radiographs alone

Key:- E 1: demineralisation in the outer half of enamel; E 2 demineralisation of the entire width of the enamel; D 1: demineralisation of the outer third of dentine without cavitation (corresponding with the SiSta classification: E1 and E2 = Stage 1; D1 = stage 2).

Fig. 6 White spot demineralisation after orthodontic care, before treatment: (a) processing by resin infiltration; (b) condition after etching with hydrochloric acid, dried with ethanol; (c) result after six months

a

b

c



PRACTICE

The operative steps (Fig. 8) will be illus-trated by the treatment of a proximal lesion of a maxillary premolar (distal sur-face of tooth 15), using as an example the following clinical case.

Mrs A., 30 years old, attends for a dental consultation before commencing ortho-dontic care. The patient has difficulty com-ing for appointments at the dental office because of her immediate professional commitments. She presents as a high car-ies risk patient with numerous proximal lesions and corroded amalgams with mar-ginal overhangs. Given the anticipated orthodontic care and the patient’s poor immediate availability, initial care is lim-ited to initial interventions to lower caries risk (plaque control and dietary advice), treatment of non-cavitated lesions by resin infiltration, treatment of cavitated lesions with direct composite restoration and replacement of amalgam restorations by adhesive long-term temporary resto-rations. Follow-up should confirm the absence of recurrent caries and decisions about prosthetic restorations should be deferred pending decisions about ortho-dontic treatment:•Indications for resin impregnation

treatment should be based on bitewing radiographs, showing an enamel stage 0 initial lesion and on the clinical situation

Fig. 7 Icon® treatment kit for smooth and proximal surfaces: (a) equipment for proximal surface treatment; (b) three screw syringes (set up for use) for etching, drying and infiltration

Fig. 8a Operative Protocol. Initial clinical view of the segment 14-16

Fig. 8f Drying with air syringe

Fig. 8b Pre-operative bitewing showing amalgam with marginal excess at 15 and several proximal initial lesions, including 14 (D) and 15 (D)

Fig. 8g Dehydration with 99% ethanol (Icon Dry®)

Fig. 8c Isolation by rubber dam and interdental wedges (amalgam in 15 removed)

Fig. 8h Application of the infiltration resin using the proximal nozzle

Fig. 8d Etching (Icon Etch®) the demineralised area for two minutes (15D)

Fig. 8i Light polymerisation of the infiltration resin from all angles for 40 s, after withdrawing the nozzle and removing excess resin with dental floss

Fig. 8e Rinsing (30 s)

a

b

Fig. 8j No immediate but short time recall radiographic examination; postoperative radiograph shows that the two lesions on 15 and 14 treated by resin infiltration have not progressed. Replacement of the amalgam with marginal excess by a composite restoration allows the patient to manage plaque control. Other Stage 0 lesions are treated identically. See: Figs 1b-c



PRACTICE

•Before treatment, the teeth must be cleaned and then isolated by rubber dam, rinsed and dried

•A plastic inter-dental wedge should be inserted into the inter-dental space

•The transparent proximal application nozzle should be screwed onto the syringe, pre-filled with 15% hydrochloric acid, and then set up correctly positioned in the interdental space

•The etching gel (Etch Icon®) should be extruded towards the affected proximal surface and left in place for two minutes to make the outer layer of enamel porous

•The transparent application nozzle should be withdrawn occlusally and the site thoroughly rinsed for 30 seconds and again dried

•The surface should be dehydrated with 99% ethanol, delivered by a metal tipped syringe (Icon dry®) to facilitate the drying process, because the TEGDMA is hydrophobic

•The proximal application nozzle of the resin can then be screwed onto the syringe pre-filled with transparent low viscosity resin and positioned to access the affected surface

•A slight excess of infiltration resin should be applied, directly in contact with the previously etched demineralised zone. It must be well spread over the interproximal contact area and be left in place for three minutes so that the resin penetrates the pores of the lesion by capillary attraction

•The transparent application nozzle is then removed, and the excess resin is removed with dental floss. The resin is then photo-polymerised from three angles (buccal, lingual, occlusal) for 40 seconds

•A new proximal application nozzle is mounted on the preloaded syringe and infiltration resin is applied a second time. This second layer of resin infiltration is applied for one minute only and light cured as before for 40 seconds

•After removing all the equipment the interproximal space is evaluated with dental floss and the cervical excess is removed using, for example, a probe or a curved mini-CK6

•A clinical and radiographic follow-up should be initiated to confirm that the lesions do not progress and that there is no recurrence. The same protocol is recommended for the treatment of white spot carious lesions on buccal and palatal surfaces, using the Icon ‘Smooth Surfaces ®’ kit, in which the proximal nozzles are replaced by nozzles with pads suitable for buccal or lingual surfaces (Fig. 9).

DISCUSSIONA systematic review of the literature comparing techniques for sealing and infiltration in the treatment of initial caries lesion, concludes, with a good level of evidence, that the sealants act by forming a superficial barrier against the penetration of bacteria and their by-products, while infiltration techniques create an internal barrier in the lesion by replacing lost minerals with low viscos-ity light-cured resin.22 Occlusion of pores by penetration of the resin into the body of the lesion is probably responsible for the retention of the material, allowing an expectation of a stable result over time. The durability of the result is dependent on the lesion’s environment. Caries inhi-bition is being maintained in a weakly demineralising environment, but it is likely that in a patient at uncontrolled risk of caries demineralisation will con-tinue or recur at the periphery of the resin infiltrated area. The technique does not make proper management of caries risk and patient monitoring redundant.

Resin infiltration seems suited particu-larly for proximal lesions where, when invasive treatment is chosen, the ratio of normal tissue to carious tissue leads to a not insignificant loss of healthy tissue in order to gain access to the lesion, even when applying micro-invasive methods of preparation such as sono-abrasion.23

It is extremely difficult for the prac-titioner to locate the border between the absence or presence of cavitation clinically and radiographically in the interproximal spaces between adjacent posterior teeth. Initial lesions evaluated as non-cavitated may nevertheless appear with broken-down surface layers.12 In a recent in vitro study assessing the degree of penetration of the resin according to ICDAS codes it has been shown that

Fig. 9 Resin infiltration treatment of a demineralisation spot on the buccal surface of a molar after the use of orthodontic bands



PRACTICE

cavitated lesions (code 5) showed signifi-cantly less resin infiltration than non-cav-itated lesions (codes 2 and 3) and the resin was unable to fill the cavities (Fig. 10).24 The technique is therefore not recom-mended for the management of cavitated lesions and it should be borne in mind that, if a proximal cavity has not previ-ously been detected, infiltration may be faulty and caries inhibition may fail. Here again, the technique does not dispense with the requirement for early detec-tion, thorough diagnosis and rigorous caries monitoring.

The risk-benefit ratio of this non-inva-sive and aesthetic technique is favour-able but clinical experience is limited, and questions arise about the aging of the resin, even though the risk of hydrolysis appears limited due to the hydrophobic nature of the resin. There is little informa-tion on the wear resistance of the impreg-nated zone and on the colour stability and aesthetics after infiltration. Finally, this technique is described as ‘without drilling and without anaesthesia’, deceptively sim-ple and fast. The duration of full treatment of a lesion is 15-20 minutes (rubber dam included) for a practitioner who masters the technique. Undertaking the treatment is relatively difficult. It requires the teeth to be perfectly cleaned and dried and iso-lated by the rubber dam. Passing the clear plastic nozzle between the proximal con-tacts is not always easy, despite the aids. Measuring the amount of infiltration resin to be placed is imprecise (Fig. 11) despite the needle screw and excess cured resin may persist in the recess, which must be carefully verified otherwise there is a risk of promoting papillary inflammation. The application of resin should always be done in two stages to fill cracks and voids in the first layer, observed by microscopy, and to obtain a better surface quality. The state of the final surface is slightly rough and imperfect and does not appear to be improved by available finishing systems, such as interproximal abrasive strips.25 The removal of the equipment (nozzle, wedge, rubber dam) frequently leads to haemorrhage due to the inevitable com-pression of the papilla for the duration of treatment. The absence of radio-opacity, inherent with unfilled resin, does not allow the result to be seen on radiograph. The alleged efficacy of the treatment

cannot be evaluated since progression of the lesion cannot be visualised at subsequent visits.

CONCLUSIONSInfiltrating resins have opened up an innovative pathway in the management of initial carious lesions, correspond-ing with the goals of the physician to heal without causing harm. The inhibi-tion of caries progression by infiltration should be considered an alternative to more invasive therapies and warrants a place in the range of minimally inva-sive dentistry techniques. Compared with remineralisation techniques that may require several follow-up visits, this therapy can be undertaken in one treat-ment session, which is important for

patients, in particular for children and their parents. The benefits depend on the overall management of caries risk and adequate follow-up. Experience is hith-erto limited. High evidence level clinical trials are needed to assess the long-term results and development is needed to simplify the system for use in ordinary dental practice.

The authors would like to thank Claudie Damour-Terrasson, President and publishing director of the Groupe ID Espace- L’Information Dentaire, Paris France, for the authorisation of translation and publication of the series in the BDJ.

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Fig. 10 The resin did not fill the small carious defect, dissuading the method for the cavitated lesions. Initial situation (a) and after resin infiltration (b)

Fig. 11 Excess resin expressed from the syringe and collected in the bottom of the dam

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25. Mueller J, Yang F, Neumann K, Kielbassa A M. Surface tridimensional topography analysis of materials and finishing procedures after resinous infiltration of subsurface bovine enamel lesions. Quintessence Int 2011; 42: 135–147.



Minimal intervention dentistry: part 7. Minimally invasive operative caries management: rationale and techniquesA. Banerjee1


in the dental literature. Minimum(al) inter-vention dentistry is the holistic patient care philosophy that encompasses the complete patient-dentist team-care approach to managing dental disease by identification and diagnosis (including caries risk assess-ment), prevention and control, restoration and recall, so educating and empower-ing the patient to take responsibility for their personal oral health.1,2 Minimally Invasive Dentistry describes contemporary ultraconservative operative management of cavitated lesions requiring surgical intervention. It does not mean unduly early operative intervention of incipient lesions, which in most cases is unnecessary as more effective and appropriate non-invasive preventive approaches exist. It is the latter definition that will be discussed further in this paper.

‘Golden triangle’ of MIDA thorough understanding and apprecia-tion of the interplay between three criti-cal factors is required to achieve success clinically when using a minimally inva-sive operative caries management strategy (MI OCMS):1. The histology of the dental substrate

being treated

INTRODUCTION

The term MI dentistry or ‘MID’ has been used for many years with several meanings

When patients present with cavities causing pain, poor aesthetics and/or functional problems restorations will need to be placed. Minimally invasive caries excavation strategies can be deployed depending on the patient’s caries risk, lesion-pulp proximity and vitality, the extent of remaining supra-gingival tooth structure and clinical factors (for example, moisture control, access). Excavation instruments, including burs/handpieces, hand excavators, chemo-mechanical agents and/or air-abrasives limiting caries removal selectively to the more superficial caries-infected dentine and partial removal of caries-affected dentine when required, help create smaller cavities with healthy enamel/dentine margins. Using adhesive restorative materials the operator can, if handling with care, optimise the histological substrate coupled with the applied chemistry of the material so helping to form a durable peripheral seal and bond to aid retention of the restoration as well as arresting the carious process within the remaining tooth structure. Achieving a smooth tooth-restoration inter-face clinically to aid the cooperative, motivated patient in biofilm removal is an essential pre-requisite to prevent further secondary caries.

2. The chemistry/handling of the adhesive materials used to restore the cavity

3. Consideration of the practical operative techniques available to excavate caries minimally.

Appreciation of these factors will ena-ble the dental practitioner to embrace the contemporary oral physician’s biological approach to operative caries management as opposed to the surgeon’s mechanistic efforts of preparing cavities of a pre-deter-mined shape, governed primarily by the properties of the chosen restorative mate-rial as opposed to the actual histopathol-ogy of the disease process and retention of tooth substance.3,4

LESION HISTOLOGY

Enamel caries

Long-term, repeated episodes of bacte-rial acid demineralisation instigated at a susceptible tooth surface by the residing plaque biofilm results in the growth of subsurface structural porosities, eventu-ally enlarging, if not controlled at the earliest stages by remineralisation/oral hygiene procedures, coalescing and ulti-mately causing cavitation. Carious enamel

1Professor of Cariology & Operative Dentistry/Hon Consultant, Restorative Dentistry, Conservative Dentistry, Floor 26, Tower Wing, King’s College London Dental Institute, Guy’s Dental Hospital, London Bridge, London, SE1 9RT Correspondence to: Professor Avijit Banerjee Email: [email protected]; Tel/fax: +44 207 188 1577/7486


• Describes minimally invasive operative caries management techniques.

• Highlights the degree to which dental caries should be excavated.

• Suggests removal of grossly softened caries-infected dentine is recommended in most situations along with the placement of a sealed restoration.

I N B R I E F

PRA

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2. Caries risk assessment in adults3. Paediatric dental care – prevention and

management protocols using caries risk assessment for infants and young children



6. Caries inhibition by resin infiltration7. Minimally invasive operative caries

management – rationale and techniquesThis paper is adapted from: Banerjee A. Stratégies invasives a minima de l’éxérèse des tissus cariés. Réalités Cliniques 2011; 22: 141–156. The authors would like to thank Claudie Damour-Terrasson, publishing director of the Groupe Information Dentaire, Paris, France, for the authorisation of translation and publication of this MI series in the BDJ.


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with its unsupported prismatic structure is weak under stress from compressive/shear occlusal loads or from tensile shrink-age forces from photo-cured resin-based adhesive materials.5 If carious enamel is retained at the margin of the cavity and subsequently restored, deficiencies may allow the ingress of plaque biofilm bacteria through micropores within the defective enamel structure - cohesive microleakage. Further complications are associated with the potential of ‘secondary’ caries devel-oping along defective marginal interfaces where plaque biofilm stagnates, further compromising tooth structure.3

Dentine cariesCarious dentine can be subdivided into two histopathological zones:1. The peripheral caries-infected

zone (close to the enamel-dentine junction [EDJ]), irreversibly damaged, necrotic and softened by long standing bacterial contamination and proteolytic denaturation of collagen and acid demineralization of the inorganic component

2. The deeper caries-affected zone, reversibly damaged by virtue of carious process, which has the potential to repair under the correct conditions as the collagen is not denatured.5-7

The soft, wet, necrotic nature of car-ies-infected dentine means it is an infe-rior chemical and physical substrate for adhesion and seal formation, whereas the potentially repairable caries-affected den-tine has been shown to exhibit adequate adhesive bonding potential, especially when surrounded by a periphery of sound dentine and enamel.8

It is important to appreciate that using the principles of minimally invasive (MI) dentistry may often lead to less carious dentine excavation overall than past caries excavation rationales based on a mechanis-tic approach to maximise the retention and physical properties of the restorative material within the cavity.9 MI cavities will exhibit cut surfaces with different qualities of enamel and dentine histology along the same cavity surface and these tissues will require han-dling in different ways in order to optimise adhesive bonding. Indeed, clinically delineat-ing between the layers of caries-infected and

affected dentine within a lesion is a rather subjective process at present. Caries-infected dentine is sticky and soft to a sharp dental explorer whereas caries-affected dentine is a little more tacky (‘scratchy and sticky’) in nature and blends to the hard, scratchy con-sistency of deeper sound dentine.3 Propylene glycol-based indicator dyes were developed to act as a marker for that carious dentine requiring excavation, but many conflicting studies exist regarding their efficacy in this regard.10 Latest developments include more specific indicators highlighting the sulphur-containing bacterial products indicative of the increased bacterial load present in car-ies-infected dentine but these have yet to be validated in vivo.

How much dentine caries should be excavated?

The answer to the above question is spe-cific to the individual tooth/lesion, oral cavity, patient and dentist as there are numerous inter-relating co-variables that have to be considered.

Pulp statusThe vitality (sensibility) of the pulp must be assessed from the clinical signs and symptoms and suitable investigations (a combination of electrical, thermal and radiographic). Signs of an acute, revers-ible pulpitis can resolve if the carious pro-cess is arrested using a sealed restoration along with effective patient control meas-ures, tipping the histopathological balance from the bacteria in favour of the heal-ing dentine-pulp complex and its acute inflammatory mediators.5,11.

Lesion depthLesion-pulp proximity affects the level of protection afforded to the vital pulp. Indirect pulp protection (capping) con-serves caries-affected dentine close to the pulp, minimising the risk of unnecessary pulp exposure, and a suitable material (for example, glass ionomer cement) with anti-bacterial properties as well as bonding and sealing chemically to the remaining dentine affords a potential seal, so per-mitting rejuvenation of the dentine-pulp complex.5,12,13

Extent of viable tooth structureThe functional and aesthetic restorability of the tooth must be assessed. A minimally

invasive approach removing only caries-infected dentine will conserve more tooth structure that can help retain and support the definitive sealed restoration. The opti-mal restorative material is natural tooth substance and smaller cavities are easier to manage for both the dentist and the patient. A reduced surface area of res-toration with its margins in cleansable, accessible areas will increase the patient’s ability to regularly agitate and remove the plaque biofilm, thus reducing the risk of further onset of caries.

Patient’s caries risk assessmentThe MI operative caries management strat-egy (OCMS) relies on close collaboration with successful prevention/control regimes instigated by the patient and the dental team. These can often be linked to the overall risk assessment of the individual patient as a motivated patient has the greater potential to be converted to low caries risk. If these are in place MI resto-rations have a good chance of medium to long-term success.14,15 If, however, the car-ies risk is high in less motivated patients then adhesive restorations may show a reduced long-term survival rate.16

Clinical factorsPractical considerations in restoration placement must play a part in deciding whether MI is a feasible option for particu-lar individuals. These may include:•Suitable access for instrumentation•Ability to control moisture levels

(ideally with rubber dam isolation)•Appreciation of the final position of

the cavity-restoration margin (supra- or subgingival)

•Appropriate handling of adhesive restorative materials by the dental team (for example, ensuring that dentine bonding agent bottle lids are replaced promptly after dispensing to ensure minimal evaporation of any solvent carrier; appropriate ratios of powder: liquid mixed when required etc).

Prospective long-term randomised con-trolled clinical trials have assessed the validity and efficacy of minimally inva-sive caries removal with or without indi-rect pulp capping in terms of restoration longevity and pulp status.13-15 Systematic analysis of the results has concluded that

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as long as there is a suitable patient-dentist team-care approach to maintaining oral health, adhesive sealed restorations placed in ultra-conservative cavity preparations can last well in the functioning oral cav-ity.9,12,17 The issue of pulp capping using a separate ‘lining’ or ‘base’ material has been reviewed in the literature. In modern day MI OCMS, using adhesive restorative materials, the clinical need of a separate layer of pulp protection has been shown to be unnecessary (apart from the scenario where the pulp may be protected with a thin layer of glass ionomer cement beneath a large amalgam restoration with close pulp proximity).18

MATERIALS SCIENCEA thorough understanding of the clini-cal relevance of contemporary adhesive dental materials science is required to implement successfully the MI OCMS. The physico-chemical interaction of the rele-vant dental substrate retained at the cavity surface with the adhesive material must be enhanced by the operator to achieve medium to long-term successful out-comes. The restoration seal is reliant upon the integrity and morphology of mineral (calcium ions, micromechanical undercuts, supported prismatic structure in enamel) and of the collagen nano-matrix/tubular structure in dentine (hybrid zone). The clinical relevance of the individual steps in adhesive bonding (acid etch, primer and bond) have been discussed in an alternative publication.4 Issues regarding chemical or micro-/nano-mechanical bond mechanisms revolve around the longev-ity of the seal achieved, which is affected adversely by physico-chemical hydrolysis and potential enzymatic degradation by indigenous, acid-activated dentine matrix

metallo-proteinases (MMPs).4,19-21 Latest in-vitro research indicates the potential use of anti-MMPs in dental adhesives to block the activity of the indigenous MMPs, hence resisting collagen degradation in the cari-ous dentine.21,22

MINIMALLY INVASIVE OPERATIVE TECHNIQUES

As can be seen from Table 1, there are several clinical technologies available for cutting teeth and removing caries. Most are not self-selective for caries-infected dentine and involve active discriminatory action from the operator when considering MI OCMS.23,24 Dentists are highly trained at using dental burs in slow speed or air turbine handpieces as well as hand exca-vators, and although not self discrimina-tory in favour of caries-infected dentine, a good operator can still practice MI OCMS effectively using these instruments as illustrated in Figures 1-6.

Ultrasonic and sonic instrumentation use the principle of probe tip oscilla-tion and micro-cavitation to chip away hard dental tissues. Lasers transfer high energy into the tooth through water caus-ing photo-ablation of hard tissues. Great control is required by the operator in order to harness this energy effectively and the effects on the remaining enamel, dentine and pulp continue to be investigated in terms of residual strength and bonding capabilities. A recent systematic review concluded that laser caries removal is not yet a viable general dental practice option for effective caries excavation.25 Enzymatic (including hypochlorite-, pep-sin- and papain-based) solutions have and are being investigated to help further breakdown of collagen in already softened carious dentine in the hope of developing

a more self-limiting technique of remov-ing caries-infected dentine alone.23 Other chemical methods include photo-acti-vated disinfection (PAD) where tolonium

Table 1 Tooth-cutting/caries removal technologies, the substrates acted upon and their mechanism of action

Mechanism Dental substrate affected Tooth-cutting technology

Mechanical, rotary Sound or carious enamel and dentine SS, CS, diamond, TC and plastic burs*

Mechanical, non-rotary

Sound or carious enamel and dentine

Hand instruments (excavators, chisels), air-abrasion, air-polishing**, ultrasonics, sono-abrasion

Chemomechanical Carious dentine Caridex™, Carisolv™ gel (amino acid-based), Papacarie® gel (papain-based), pepsin-based solutions/gels

Photo-ablation Sound or carious enamel and dentine Lasers

Others bacteria Photo-active disinfection (PAD), ozone

Key: SS = stainless steel; CS = carbon steel; TC = tungsten carbide; * = works only on carious dentine; ** = used for stain-removal3

Fig. 1 Cavitated occlusal lesion 17 with demineralised, unsupported peripheral enamel and visible caries-infected dentine. Symptoms were those of an early reversible pulpitis and the pulp was vital to electric pulp testing and ethyl chloride

Fig. 2 Radiograph of 17 showing demineralisation extending into the inner third of dentine towards the pulp. The pulp chamber is clearly visible with a potential bridge of dentine between it and the advancing lesion. There is no proximal cavitation

Fig. 3 The peripheral unsupported enamel has been removed using a long tapered diamond bur in a high speed air turbine handpiece and the sound margins lightly bevelled



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chloride is introduced into the cavity, absorbed by the residual bacteria in the cavity walls and then activated using light of a specific wavelength causing cell lysis, death and ozone (gaseous ozone infused into early lesions causing bacterial death). These technologies currently suffer from a paucity of clinical evidence to validate them for routine clinical use.26

Air-abrasionAir-abrasion is a 68-year-old dental oper-ative technique used for the removal of enamel and dentine during cavity prepara-tion.27,28 Air abrasion units are capable of minimally invasive tooth preparation using 27 μm aluminium oxide (α-alumina).24,29,30 However, dentists are used to the param-eters of tactile feedback and an apprecia-tion of finite cutting depth when using rotary tooth-cutting techniques, both of which the end-cutting alumina air abrasive jet lacks. This makes the use of alumina air abrasion highly operator-sensitive and requires careful education of clinicians to realise its potential for minimally invasive preparation and the prevention of cavity over-preparation.31 Studies have been published that characterise the efficacy of alumina air-abrasion and its cutting characteristics on both sound and carious enamel and dentine and collectively these show the technique to be efficient if spe-cific operating parameters (for example, air pressure, powder flow rate and reser-voir volume, nozzle diameter and work-ing distance) are regulated judiciously by the operator.32–35 Clinical studies have indicated good patient acceptance of the technology in terms of the lack of vibra-tion, no heat generation and the reduced need for local analgesia.36,37

An important clinical use of air-abrasion is obtaining suitable enamel access in min-imally invasive preventive resin restora-tions. Meticulous cleaning of the occlusal surface before visual examination using a rotary brush or air-polishing is essential for caries detection,38 followed by the use of a small head dental bur or alumina air-abrasion for the removal of the carious, demineralised enamel. The microscopically roughened enamel surface created by alu-mina air-abrasion is devoid of weakened prisms and is therefore better adapted for adhesive bonding. However, lack of substrate selectivity and no self-limiting

operator feedback when using these oper-ative technologies can result in cavity over-preparation. Innovation in abrasive powder development has resulted in the production of a commercially available bio-active glass powder capable of remov-ing extrinsic dental stain, desensitising

Fig. 4 The dentine at the periphery has been initially excavated to a depth of caries-affected dentine but flakes of very soft infected dentine remain over the pulpal aspect of the cavity

Fig. 7 Cavitated occlusal caries with soft infected dentine evident

Fig. 5 The dentine adjacent to the enamel-dentine junction is both scratchy and slightly sticky to a dental probe, indicating it is affected histologically. The peripheral enamel margin is sound histologically

Fig. 8 Initially clear, slightly viscous Carisolv™ gel introduced into the cavity using the mace-tip hand instrument and left for 40 seconds before excavation

Fig. 6 The final resin composite restoration has been placed and finished to reduce plaque biofilm adherence in the oral cavity

Fig. 9 This process is continued until the gel has a muddy consistency when it is washed out of the cavity and the relative hardness of the remaining cavity walls tested using a sharp dental explorer

Fig. 10 MI prepared cavity with affected dentine retained over the pulpal aspect of the cavity. The peripheral margins in the case have purposely been excavated to histologically sound dentine to aid the restorative peripheral seal

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exposed dentine and exhibiting an intrin-sic selectivity towards carious, dem-ineralised enamel and resin composite restorations.39–41 Research is ongoing into development of a self-selective air-abra-sive powder for caries-infected dentine.

Chemo-mechanical caries removalAfter the development and subsequent demise of the Caridex™ system in the 1970s, chemo-mechanical caries removal techniques were resurgent with the com-mercialisation of Carisolv™ gel in the late 1990s. This hypochlorite/amino acid-based gel system assists the MI OCMS with special non-cutting hand instru-ments offering greater tactile sensitivity to the operator, thus permitting selective infected and affected dentine removal.23,24 Studies indicated good patient acceptance of this technique.37 An example of MI car-ies excavation using Carisolv™ gel is given in Figures 7-10. Developments in chemo-mechanical technology include the labo-ratory development of pepsin-based gels using specially designed nylon brushes and plastic disposable hand instruments to abrade the softened infected dentine as well as papain-based systems (see Table 1).

CONCLUSIONSThe evidence for the minimally inva-sive operative caries removal strat-egy in appropriately selected patients exists. The removal of grossly softened caries-infected dentine is recommended in most situations (except perhaps in a deep lesion overlying the pulp where its vitality assessment leans towards an acute inflammatory response and an adequate clinical seal can be achieved at the periphery of the cavity). Peripheral caries removal should extend to sound dentine where inadequate quantity and quality of enamel remains. It is at this tooth-restoration interface that the peripheral seal is critical to prevent fur-ther histopathological progress of the disease. The seal can be achieved using adhesive dental biomaterials that pen-etrate micro-/nano-mechanically to the mineral and collagenous components of enamel and dentine respectively. With

judicious use of contemporary adhesives with their bacteriocidal/static properties, there is little need clinically for a separate lining/base layer to protect the pulp. A thorough understanding of the chemistry of the materials and how they relate to the histology of the tissues is necessary to ensure the best prognosis of a sealed, adhesive restoration.

Figures 1‑6 have been reproduced with publisher’s permission from Banerjee A. A large carious lesion. In Odell E W (ed) Clinical problem solving in dentistry. 3rd ed. pp 43‑48. Edinburgh: Churchill Livingstone, 2010.

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