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Minimal intervention dentistry: IN BRIEF

• Explains the differences between minimal


part 1. From ‘compulsive’ intervention dentistry, minimally invasive

PRACTICE
dentistry, micro-dentistry, atraumatic
restorative treatment and selective tissue

restorative dentistry to excavation.


• Examines the foundations of minimal
intervention dentistry.

rational therapeutic strategies • Considers the implementation of modern


concepts into everyday clinical practice.

J. D. B. Featherstone1 and S. Doméjean2

VERIFIABLE CPD PAPER

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.

INTRODUCTION of its pathogenesis, its transmission, the


Cariology has advanced over the past demineralisation and remineralisation con-
30  years with scientific advances in the tinuum, the mode of action of fluoride, but
knowledge of the caries process in terms also with respect to the great technologi-
cal developments in biomaterials, equip-
ment for the detection of caries lesions
MINIMAL INTERVENTION and methods for cavity preparation. This
DENTISTRY new scientific knowledge combined with
1. From ‘compulsive’ restorative dentistry to developments both technological and tech-
rational therapeutic strategies nique related, impose that both medically
2. Caries risk assessment in adults
and ethically, the sole pertinent therapeutic
3. Paediatric dental care – prevention and
management protocols using caries risk model that is relevant is one that is based
assessment for infants and young children on prevention and treatment using the
4. Detection and diagnosis of initial least invasive of approaches. This ‘rational’
caries lesions
model of care is known as minimal inter-
5. Atraumatic restorative treatment (ART) – a
minimum intervention and minimally vention dentistry and is applicable not only Fig. 1 The limitations of traditional dental
invasive approach for the management to cariology but to periodontology and all treatment
of dental caries
other areas of dentistry.1-3
6. Caries inhibition by resin infiltration
Studies conducted in France in the early
7. Minimally invasive operative caries
management ‑ rationale and techniques 2000s indicated that dental practitioners of restorations results in the restoration
This paper is adapted from: Featherstone J D B, Doméjean S. Le had not yet integrated this concept of increasing in size each time the restoration
concept d’intervention minimale en cariologie. De la dentisterie
restauratrice ‘compulsive’ aux stratégies thérapeutiques cariology into practise4-7 even though, is renewed, leading to eventual loss of the
raisonnées. Réalités Cliniques 2011; 22: 207–212.
since the 1990s, Elderton had already tooth.2,8,11,12 Figure 1 illustrates a patient,
denounced traditional approaches to con- aged 33 at the time of the photograph,
servative dentistry when considered in who has, judging by the number of endo-
Office of the Dean, Box 0430, 513 Parnassus Ave,
1*

University of California at San Francisco, San Francisco


isolation.8-10 Indeed, traditional oral care, dontic treatments present, been obliged to
CA 94143‑0430, USA; 2CHU Clermont-Ferrand, which comprises largely conservative/ visit the dentist on numerous occasions in
Service d’Odontologie, Hôtel-Dieu, F‑63001
Clermont-Ferrand, France
operative dentistry, including scaling and the past. The problem of oral hygiene has
*Correspondence to: Professor John D. B. Featherstone polishing, has very little impact on the oral not been resolved and, the caries process,
Email: John.Featherstone@ucsf.edu;
Tel: +01 415 476 1323
health of patients both in children and which is very aggressive, has not been
adults because the patient finds himself/ halted. Restorative and endodontic treat-
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2012.1007
herself caught in a repeat restoration spi- ment do not in themselves solve the prob-
© British Dental Journal 2012; 213: 441-445 ral of care, where successive replacement lems of oral health. The reasons for the

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


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

delay in adopting minimal intervention in rich in fermentable carbohydrates, coupled


routine dental practice are certainly many, with poor oral hygiene habits.
including lack of initial training and con- Secondary prevention aims at prevent-
Minimal
tinuous education of practitioners in this ing the disease from becoming established
subject area, lack of time and personnel for and progressing. This includes screening to intervention
its easy implementation in general prac- detect carious lesions at the earliest pos-
tice, lack of knowledge and appreciation sible stage so that appropriate treatment
of preventive and non-invasive therapeu- can be delivered. Minimally
tic strategies by the public authorities and Tertiary prevention, for its part, aims to invasive dentistry
their lack of incorporation into financial prevent recurrence of disease as well as the
Micro-dentistry
reimbursement schemes. Adapted from a failure of preventive and restorative care
series first published in French in Réalités initially implemented.
Cliniques, the BDJ offers a series of arti- The concept of minimal intervention is
cles on the general topic of minimal inter- based on all the factors that affect the onset Fig. 2 Diagram illustrating how minimal
intervention dentistry and minimal invasion
vention dentistry written by international and progression of disease and therefore (minimally invasive dentistry) are two terms
authors to help the dental practitioner integrates concepts of prevention, control that are not interchangeable. Minimally
integrate this concept into daily clinical and treatment. The field of minimal inter- invasive dentistry is actually a phase of
minimal intervention
practice. vention dentistry is wide, including the
detection of lesions as early as possible, the
WHAT ARE THE DIFFERENCES identification of risk factors (risk assess-
BETWEEN MINIMAL ment) and the implementation of preven-
INTERVENTION DENTISTRY, tive/control strategies and health education
MINIMALLY INVASIVE DENTISTRY, for the patient. When the effects of the
MICRO-DENTISTRY, ATRAUMATIC disease are present, in the form of a cari-
RESTORATIVE TREATMENT ous lesion, other therapeutic strategies are
AND SELECTIVE TISSUE required, but in this case the least invasive a
EXCAVATION AND HOW
solutions should be chosen for example,
SHOULD EACH BE DEFINED?
remineralisation, therapeutic sealants and
A primary source of confusion for practi- restorative care aimed at conserving the
tioners concerns the terminology used since maximum amount of dental tissue.
‘minimally invasive dentistry’ and ‘minimal
intervention dentistry’ are often used inter- Minimally invasive dentistry, ultra-
changeably although they describe different
conservative and micro-dentistry
concepts. This first section aims to define Minimally invasive dentistry, ultraconser- b
the terms most commonly used that are vative and micro-dentistry are terms that Figs 3a and b Photographs of multiple
associated with minimal intervention. embrace operative restorative approaches caries lesions and ART – prophylactic phase
that respect both the dental tissues and in the management of the caries process
Minimal intervention dentistry patient’s comfort. The excavation of den-
Minimal intervention dentistry is a concept tine caries is performed with the objective
of patient care that deals with the causes of preserving not only sound tooth tissue
of dental disease and not just the symp- but also that tissue which has the poten-
toms.1,13,14 Based on biological solutions tial to remineralise. The use of adhesive
rather than purely restorative, minimal biomaterials is preferred, for example,
intervention is based entirely on preven- resin composite of different viscosities
tion and control of oral disease. selected according to the clinical situation
Primary prevention focuses on prevent- and glass-ionomer cements, particularly
ing new cases of oral diseases. It uses collec- those of high viscosity.15 One should not
tive prevention measures such as artificial confuse minimal intervention dentistry Fig. 3c Photograph taken after first session
of ART
fluoridation of water or school oral health and minimally invasive dentistry since
programmes. At the individual level, pri- the latter is merely a component of the overall management of patient care where
mary prevention aims to prevent the early minimal intervention treatment (care) plan restorations are indicated only when the
colonisation of childrens’ teeth by cario- (Fig. 2). In traditional dentistry the prepa- lesion has advanced to frank cavitation
genic bacteria (for example, Streptococcus ration and restoration of cavities are the and where remineralisation techniques
mutans, one of the species associated only and systematic response to the pres- have reached their limits. Micro-dentistry
with the initiation of the caries process). ence of carious lesions. With a minimal is performed preferably using optical aids
Prevention also includes the management intervention approach, the placement of (magnification, microscopes, intra-oral
of other factors such as a cariogenic diet restorations is an ancillary phase of the cameras) and can also make use of more

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

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
Minimal patient.
Diagnostic Prophylaxis
phase intervention phase
MINIMAL INTERVENTION
DENTISTRY: BUILDING THE
TREATMENT (CARE) PLAN?
‘Rational’ clinical practice is based on
R e c a ll
four key elements:
1. Control of the disease by identifying
Restorative
and managing the risk factors
phase
2. The detection and remineralisation of
Fig. 4 The minimal intervention treatment (care) plan early lesions
3. Minimally invasive surgical
intervention
4. Where possible the repair rather
Risk than replacement of defective
predictors restorations.15,16
Clinically, a cariology-based care plan
comprises three main phases: the diagnos-
tic phase, the prophylactic phase and the
Protective (recall) monitoring phase (Fig. 4).
Pathological
factors
factors The diagnostic phase
The 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-
Fig. 5 Diagram of imbalance between protective factors, pathological factors and risk ence and activity) for the application
predictors existing in the case of high caries risk. Concept developed by J. D. B. Featherstone27-29
during the next phase, of non-invasive
therapeutic solutions.
sophisticated devices other than traditional sealing of adjacent pits and fissures. In The determination of caries risk of indi-
rotary instruments mounted on a contra- the case of ART, the restoration and seal- vidual patients is based on the identification
angle handpiece or air-turbine, such as ant are placed simultaneously using high- of the presence of pathological and protec-
chemo-mechanical, air-abrasion, sono- viscosity glass-ionomer cement. Initially, tive factors that affect the demineralisation
abrasion and laser systems. this approach was proposed for the man- and remineralisation process respectively
agement of patients in developing coun- but also on the identification of risk pre-
Atraumatic restorative treatment tries because it can be performed using dictors.17-19 Within the term ‘risk predictors’
(ART) only manual instruments. The excellent are grouped all those factors which, while
The atraumatic restorative treatment results from clinical studies suggest that being not directly related to the caries pro-
(ART) approach is part of the therapeutic it also has its applications in industrial- cess itself, have been shown in longitudinal
armamentarium of minimal intervention ised countries especially for patients with studies to be correlated with the appearance
dentistry and is minimally invasive. The multiple caries lesions during the stabi- of new lesions. The main risk predictors are
manual selective excavation of tissues lisation and motivation phase. Figure  3 past exposure to caries, the presence of cav-
destroyed by the caries process, involv- illustrates the prophylactic phase in the itated caries lesions or recent restorations
ing excavation of the infected dentine management of the caries process. This placed due to caries, as well as demographic
while conserving the affected dentine, patient consulted the dental department factors relating to the patient in terms of
is described in a separate article later in of the University Hospital of Clermont- age, level of education and disabilities
this series. A sealant restoration is then Ferrand for restoration of his teeth. Many that potentially expose the patient to risk
placed, which comprises a conventional open lesions can be observed as well as habits – a teenager with uncontrolled eat-
adhesive restoration combined with the the presence of abundant plaque. Brushing ing habits, the elderly where oral hygiene

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

is more difficult to maintain due to loss solution to manage the caries process. The authorisation of translation and publication of the
series in the BDJ, and Christopher Holmgren for his
of motor skills, education associated with restorative component is of course not assistance with the translation of the present article.
the level of care one takes of oneself and excluded, when required, from a minimal 1. Sheiham A. Minimal intervention in dental care.
harmful lifestyles, which expose people to intervention care plan, but has no effect on Med Princ Pract 2002; 11(Suppl 1): 2–6.
2. Elderton R J. Preventive (evidence-based) approach
situations of poor hygiene and failure to the aetiologic factors and is not an essential
to quality general dental care. Med Princ Pract
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Figure  5 illustrates the imbalance above. Restorative treatment is therefore 3. Bowley J. Minimal intervention prosthodontics: cur‑
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L, Tubert-Jeannin S. Caries management decision:
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6. Doméjean-Orliaguet S, Tubert-Jeannin S, Riordan
terbalance them in the implementation of and surveillance. It must follow a minimally P J, Espelid I, Tveit A B. French dentists’ restorative
measures tailored to the pathological fac- invasive approach, where caries removal/ treatment decisions. Oral Health Prev Dent 2004;
2: 125–131.
tors present for each clinical case. cavity preparation is delayed until there are 7. Tubert-Jeannin, S, Doméjean-Orliaguet S, Riordan
cavitated dentine lesions and through the P J, Espelid I, Tveit A B. Restorative treatment
strategies reported by French university teachers.
Prophylactic phase use of adhesive materials, these cavities can J Dent Educ 2004; 68: 1096–1103.
The second prophylactic phase aims to remain minimally invasive.13,15,16,33-37 Such 8. Elderton R J. Iatrogenesis in the treatment of dental
caries. Proc Finn Dent Soc 1992; 88: 25–32.
readjust the balance between pathological cavities are, by definition, conservative in 9. Elderton R J. Overtreatment with restorative
and protective factors. During this phase, design and there is no so-called ‘extension dentistry: when to intervene? Int Dent J 1993;
43: 17–24.
measures required to curb the phenomena for prevention’, although sometimes it might 10. Elderton R J, Mjör I A. Changing scene in cariology
of demineralisation and to initiate rem- be necessary to remove some sound tissue and operative dentistry. Int Dent J 1992;
42: 165–169.
ineralisation are implemented. Emphasis for example, reducing a weakened cusp 11. Sheiham A. Impact of dental treatment on the
is placed on recommendations relating to or making retentive features. In the case incidence of dental caries in children and adults.
Community Dent Oral Epidemiol 1997; 25: 104–112.
hygiene and dietary habits, antibacterial of lesions close to the pulp, the complete 12. Elderton R J. Clinical studies concerning re-
therapy, prescription of appropriate fluo- removal of all the carious dentine is now restoration of teeth. Adv Dent Res 1990; 4: 4–9.
13. Mount G J. A new paradigm for operative dentistry.
ride measures and the placement of pre- called into question since glass-ionomer Aust Dent J 2007; 52: 264–270.
ventive sealants. In the case of patients cements allow ion exchange leading to the 14. Featherstone J D. The science and practice of caries
prevention. J Am Dent Assoc 2000; 131: 887–899.
with cavitated lesions involving the den- remineralisation of demineralised tissue.38-44 15. Tyas M J, Anusavice K J, Frencken J E, Mount G J.
tine, atraumatic restorative care can com- Defective restorations are not systematically Minimal intervention dentistry ‑ a review. FDI
Commission Project 1–97. Int Dent J 2000;
plement the arsenal of prophylactic or removed and replaced. These radical solu- 50: 1–12.
partial excavation of caries. ART reduces tions need to be rethought and nuanced; 16. Mount G J, Ngo H. Minimal intervention: a new
concept for operative dentistry. Quintessence Int
the bacterial load, places a glass-ionomer polishing reduces the indications for the 2000; 31: 527–533.
cement restoration, eliminates the cavity complete replacement of the restoration, the 17. Beck J D. Risk revisited. Community Dent Oral
Epidemiol 1998; 26: 220–225.
responsible for retention of the plaque bio- margins of restorations can be sealed and 18. Stamm J W, Stewart P W, Bohannan H M, Disney
film and protects the dentine allowing the restorations can be repaired.15,45-48 J A, Graves R C, Abernathy J R. Risk assessment for
oral diseases. Adv Dent Res 1991; 5: 4–17.
patient to develop efficient oral hygiene. 19. Bader J D, Perrin N A, Maupomé G, Rush W A,
CONCLUSIONS Rindal B D. Exploring the contributions of
Follow-up monitoring High quality modern dentistry based on
components of caries risk assessment guidelines.
Community Dent Oral Epidemiol 2008;
and maintenance minimal intervention focuses on preven- 36: 357–362.
20. Tagliaferro E P, Pereira A C, Meneghim Mde C,
The third phase includes follow-up moni- tion and control of disease with operative Ambrosano G M. Assessment of dental caries pre‑
toring and maintenance. It concerns the dental interventions that are limited to the dictors in a seven-year longitudinal study. J Public
Health Dent 2006; 66: 169–173.
reinforcement of patient education, moni- absolute minimum.1 Ideally, care strategies 21. Tinanoff N. Dental caries risk assessment and
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22. Enjary C, Tubert-Jeannin S, Manevy R, Roger-Leroi
control measures implemented for example, tiveness, ‘does it work in dental practice?’ V, Riordan P J. Dental status and measures of dep‑
fluoride and preventive sealants, and thera- and efficiency, ‘is the cost–effectiveness rivation in Clermont-Ferrand, France. Community
Dent Oral Epidemiol 2006; 34: 363–371.
peutic measures for example, the integrity adequate?’ Although there is a growing 23. Azogui-Lévy S, Lombrail P, Riordan P J et al.
of therapeutic sealants and restorations. scientific evidence-base about the effec- Evaluation of a dental care program for school
beginners in a Paris suburb. Community Dent Oral
During follow-up visits, potential failures tiveness of minimal intervention dentistry, Epidemiol 2003; 31: 285–291.
can be intercepted and the recall interval it is nevertheless clear that the problem of 24. de Saint Pol T. La santé des plus pauvres. Insee
Premiere 2007; 1161.
adjusted based on new clinical findings and efficiency arises in the context of imple- 25. Haut Comité de la santé publique. La progression
the behaviour of the patient.30-32 mentation levels within current healthcare de la précarité en France et ses effets sur la santé.
Rennes: Haut Comité de la santé publique, 1998.
systems in different countries. 26. Powell L V. Caries prediction: a review of the litera‑
Restorations ture. Community Dent Oral Epidemiol 1998;
The authors would like to thank Claudie Damour- 26: 361–371.
The placement of restorations has long Terrasson, publishing director of the Groupe 27. Featherstone J D. The caries balance: contributing
been regarded, incorrectly, as the primary Information Dentaire, Paris France, for the factors and early detection. J Calif Dent Assoc 2003;

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31: 129–133. lesions. Quintessence Int 2000; 31: 535–546. 2006; 3: CD003808.
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© 2012 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Reviews the importance of caries risk
part 2. Caries risk assessment assessment in adults.

PRACTICE
• Demonstrates how risk assessment can
be incorporated in everyday clinical

in adults practice.
• Presents a clinical case report of a
patient with a moderate to high risk of
dental caries.
M. Fontana1 and C. Gonzalez-Cabezas2

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.

INTRODUCTION and efforts to remineralise non-cavitated add no value to the clinician or the patient.
Risk-based prevention and disease man- lesions with the prompt provision of pre- However, dental caries is unequally dis-
agement have been recognised as the ventive care in order to minimise operative tributed in most populations around the
cornerstones of modern caries manage- intervention. When operative interven- world, with a small percentage of individu-
ment1-3 and are essential components of tion is required unequivocally, typically als carrying the heavier burden of caries
the minimal (minimum) intervention (MI) for an active cavitated lesion, the proce- disease.7 For most dentists in private prac-
approach. MI stresses a preventive philoso- dure used should be as minimally inva- tice, it becomes imperative to be able to
phy with individualised risk assessment, sive as possible.4,5 This risk-based clinical identify a patient’s risk status in order to
accurate and early detection of lesions decision-making for caries management in be able to develop the most cost-effective
everyday clinical practice should be based treatment strategy for that individual. Due
on the best available evidence whilst tak- to the multifactorial nature of the caries
MINIMAL INTERVENTION
ing into account the dentist’s knowledge process, and the fact that the disease is
DENTISTRY
and expertise and focusing on the needs dynamic (for example, lesions can progress
1. From ‘compulsive’ restorative dentistry to and desires of the patient.6 and/or regress), studies on risk assessment
rational therapeutic strategies
Opponents of this strategy maintain tend to be complex, with a multitude of
2. Caries risk assessment in adults
that it is difficult to identify such patients variables challenging the prediction at
3. Paediatric dental care: prevention and
management protocols using caries risk accurately, and that even if we could, the different times during the life of an indi-
assessment for infants and young children evidence for preventive measures on high- vidual.8 Most studies on risk assessment
4. Detection and diagnosis of initial risk individuals is still not very strong. All have been conducted in children (see
caries lesions
of this is in part true; however, we contend later article in this BDJ series) and there
5. Atraumatic restorative treatment (ART) – a
minimum intervention and minimally that when the wellbeing of the patient is is very little evidence from adults or the
invasive approach for the management considered, it is more important to carry elderly to help guide practitioners on how
of dental caries
out a risk assessment incorporating the to apply risk assessment models to adult
6. Caries inhibition by resin infiltration
best available evidence than just doing populations.2,9
7. Minimally invasive operative caries
management: rationale and techniques nothing due to lack of strong evidence. Therefore, caries risk assessment should
This paper is adapted from: Featherstone J D B, Doméjean S. Le Others allege that similar preventive meas- be useful in the clinical management of
concept d’Intervention minimale en cariologie. De la dentisterie
restauratrice ‘compulsive’ aux stratégies thérapeutiques ures should be administered to the whole dental caries by helping to:
raisonnées. Réalités Cliniques 2011; 22: 207‑12.
population, regardless of the risk. However, • Determine lesion activity
for the current environment of increasing • Estimate the degree of risk so the
healthcare costs and resource constraints, intensity of the treatment (for
Associate Professor, Department of Cariology, Re-
1*-2

storative Sciences and Endodontics at the University of


targeted healthcare delivery has become example, fluoride concentration and
Michigan School of Dentistry, Michigan 48109, USA paramount, depending profoundly on risk delivery method) and frequency of
*Correspondence to: Margherita Fontana
Email: mfontan@umich.edu; Tel: +1 734 647 1225
assessment. If a clinician practices in an appointments can be customised
environment in which all patients have a • Identify the main aetiological agents
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2012.1008
similar risk of caries, then we agree that contributing to the current disease that
© British Dental Journal 2012; 213: 447-451 doing individual risk assessments would might be targeted in the management

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

of the disease (for example, diet control) over their lifetime and sometimes we are be attained easily from data obtained
• Establish the need for additional simply seeing the consequences of the dis- at periodic dental examinations and do
diagnostic procedures (for example, ease that occurred years ago. Nevertheless, not require additional testing routinely.
salivary flow rate/buffering as mentioned earlier, epidemiological stud- This is, of course, very encouraging for
measurements) ies have shown a positive strong correla- every day clinical practice
• Formulate the best restorative tion between past caries experience and • The fact that previous caries
treatment (care) plan for this patient future caries development, which is why experience is such a strong predictor
(for example, dental material selection) all available risk tools include this indicator is, from a disease management
• Enhance the overall prognosis of the very prominently. In adults, there is also perspective, a less than desirable
patient a clear association between coronal caries outcome, considering the fact that the
• Appraise the efficacy of the caries and the risk of developing root caries 14,15 disease is actually manifest before it
management plan established at recall It is important to assess not only cavi- can be accurately predicted, and the
visits. tated lesions, but non-cavitated lesions ultimate goal of caries management is
also. If lesions are present it is imperative to prevent disease in the first case
This paper reviews the importance of to decide whether they are likely active or • The fact that the existence of recent
caries risk assessment in adults as a pre- arrested, as this will influence the analysis restorations is one of the greatest
requisite for appropriate caries preventive of future risk. Presence of current activ- indicators of risk for the development
and treatment intervention decisions. ity would indicate a high likelihood that of new caries lesions only proves that
if conditions do not change, activity will the act of treating the caries lesion
RISK INDICATORS continue in the future. surgically does little to reduce the risk
Traditionally, caries disease indicators Another important aspect to take into of developing the next lesion9,13,17
have been defined as clinical observa- consideration is the site specificity of the • In a systematic review, Zero et al.
tions that tell about the past caries history disease. Caries lesions develop in areas concluded that for caries prediction in
and activity. They are indicators or clini- where dental plaque is stagnant for long permanent teeth in adults, past caries
cal signs that there is disease present or periods of time. For younger individuals, experience was the best predictor,
that there has been recent disease.1 These the occlusal surfaces of posterior teeth are followed by education and marital
indicators also include variables that say by far the areas more frequently affected status, probably because these factors
nothing about what caused the disease by the disease, but for older patients, influenced attitudes towards oral
or how to treat it, but that are related to however, this might not be the case. health9
disease experience (for example, socioeco- Frequently, older adults have very few or • It is very important to realise that the
nomic status, education). Caries experience no fissures without restorations in pos- assessment of all risk factors not only
is an illustration of an indicator that shows terior teeth reducing the risk of caries in allows a more complete assessment
how the host copes with the biological those high risk surfaces when restorations of future risk of disease, but most
activity.10 However, as before, others have in good condition are present. However, importantly identifies the aetiological
defined risk indicators as factors estab- restorations with significant defects will factors responsible for the disease in a
lished only in cross-sectional studies as accumulate significant amounts of plaque particular patient.2
being associated with the disease without biofilm, increasing the risk at that specific
any longitudinal validation.11 site. In these people, newly exposed root RISK FACTORS
surfaces and defective restorations need to Traditionally, a risk factor plays an essen-
Caries experience be carefully examined and have their risk tial role in the aetiology of the disease,
The strongest risk indicator is past caries for caries determined. while a risk indicator is indirectly associ-
experience and current lesion activity.8,12,13 ated with the disease. In other words, car-
As a predictor it is simple, inexpensive and Socio-demographic indicators ies risk factors are the biologic reasons, or
fast, as it requires a dental examination Although socioeconomic status is a factors, that have caused or contributed to
only. If approximal lesions are included in stronger predictor of caries risk in chil- the disease, or will contribute to its future
the risk analysis, then radiographs, espe- dren than in adults, it is still important in manifestation on the tooth (for example,
cially radiographic follow-up of existing adults 13,16 However, because dental caries bacteria, diet etc).8
lesions, would enhance the diagnosis. Past generally is more prevalent in lower than
caries experience summarises the cumula- higher socioeconomic classes, the dentist Genetics
tive effect of all risk factors and protective should consider the social environment Although this is the only factor that can-
factors to which an individual has been of the patient (for example, education, not be measured currently in clinical prac-
exposed over a lifetime. However, exposure income, occupation etc) as available to tice, it is important to highlight that even
to risk factors may change over a lifetime, him/her through the medical history, in when there is still much to learn about
and this affects the predictive power of this the analysis of caries risk. the genetic-environmental relationships
indicator making it less than 100% accu- in dental caries aetiology and risk assess-
rate. Risk factors that lead to the patient’s Notes ment, the amount of evidence relating to
past caries experience might have changed • The best indicators of caries risk can genes and caries experience has increased

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

significantly in the last decade. As ‘is your mouth dry?’ are not predictive at captured the greatest interest among
reviewed recently by Wright, genes have all, since most people have dry mouths in researchers and clinicians. There is
been identified linking tooth development, the mornings due to the normal decrease great controversy in the literature
salivary function and diet/taste to caries in salivary flow rate which occurs during regarding the accuracy of salivary
risk or protection.18 This is very important sleep. tests for mutans streptococci and
because as the understanding of genet- Many current medications (for example, lactobacilli in predicting future caries
ics associated with caries risk increase, so psycho-pharmaceutical products) reduce in adults.13 Several tests exist in the
does the future possibility of using sali- the flow rate of saliva in a percentage of market to measure salivary bacteria
vary diagnostics based on genetic scans to the population using them, and there- based on culturing. These tests have
develop either better risk assessment tools fore may affect their caries risk. Also, disadvantages because they require
or to better target specific interventions certain diseases, especially those related incubators, many enumerate bacteria
that would improve the oral and general to decreases in salivary flow rate, such in saliva only (not in plaque), and in
health of at-risk populations. as Sjögren’s syndrome and uncontrolled general they correlate poorly in adults
diabetes, can increase the risk of caries. with future caries risk. However, they
Saliva may be useful to motivate and monitor
It is well established that saliva plays an Bacteria oral hygiene, assess the effectiveness
important role in the health of soft and Dental caries is a microbial disease in of oral antimicrobials and monitor
hard tissues in the oral cavity. Dentists which the aetiological agents are normal dietary changes.
can assess several salivary parameters as constituents of the dental plaque bio-
related to caries risk, but the most common film that cause problems only when their Newer tests are available that measure
ones include salivary flow rate, buffering pathogenicity and proportions change in site-specific plaque pH, or measure bacte-
capacity and pH. Chronically low salivary response to environmental conditions. rial load using either monoclonal antibod-
flow rate (that is, true hypo-salivation) It is clear that without any plaque bio- ies, or responses to ATP bioluminescence
has been found to be one of the strongest film there would be no caries. However, and although useful for patient education,
salivary indicators for an increased risk of most patients do not remove plaque effec- many of these have not been validated
dental caries.19 Apart from this scenario, tively from areas at high risk. The principle longitudinally yet for risk assessment.
the caries prediction of saliva parameters is of microbial testing in clinical practice is
modest to low, and thus hard to justify rou- the thought that people with high numbers Diet
tinely in dental practice for every patient. of cariogenic bacteria are at higher risk Sugar exposure is an important aetiologi-
Oral complications as a result of sali- for developing future lesions and, as such, cal factor in caries development. Due to
vary gland hypofunction include altered should be treated, however: the wide use of fluoride and its effect in
oral sensations, taste dysfunction, mucosal • Most plaque indices are ineffective lowering the incidence and rate of caries,
dryness resulting in infection and tooth predictors of future caries because it is difficult to show a strong, clear-cut,
wear due to abrasion, among other factors. dental caries typically develops in positive association between a person’s
Pain and diminished quality of life are also fissures and interproximal areas, while total sugar consumption and his/her car-
common complaints associated with sali- most plaque indices were developed ies development. Thus, for example, self-
vary hypofunction.20 Many dentists tend to evaluate periodontal disease or reported sugar intake seems to have little
to rely on the complaint of dry mouth or gingivitis based on smooth surface value at identifying, by itself, patients at
xerostomia to diagnose hyposalivation. scores risk. However, diet is one of the main driv-
Unfortunately, subjective complaint of • To solely evaluate the effectiveness ers of caries activity, and recognising the
xerostomia often does not correlate with of mechanical cleaning is difficult behaviours that are placing the patient at
objective findings of reduced salivary flow because tooth brushing usually risk may be very important for caries pre-
rate. Fox et al.21 recommended that den- involves a dentifrice with fluoride. vention and management.22
tal care professionals ask their patients However, it is known that any Other dietary considerations include the
the following questions: does your mouth conditions that compromise the retentiveness of the food, frequency of con-
feel dry when eating a meal? Do you sip long-term maintenance of good oral sumption (this being the most important),
liquids to aid swallowing dry foods? Do hygiene, and for which the patient has consumption between meals, the presence
you have difficulty swallowing any foods? not been able to show the ability to of protective factors in foods (for example,
Does the amount of saliva in your mouth maintain plaque-free, are positively calcium, fluoride) and the type of carbohy-
seem to be too little, too much or do you associated with caries risk drate. Although sugar in liquid form (for
not notice it? A positive answer to any of • Salivary bacterial tests have existed example, soft drinks) is less cariogenic than
these questions should prompt considera- for several years and are based on the sugar in solid form (for example, sweets),
tion as to how long the patient has expe- premise that saliva levels represent excessive frequent consumption of soft
rienced the problem, whether or not an levels in the oral biofilm. As one drinks remains a major risk factor that
increased caries experience has resulted of the primary aetiologic agents of may be partly responsible for the high rate
and lead to an objective measurement of dental caries, mutans streptococci of caries in teenagers and young adults in
salivary flow rate. Other questions, such as and lactobacilli historically have many parts of the world. As a reminder,

BRITISH DENTAL JOURNAL VOLUME 213 NO. 9 NOV 10 2012 449


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

starches are considered less cariogenic than periodic professional fluoride exposures.
the simple sugars sucrose, glucose and fruc- The dentist should then determine if this
tose, with sucrose possibly being the most history/pattern of fluoride exposure has
cariogenic due to its unique role in the pro- arrested the appearance or progression
duction of extracellular polysaccharides. of carious lesions (incipient or cavitated)
over time. If new lesions have appeared or
Others existing lesions have progressed, then the
Mental and/or physical disabilities that patient’s fluoride exposure is inadequate.
affect regular oral hygiene or which As the risk is increased, so should be the
require a more frequent carbohydrate- level of fluoride exposure, both at home
enriched diet also may affect the individu- and in office.2,24 In addition, fluoride use
al’s risk. Additionally, enamel defects, such should be individually determined for each
as hypoplasia, have also been related to patient based on age, physical abilities,
increase caries risk, especially in children. health awareness and attitude.

PROTECTIVE FACTORS CASE REPORT


Caries protective factors are biologic or For the patient presented in the following
therapeutic factors/measures that can col- case report (Figs 1-3) it is not necessary
lectively offset the challenge presented by to complete a complicated and long risk
caries risk factors. The more severe the risk assessment form or to measure risk factors
factors, the higher the protective factors using chair-side bacterial or salivary tests
need to be to keep the patient in balance available in the market to determine that Figs 1-3 Clinical photographs presenting
patient with a moderate to high risk of
or to reverse the caries process. the patient is at elevated risk for dental car- dental caries
We recommend that risk assessment in ies. The presence of clear clinical signs of
adults include an analysis of risk indica- disease activity (presence of active caries
tors, risk factors and protective factors. lesions) can be used to help predict a higher symptoms of salivary dysfunction. None
To determine the risk status of a patient risk of future disease progression. But, what of the conditions, which could affect the
we must balance the presence of risk fac- if there had not been any signs of active dis- salivary flow rate, such as Sjögren’s syn-
tors that the patient currently has, plus ease? Does this mean the risk of developing drome, uncontrolled diabetes or medica-
risk indicators of past and current disease caries lesions in the next few years is low? tions, were present in the patient described.
history and weigh that against the protec-
tive factors that the patient is exposed to.1 Risk indicators Bacteria
Although the clinician should analyse all Caries experience This patient presented mature, stagnant
protective factors the patient is exposed plaque around most cervical and inter-
to, of great importance is the exposure to Caries experience has been high and there proximal areas, with gingivitis associated
fluorides. The widespread use of fluoride are numerous lesions present that appear with it. This clinical observation suggests
has reduced dramatically the prevalence of active; therefore, we should classify this these are risk areas for caries development
dental caries and the rate of the progression patient, as explained later on, as moderate in this patient.
of carious lesions.23 Its use, which should be to high risk. Although this information is
considered one of the most important pro- helpful, we still do not know the specific Diet
tective factors when assessing a patient’s reasons behind the caries experience of When initially questioned, the patient did
caries risk, allows more conservative man- this patient. not think she had a high sugar-rich diet.
agement strategies for the prevention and However, her active lesions suggested
treatment of dental caries. The frequency of Socio-demographic indicators there must be a current dietary factor in
fluoride exposure is one of the most impor- The patient is female, 63 years old, of lower play. Upon closer examination, she admit-
tant considerations when considering its middle class, divorced, living independently ted to drink very frequently throughout
use as a management and preventive strat- for the last seven years, but under a lot of the day coffee with sugar, usually with a
egy to control dental caries. This is because financial stress. Although none of these fac- cookie or two. Although not an unusual
the main mechanism by which fluoride tors are a strong predictor of her future risk, behaviour for some people, the combina-
prevents against caries is by enhancing they point to an environment which may tion of this habit with presence of stagnant
remineralisation. When does remineralisa- be conducive, for example, to difficulty mature plaque and lack of protective fac-
tion need to happen? Every time there is accessing care as frequently as needed. tors (discussed next) increases the risk of
demineralisation. The dental care profes- the patient.
sional should consider all fluoride sources Risk factors
to which the patient is exposed, for exam- Protective factors
Saliva
ple, fluoridated drinking water, foods/ The patient used to brush twice a day with
drinks, home topical fluoride products and In the present case, there were no signs or a dentifrice with fluoride; however, since

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


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

her divorce seven years ago she is brushing adopt treatments based on assessment of 10. Bratthall D, Hänsel Petersson G. Cariogram – a mul-
tifactorial risk assessment model for a multifacto-
less than once a day. In addition, she has caries-risk.26 Another practice-based study rial disease. Community Dent Oral Epidemiol 2005;
received no in-office fluoride treatments showed that in France decision-making in 33: 256–264.
11. Burt B A. Definitions of risk. J Dent Educ 2001;
over the last two  decades. Even though caries management does not only depend 65: 1007–1008.
she may have had an appropriate level of on pathophysiology.27 Thus, a more objec- 12. Powell L V. Caries prediction: A review of the litera-
ture. Community Dent Oral Epidemiol 1998;
fluoride exposure at one time, currently tive, easy to implement, and validated risk 26: 361–371.
this level is not enough to balance out the assessment instrument is desirable and this 13. National Institutes of Health (US). Diagnosis and
management of dental caries throughout life. NIH
plaque and dietary factors she is being is reflected in the multiple risk assessment Consensus Statement 2001; 18: 1–23.
14. Ritter A V, Shugars D A, Bader J D. Root caries
challenged with. tools that have been developed during the risk indicators: a systematic review of risk models.
last few years. Examples for adults include Community Dent Oral Epidemiol 2010;
Re-evaluation the American Dental Association’s caries 38: 383–397.
15. Sánchez-García S, Reyes-Morales H, Juárez-Cedillo
In order to provide frequent counselling risk tool for adults,28 the caries manage- T, Espinel-Bermúdez C, Solórzano-Santos F, García-
Peña C. A prediction model for root caries in an
and exposure to in–office fluoride, the ment by risk assessment (CAMBRA) tool elderly population. Community Dent Oral Epidemiol
recall interval was set at four months. for adults,29 and the cariogram.30–32 2011; 39: 44–52.
16. Jamieson L M, Mejía G C, Slade G D, Roberts-
Risk assessment is an essential compo- Thomson K F. Predictors of untreated dental decay
CONCLUSIONS nent of clinical practice for caries manage- among 15‑34‑year-old Australians. Community
Dent Oral Epidemiol 2009; 37: 27–34.
Considering the current understanding of ment. Most of the information needed is 17. Fejerskov O. Changing paradigms in concepts on
the caries disease process, we propose the readily available in a properly done health/ dental caries: consequences for oral health care.
Caries Res 2004; 38: 182–191.
following factors, whether appearing singly dental history and a clinical examination, 18. Wright J T. Defining the contribution of genetics
or in combination, would yield a moderate with the subjective impression of the clini- in the etiology of dental caries. J Dent Res 2010;
89: 1173–1174.
to high risk assessment of caries (as in the cian having been shown to be very use- 19. Leone C W, Oppenheim F G. Physical and chemical
case presented in this paper): the develop- ful. Most of the risk indicators or factors aspects of saliva as indicators of risk for dental car-
ies in humans. J Dent Educ 2001; 65: 1054–1062.
ment of new caries lesions, the presence provide (either by themselves or combined) 20. Navazesh M. Salivary gland hypofunction in elderly
patients. J Calif Dent Assoc 1994; 22: 62–68.
of active lesions and the placement of res- only a modest possibility of accurately 21. Fox P C, van der Ven P F, Sonies B C, Weiffenbach
torations due to active disease since the predicting adults at future risk. However, J M, Baum B J. Xerostomia: evaluation of a symp-
tom with increasing significance. J Am Dent Assoc
patient’s last examination (assuming a one even with these limitations risk assess- 1985; 110: 519–525.
to two-year lapse between the previous and ment can enhance patient care. The most 22. Zero D T. Sugars – the arch criminal? Caries Res
2004; 38: 277–285.
current appointment). Finally, of greatest important factor in predicting future risk 23. Centers for Disease Control and Prevention.
importance is that for moderate and high is recent caries experience and current dis- Recommendations for using fluoride to prevent
and control dental caries in the United States. CDC,
risk individuals; once you have determined ease activity. However, a careful analysis 2001. Online article available at http://www.cdc.
they are at risk and have identified the of all risk and protective factors will allow gov/mmwr/preview/mmwrhtml/rr5014a1.htm
(accessed October 2012).
reasons why, the dental team then has to the dental team and patient to understand 24. American Dental Association Council on Scientific
decide what is the simplest and most likely the specific reasons for the caries disease Affairs. Professionally applied topical fluoride:
evidence-based clinical recommendations. J Am
successful strategy, both from the biologi- and thus will allow them to tailor the treat- Dent Assoc 2006; 137: 1151–1159.
cal and behavioural perspective, for man- ment plan and recall interval specifically 25. Disney J A, Graves R C, Stamm J W, Bohannan H M,
Abernathy J R, Zack D D. The University of North
aging the caries disease in that particular to the patient’s needs. Carolina Caries Risk Assessment study: further
developments in caries risk prediction. Community
patient. This includes a decision of both The authors would like to thank Claudie Damour- Dent Oral Epidemiol 1992; 20: 64–75.
preventive and restorative approaches. Terrasson, publishing director of the Groupe 26. Riley J L 3rd, Gordan V V, Rindal D B et al.
Information Dentaire, Paris France, for the autorisa- Preferences for caries prevention agents in adult
We also propose that a low caries risk tion of translation and publication of the series in the patients: findings from the dental practice–based
assessment be based on the following fac- BDJ and Dr Sanjay Karunagaran for kindly provid- research network. Community Dent Oral Epidemiol
ing the clinical pictures used in the present article. 2010; 38: 360–370.
tors: no caries lesion development or pro- 27. Doméjean-Orliaguet S, Léger S, Auclair C, Gerbaud
gression for a period of one to three years; 1. Featherstone J D. The caries balance: contributing L, Tubert-Jeannin S. Caries management decision:
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amount of plaque accumulation; frequency 31: 129–133. vision of dental services. J Dent 2009; 37: 827–834.
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J Am Dent Assoc 2006; 137: 1231–1249. (patients over 6 years). ADA, 2008. Online form
salivary problems; behavioural or physi- 3. Featherstone J D. The science and practice of caries available at http://www.ada.org/sections/profes-
cal disability changes; history of fluoride prevention. J Am Dent Assoc 2000; 131: 887–899. sionalResources/pdfs/topic_caries_over6.pdf
4. Fontana M, Young D A, Wolff M S, Pitts N B, (accessed October 2012).
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A dentist’s overall subjective impres- beyond. Dent Clin North Am 2010; 54: 423–440. L, Wolff M, Young D A. Caries risk assessment in
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sion of the patient has a relatively good Int Dent J 1999; 49: 15–26. 2007; 35: 703–707, 710–713.
6. American Dental Association. Policy of evi- 30. Fure S, Zickert I. Incidence of tooth loss and
predictive value for caries risk,25 but it is dental caries in 60‑, 70‑and 80‑year‑old Swedish
dence based dentistry. USA: ADA, 2008. Online
unclear how this information is incor- article available at http://www.Ada.Org/1754.Aspx individuals. Community Dent Oral Epidemiol 1997;
(accessed October 2012). 25: 137–142.
porated into everyday clinical practice. 31. Hänsel Petersson G, Fure S, Bratthall D. Evaluation
7. Edelstein B L. The dental caries pandemic and dispari-
Recent concepts in caries management ties problem. BMC Oral Health 2006; 6(Suppl 1): S2. of a computer-based caries risk assessment
8. Twetman S, Fontana M. Patient caries risk assess- program in an elderly group of individuals. Acta
have not been largely accepted: a recent ment. Monogr Oral Sci 2009; 21: 91–101. Odontol Scand 2003; 61: 164–171.
survey of clinical practices within a U.S. 9. Zero D, Fontana M, Lennon A M. Clinical applica- 32. Ruiz Miravet A, Montiel Company J M, Almerich
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practice-based research network suggests caries management. J Dent Educ 2001; population. Med Oral Patol Oral Cir Bucal. 2007;
that a significant proportion had yet to 65: 1126–1132. 12: E412‑E418.

BRITISH DENTAL JOURNAL VOLUME 213 NO. 9 NOV 10 2012 451


© 2012 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Examines the problem of early childhood
part 3. Paediatric dental care – caries and how it can be minimised.

PRACTICE
• Informs caries is a transmissible,
infectious disease, which can be passed

prevention and management from mother to child.


• Stresses the importance of risk
assessment and preventive dentistry in

protocols using caries risk paediatric healthcare.

assessment for infants


and young children
F. J. Ramos-Gomez,1 Y. O. Crystal,2 S. Domejean3 and J. D. B. Featherstone4

VERIFIABLE CPD PAPER

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.

MINIMAL INTERVENTION INTRODUCTION accurate identification of children at risk is


DENTISTRY Despite progress made in caries control of great importance for cost-effective car-
1. From ‘compulsive’ restorative dentistry to worldwide by the protective effects of ies control. Signs of ECC can be detected
rational therapeutic strategies fluoride, increased dissemination of oral soon after the eruption of the first tooth.
2. Caries risk assessment in adults hygiene information and widespread If risk indicators are identified early and
3. Paediatric dental care – prevention and healthy diet education, dental caries still oral health preventive practices are imple-
management protocols using caries risk
assessment for infants and young children remains the most common chronic child- mented at a young age, the disease can
4. Detection and diagnosis of initial hood disease. Consequently, it is a major be controlled and its progression slowed.
caries lesions financial burden on society in many coun- In the USA, the American Dental
5. Atraumatic restorative treatment (ART) –  tries throughout the world. In recent years, Association (ADA), the American Academy
a minimum intervention and minimally
invasive approach for the management reports show that caries in the primary of Paediatric Dentistry (AAPD), the
of dental caries dentition has been increasing in the USA, American Academy of Paediatrics (AAP),
6. Caries inhibition by resin infiltration UK, Canada, Australia, the Netherlands the American Association of Public Health
7. Minimally invasive operative caries and other countries.1-8 Dentistry (AAPHD) and the Academy of
management – rationale and techniques
This paper is adapted from: Ramos-Gomez F J, Crystal Y O,
Early childhood caries (ECC) is more General Dentistry (AGD) all recommend
Doméjean S, Featherstone J D B. Odontologie pédiatrique. prevalent among young children from that a child should see a dentist and estab-
Prévention et prise en charge de la maladie carieuse basées
sur l’évaluation du risque pour les jeunes enfants. Réalités low socioeconomic, ethnic minority popu- lish a ‘dental home’ by one year of age or
Cliniques 2011; 22 (3): 221–232.
lations.9 This uneven distribution occurs when the first tooth erupts.12-16 A dental
in many developed countries with 25% of home is defined as the ongoing relationship
University of California, Los Angeles, USA; 2New-
1*
children bearing 75% of the affected sur- between the dentist and the patient where
York University, USA; 3CHU Clermont-Ferrand, Service
d’Odontologie, Hôtel-Dieu, F‑63,001 Clermont-Ferrand,
faces. Dental caries is a preventable and accessible and coordinated oral healthcare
France; 4University of California, San Francisco, USA transmissible infectious disease; it is well can be delivered comprehensively while
*Correspondence to: Francisco Ramos-Gomez
Email: frg@dentistry.ucla.edu; Tel: +1 310 825 9460
documented that the presence of caries in actively involving family participation.17
the primary dentition is one of the best Despite the widespread advocacy of a
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2012.1040
indicators for future caries in the per- ‘medical’ and a ‘dental home’ by age one,
© British Dental Journal 2012; 213: 501-508 manent dentition.10,11 Thus, the early and infant oral health visits have not yet been

BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012 501


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

embraced universally by practicing clini-


Table 1 CAMBRA for dental providers (0‑5 years) assessment tool**
cians. Many paediatricians are unaware of
current oral health evidence–based proto- Biological factors High risk Moderate Protective
cols and recommendations and refer chil- factors risk factors factors
dren only when there is clinical evidence Mother/primary caregiver has active caries Yes
of established dental disease. Since family
Parent/caregiver has low socioeconomic status Yes
physicians and paediatricians often see
children up to six  times before age two, Child has >3 between meal sugar containing snacks
Yes
it is crucial to take these appointments or beverages per day

as opportunities to increase awareness of Child is put to bed with a bottle containing any sugar Yes
oral health evaluations and screen young
Child has special health care needs Yes
children for caries risk and refer for dental
care.18 However, general dentists have to Child is a recent immigrant Yes
be prepared to accept these young children Protective Factors
for their first dental visit’s evaluation and
Child receives optimally fluoridated drinking water or
treatment. This article presents an updated, Yes
fluoride supplements
simple and systematic six-step protocol for
Child has teeth brushed daily with fluoridated toothpaste Yes
an infant oral examination that will ease
implementation of early visits into dental Child receives topical fluoride from health professional Yes
practice.19 Due to the infectious and trans- Child has dental home/regular dental care Yes
missible nature of dental caries, the first
Primary caregiver uses xylitol chewing gum/lozenges Yes
step in preventing the development of ECC
is to provide perinatal oral healthcare to Clinical Findings
expectant mothers as soon as possible. Child has more than one dmfs Yes

PERINATAL ORAL HEALTH Child has active white spot lesions or enamel defects Yes

Caries is a transmissible, infectious disease. Child has elevated mutans streptococci Yes
If this disease keeps progressing, surface Child has plaque on teeth Yes
cavitation and destruction of dental tis-
Overall assessment of the child’s dental caries risk: High Moderate Low
sue worsens over time. The mutans strep- **Modified from Ramos-Gomez et al. CDA Journal 2007; 35: 687‑702; and ADA caries risk assessment forms available at http://www.ada.org/
tococci (MS) group of bacteria (primarily sections/professionalResources/pdfs/topic_caries_over6.pdf (accessed October 2012). Copyright 2007/2010 California Dental Association.
Reprinted with permission
streptococcus mutans and streptococcus
sobrinus) are key pathogens in the caries
process, due to their ability to adhere to Dental professionals are beginning ideas that would improve their offspring’s
smooth tooth surfaces and produce acid.20 to recognise the essential role a mother oral health,25 making this the best ‘win-
Generally, colonisation of MS in the oral plays in ensuring her child’s oral health. dow of opportunity’ for preventive care.
cavity of children is the result of transmis- Improving expectant mothers’ oral health Therefore, dental, medical and obstetric
sion of these organisms from the child’s by reducing pathogenic bacteria levels in providers have the prime opportunity to
primary caregiver.21 A direct relationship their own mouths, will delay the acqui- educate mothers with positive reinforce-
exists between MS levels in adult caregiv- sition of oral bacteria and the develop- ment and effective behavioural changes
ers and that of caries prevalence in their ment of ECC in their children.20 Restoring that could affect significantly their chil-
children.22 Factors influencing colonisa- carious lesions, by itself, is insufficient to dren’s future oral health.
tion include frequent sugar exposure in reduce a mother’s risk of transmitting cari-
the infants and habits that allowed salivary ogenic bacteria to her offspring. An effec- INITIAL INFANT ORAL CARE VISIT
transfer from mother/caregiver to infants. tive perinatal program should institute Infants and parents (caregivers) will benefit
Maternal factors, such as high levels of MS, practices such as therapeutic interventions from an early infant oral health visit and
poor oral hygiene, low socioeconomic sta- and lifestyle modification counselling both the establishment of a ‘dental home’. An
tus and frequent snacking increase the risk during pre- and post-partum to reduce infant oral health visit should include caries
of bacterial transmission to her infant.23 maternal MS and lactobacilli levels.24 risk assessment, individualised preventive
Infants have been identified with high lev- Unfortunately, pregnant women often do strategies and anticipatory guidance.26,27
els of MS in their mouths even before the not receive oral healthcare and education Establishing periodicity supervision of care
eruption of the first tooth.19 Therefore, it in a timely manner. Many women do not intervals and age-appropriate ‘care paths’
is critical to consider an infant oral care know they should seek dental care dur- is determined based on the risk of disease
programme in the context of a participat- ing their pregnancy. Of those who do, they of each individual patient.28 Infants and
ing pair or mother-and-child dyad, which often encounter dentists unwilling to pro- toddlers are not expected to be coopera-
includes comprehensive maternal perinatal vide care to pregnant mothers. New moth- tive during an oral examination; crying
oral healthcare, counselling and treatment. ers are also more likely to be receptive to and movement are common responses.

502 BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012


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PRACTICE

Explaining to the caregivers exactly what Clinical disease indicators from oral
to expect during this visit and engaging examinations are used to diagnose car-
them to participate may allay some of their ies. These include cavitated carious
fears and concerns. lesions, white spot lesions/decalcifications
An infant oral health visit consists of a observed visually or by radiographs and
six-step protocol: recent restorations. However, these physi-
1. Caries risk assessment cal manifestations of caries do not tell us
2. Proper positioning of the child why the disease is present (Fig. 1). In the
(knee-to-knee exam) three clinical cases presented in Figure 1, Fig. 1a Carious lesions at different clinical
3. Age appropriate tooth brushing the clinical signs (carious lesions at differ- stages: child, 18 months old, with advanced
cavitated lesions
prophylaxis ent clinical stages) indicate the presence
4. Clinical examination of the child’s of active carious processes. The caries risk
oral cavity and dentition assessment and the determination of the
5. Fluoride varnish treatment pathological factors, in particular, will
6. Assignment of risk, anticipatory guide the decision-making and the cus-
guidance and counselling. tomisation of the therapeutic and the pre-
vention strategies, specific to each patient.
Caries risk assessment Biological risk factors, also known as
An individualised risk assessment of an pathological factors, include presence of Fig. 1b Child, three years old, with
infant or toddler for developing caries plaque, gingival bleeding (an indicator of cavitated lesions localised on the buccal
surfaces of the anterior maxillary teeth
serves as the foundation for healthcare dense plaque), low pH and dry mouth. Any
providers and parents/caregivers to iden- of these recorded indicators can be then
tify and understand the child’s ECC risk combined with the data from the inter-
factors. A systematic assessment of car- view to determine the risk for that patient
ies risk serves as a guide for dentists to (Fig. 2). In older children, the presence of
design treatment and preventive protocols dental or orthodontic appliances increases
for children already with disease and those plaque retention and the risk for caries.
deemed at risk. For optimal outcomes, Protective factors, which are indicators
Fig. 1c Child, three years old, with cervical
caries risk assessment should be done as that may reduce a child’s risk for ECC, can white spot lesions (reversible enamel
early as possible, and preferably before also be assessed during the interview with lesions) localised on the canines and
the onset of the disease process. Due to the parent. These factors include optimal posterior teeth
the fact that caries in the primary denti- exposure to fluoride, access to regular
tion is a strong predictor of caries in the dental care (for example, the presence of
permanent dentition, caries risk assess- a dental home), consistent brushing with
ment and management is crucial, as is the fluoride toothpaste, use of fluoridated tap
subsequent follow-up.29,30 The caries bal- water and xylitol among other combina-
ance concept states that the progression or tion therapy.
reversal of dental caries is determined by
the balance between pathological factors Proper positioning
and caries protective factors.31-33 Risk fac- Proper positioning of the child is critical to
tors are determined from an interview with conducting an effective and efficient clini-
the parent and from a clinical assessment cal exam in a young child. In general, the
Fig. 2 Biological risk factors. Three-year-old
of the child (Table 1). knee-to-knee position should be used with child, with high caries risk. Presence of visible
During the interview with the parent/ children aged six months to three years, or dental plaque, gingival bleeding and cervical
caregiver, the assessment should explore up to age five with children who have spe- white spots lesions on the posterior teeth
biological and lifestyle risk factors that cial healthcare needs. Children older than
contribute to the development or progres- three years may be able to sit forward on
sion of caries. Examples of risk factors their caregiver’s lap or sit alone in a chair.
include recently placed dental restora- Examiners and caregivers need to work
tions in the mother, low socioeconomic together to transition the child smoothly
status of the family, low health literacy from the interview to the exam (Fig. 3).
of caregiver, the child’s frequent intake The clinician should explain what will
of fermentable carbohydrates, sleep- happen (tell, show and do) before starting,
ing with a bottle that contains liquids and anticipate that young children may
other than water and prolonged use of cry since crying is developmentally appro-
a ‘sippy cup’ containing milk, juice or a priate for children of this age. Knee-to-
sweetened beverage. knee positioning allows the child to see the Fig. 3 The knee-to-knee position

BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012 503


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

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

Risk category Diagnostic Preventive intervention 


 
(ages 0 to
Xylitol
2 years) Periodic oral exams Radiographs Saliva test Fluoride

Low Annual Posterior bitewings at 12‑24 month Optional baseline In office: no


intervals if proximal surfaces cannot Home: brush twice a day w/ smear of F Not required
be examined visually or with a probe toothpaste

Moderate Every six months Posterior bitewings at 6‑12 month Recommended In office: F varnish initial visit & recalls Child: xylitol wipes
intervals if proximal surfaces cannot Home: Brush twice a day w/smear of F Caregiver: two sticks of gum
be examined visually or with a probe toothpaste or two mints four times a day
Caregiver: OTC sodium fluoride treat-
ment rinses

Moderate; Every three to six months Posterior bitewings at 6‑12 month Required In office: F varnish initial visit & recalls Child: xylitol wipes
non-compliant intervals if proximal surfaces cannot Home: Brush twice a day w/smear of Caregiver: two sticks of gum
be examined visually or with a probe F toothpaste combined w/smear of or two mints four times a day
900 ppm calcium- phosphate paste
leave-on at bedtime Caregiver: OTC
sodium fluoride treatment rinses

High Every three months Anterior (#2 occlusal film) and Required In office: F varnish initial visit & recalls Child: xylitol wipes
posterior bitewings at 6‑12 month Home: Brush twice a day w/smear of Caregiver: two sticks of gum
intervals if proximal surfaces cannot F toothpaste combined w/smear of or two mints four times a day
be examined visually or with a probe 900 ppm calcium- phosphate paste
leave-on at bedtime Caregiver: OTC
sodium fluoride treatment rinses

High; Every one to three months Anterior (#2 occlusal film) and Required In office: F varnish initial visit & recalls Child: xylitol wipes
non-compliant posterior bitewings at 6‑12 month Home: Brush twice a day w/smear of Caregiver: two sticks of gum
intervals if proximal surfaces cannot F toothpaste combined w/smear of or two mints four times a day
be examined visually or with a probe 900 ppm calcium- phosphate paste
leave-on at bedtime Caregiver: OTC
sodium fluoride treatment rinses

Extreme Every one to three months Anterior (#2 occlusal film) and Required In office: F varnish initial visit and recalls Child: xylitol wipes
posterior bitewings at 6‑12 month Home: Brush twice a day w/smear of Caregiver: two sticks of gum
intervals if proximal surfaces cannot F toothpaste combined w/smear of or two mints four times a day
be examined visually or with a probe 900 ppm calcium- phosphate paste
leave-on at bedtime Caregiver: OTC
sodium fluoride treatment rinses

parent throughout the exam. It also allows at least twice a day, especially before bed- risk and establish an oral diagnosis and
the parent/caregiver to observe clini- time. The use of fluoride toothpaste should formulate an individualised care (treat-
cal findings and hygiene demonstrations be emphasised since fluoride has been ment) plan.
directly, while gently helping to stabilise shown to be effective topically to prevent The following information should be
the child safely for the clinical examina- caries. Parents and caregivers should be documented:
tion. If the child can perceive a friendly instructed to use a ‘pea-sized’ amount of • Visible plaque and its location
and comfortable interaction between the fluoride toothpaste for children age two • White spot lesions
clinician and caretaker, he or she will be to six and a ‘smear’ for children under • Brown spots that on the occlusal
more likely to cooperate and result in a age two.34,35 surfaces may indicate caries
smoother examination. • Tooth defects, deep pits/fissures,
Clinical examination tooth anomalies
Toothbrush prophylaxis The examiner ‘counts’ the child’s teeth • Missing and decayed teeth
Toothbrush prophylaxis is efficient in aloud, using the toothbrush handle as a • Existing restorations
removing plaque in most young children. mouth prop if necessary. Many providers • Defective restorations
It is non-threatening to young children make a game of this task, singing songs, • Gingivitis or other soft
and serves to demonstrate the proper engaging the child’s attention, and if all tissue abnormalities
technique of brushing to the caregiver. else fails, distracting the child with a • Occlusion
The examiner retracts the child’s lips and brightly coloured toothbrush or toy. Praise • Indications of trauma.
cheeks and demonstrates brushing along the child at each step for their cooperation
the gingival margins. The spongy handle and/or good behaviour. While ‘counting’ Fluoride treatment
of an age-appropriate sized toothbrush can the teeth, the examiner also inspects the Fluoride is an important and cost-effective
be used to prop open the child’s mouth. soft tissues, hard tissues and occlusion, if prevention method to strengthen tooth
The handle of a second toothbrush can be the child is able to cooperate. Data from enamel and prevent caries. The ADA and
used as a mouth prop. During this ‘tell- the clinical exam results should be com- the UK NHS Department of Health recom-
show-do’ encounter, the caregiver should bined with data from the caregiver inter- mends that high caries risk children receive
be encouraged to brush their child’s teeth view to determine the child’s overall caries a full-mouth topical fluoride varnish (FV)

504 BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012


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PRACTICE

Restoration

Sealants Antibacterials Anticipatory guidance/ Self-management goals White spot/precavitated Existing lesions
counselling lesions

No No Yes No n/a n/a

Fluoride releasing sealants No Yes No Treat w/ fluoride products n/a


recommended on deep pits as indicated to promote
and fissures remineralisation

Fluoride releasing sealants Recommend for caregiver Yes Yes Treat w/ fluoride products n/a
recommended on deep pits as indicated to promote
and fissures remineralisation

Fluoride releasing sealants Recommend for caregiver Yes Yes Treat w/ fluoride products ITR (interim therapeutic
recommended on deep pits as indicated to promote restorations) or conventional
and fissures remineralisation restorative treatment as
patient cooperation and family
circumstances allow

Fluoride releasing sealants Recommend for caregiver Yes Yes Treat w/ fluoride products ITR or conventional restorative
recommended on deep pits as indicated to promote treatment as patient
and fissures remineralisation cooperation and family
circumstances allow

Fluoride releasing sealants Recommend for caregiver Yes Yes Treat w/ fluoride products ITR or conventional restorative
recommended on deep pits as indicated to promote treatment as patient
and fissures remineralisation cooperation and family
circumstances allow

application and re-application consistently protocol as the most cost-effective method necessary changes in the child’s diet, tooth
at three/four-month intervals.36 A minimum with the best outcome.39 Others argue that brushing and fluoride application can be
of every six months is recommended for chil- three consecutive varnishes over a week’s identified from the risk analysis.
dren at moderate caries risk even if the child time-period, once annually, are more The science of caries prevention contin-
lives in a community that already receives effective than semi-annual treatments.40-42 ues to evolve. Table  2 illustrates how to
the benefits of water fluoridation. The pro- Regardless, all sources agree that FV is develop care paths for a practice’s patients.
vider should reiterate the cumulative benefit useful as a necessary standard of care There are many alternative approaches to
of the fluoride varnish, even if it has been component for the prevention of dental the prevention and treatment of dental
mentioned earlier in the visit. After applica- caries and crucial as a tool in oral health caries, with more emerging continuously.
tion, the caregiver should be reminded not maintenance for all ages.40-42 Care paths should remain dynamic and
to allow the child to brush their teeth or to change over time as the effectiveness of
eat crunchy/sticky foods for the rest of the Assignment of risk, anticipatory new as well as current protocols is vali-
day to allow fluoride varnish to be effective.
guidance and counselling dated by scientific evidence.
FV is one of the most efficacious and An individualised care plan for each infant/ Parents should be given additional
prevalent methods used by modern den- caregiver is designed based upon the risk information and anticipatory guidance on
tists to combat early childhood caries. determined from the parent interview oral health prevention that is specific to
According to the ADA, extensive research and the clinical examination of the child the needs of their child. Such information
has shown FV to be safe and effective (Tables 2 and 3). A dual approach is essential includes oral hygiene, growth and devel-
for patients of all ages.37 FV is painless, for moderate and high caries risk children opment issues (that is, teething, digit or
quick to apply, and therefore can be used and their parent/caregivers. Strategies need dummy habits), oral habits, diet and nutri-
on very young children.38 There is, how- to be employed to decrease the maternal or tion and injury prevention (Tables 2 and
ever, widespread debate on the results in caregiver transmission of cariogenic bacte- 3). The anticipatory guidance approach is
reference to differing recommendations ria to infants through the potential use of designed to take advantage of time-criti-
for the frequency and periodicity of FV chlorhexidine rinse and xylitol products for cal opportunities to implement preventive
application. Some sources advocate FV caregivers, and fluoride varnish for both the health practices and reduce the child’s risk
treatments every six  months, citing this caregiver and the child.34 Additionally, the of preventable oral disease.43-45

BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012 505


© 2012 Macmillan Publishers Limited. All rights reserved.
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 Fig. 4 The motivational interviewing (counselling)
two-way communication between the cli-
nician and the patient or parent46 (Fig. 4). early on when new behavioural change is healthcare professionals with the aim of
This includes establishing a therapeutic required and time to ask questions regard- providing preventive care for our high risk
alliance (that builds rapport and trust), by ing any difficulties with following the rec- populations is crucial to achieving better
asking questions to help parents identify ommendations. They should be aware that oral health outcomes in the future. The
the problem and listening to what they say, changing home practices does not happen overall aim is to lower the risk level over
encouraging self-motivational statements, overnight. At these infant oral care visits, time and eliminate the need for further res-
preparing for change (discussing the hur- it is essential to reassess the risk status torations by controlling the caries process.
dles that interfere with action), responding and monitor improvement on the previ- The authors would like to thank Claudie Damour-
to resistance and scheduling follow-up, as ously set self-management goals. During Terrasson, publishing director of the Groupe
Information Dentaire, Paris France, for the authori-
well as preparing the parent for the inevi- these reassessment appointments, changes sation of translation and publication of the series
table bumps in the road.47 can be made and prevention protocols in the BDJ; Dr Norman Tinanoff, Dr Manwai Ng
for contributing their support and knowledge to this
Following the brief motivational inter- reinforced. project; Ms Debra Tom for her editorial assistance;
viewing (counselling), the parent/caregiver and the HRSA Oral Health Disparities Collaborative
is asked to select two  self-management CONCLUSIONS for the implementation of the CAMBRA instrument
and the development of the self-management goal
goals or recommendations as their assign- Paediatric dentists and general dentists instrument through High Plains Health Center.
Finally, they wish to acknowledge the AAPD and
ments before the next re-evaluation den- have the most influential role in prevent- AAP for their support and leadership on Caries
tal visit. The parent/caregiver is asked to ing and reducing the severity of early Risk Assessment development.
commit to the two  goals selected and is childhood caries in young children. By 1. World Health Organization. Oral health country/
informed that the oral healthcare providers embracing the concepts of the ‘dental area profile program (CAPP). Geneva: WHO, 2006.
Online programme available at http://www.whocol-
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status: United States, 1988-1994 and 1999-2004.
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392–398. Pediatrics 2003; 111: 1113–1116. 36. American Dental Association Council on Scientific
12. American Dental Association. Statement on early 15. American Association of Public Health Dentistry. Affairs. Professionally applied topical fluoride:
chidlhood caries. Chicago: ADA, 2007. ADA. Online First oral health assessment policy. AAPHD, 2004. evidence-based clinical recommendations. J Dent
statement available at http://www.ada.org/2057. Online policy available at http://www.aaphd.org/ Educ 2007; 71: 393–402.
aspx (accessed October 2012). default.asp?page=FirstHealthPolicy.htm (accessed 37. Autio-Gold J. Recommendations for fluoride var-
13. American Academy of Pediatric Dentistry reference October 2012). nish use in caries management. Dent Today 2008;
manual 2010–2011. Pediatr Dent 2010-2011; 16. Academy of General Dentistry. Policies, guidelines, 27: 64–67.
32: 1–334. positions statements and fact sheets. Online infor- 38. Moberg Sköld U, Petersson L G, Lith A, Birkhed D.
14. Hale K J, American Academy of Pediatrics Section mation available at http://www.agd.org/issuesadvo- Effect of school-based fluoride varnish programmes
on Pediatric Dentistry. Oral health risk assessment cacy/policies/dentalcare/ (accessed October 2012). on approximal caries in adolescents from different

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PRACTICE

caries risk areas. Caries Res 2005; 39: 273–279. Database Syst Rev 2004: CD002780. 26: 81–83.
39. Irigoyen M E, Luengas I, Zepeda M A, Sánchez-Pérez 43. American Academy of Pediatric Dentistry Clinical 46. Weinstein P, Harrison R, Benton T. Motivating parents
L T. Frequency of fluoride varnish application in Affairs Committee, American Academy of Pediatric to prevent caries in their young children: one-year
prevention of dental caries. Xochimilco, Mexico: Dentistry Council on Clinical Affairs. Guideline findings. J Am Dent Assoc 2004; 135: 731–738.
Universidad Autonoma Metropolitana. on periodicity of examination, preventive dental 47. Weinstein P. Provider versus patient-centered
40. Marinho V C, Higgins J P, Logan S, Sheiham A. services, anticipatory guidance/counseling, and oral approaches to health promotion with parents of
Fluoride varnishes for preventing dental caries in treatment for infants, children, and adolescents. young children: what works/does not work and
children and adolescents. Cochrane Database Syst Pediatr Dent 2008; 30: 112–118. why. Pediatr Dent 2006; 28: 172–176.
Rev 2002: CD002279. 44. American Academy of Pediatric Dentistry Clinical 48. Ramos-Gomez F J, Crall J, Gansky S A, Slayton R L,
41. Marinho V C, Higgins J P, Logan S, Sheiham A. Affairs Committee, American Academy of Pediatric Featherstone J D. Caries risk assessment appropri-
Topical fluoride (toothpastes, mouthrinses, gels or Dentistry Council on Clinical Affairs. Guideline ate for the age 1 visit (infants and toddlers). J Calif
varnishes) for preventing dental caries in children on periodicity of examination, preventive dental Dent Assoc 2007; 35: 687–702.
and adolescents. Cochrane Database Syst Rev 2003: services, anticipatory guidance, and oral treatment 49. American Academy on Pediatric Dentistry
CD002782. for children. Pediatr Dent 2005-2006; 27: 84–86. Clinical Affairs Committee- Restorative Dentistry
42. Marinho V C, Higgins J P, Sheiham A, Logan S. One 45. American Academy of Pediatric Dentistry. Clinical Subcommittee, American Academy on Pediatric
topical fluoride (toothpastes, or mouthrinses, or guideline on periodicity of examination, preventive Dentistry. Council on Clinical Affairs Guideline on
gels, or varnishes) versus another for preventing dental services, anticipatory guidance, and oral pediatric restorative dentistry. Pediatr Dent 2008-
dental caries in children and adolescents. Cochrane treatment for children. Pediatr Dent 2004; 2009; 30: 163–169.

Erratum
Practice 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.

508 BRITISH DENTAL JOURNAL VOLUME 213 NO. 10 NOV 24 2012


© 2012 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Discusses the methods recommended for
part 4. Detection and diagnosis clinical diagnosis of initial carious lesions.

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

of initial caries lesions treatment.


• Presents a clinical case to consolidate
diagnostic methods.

A. Guerrieri,1 C. Gaucher,2 E. Bonte3 and J. J. Lasfargues4

VERIFIABLE CPD PAPER

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.

INTRODUCTION being treated by non-invasive procedures enamel-dentine junction (EDJ) and, in the
The initial caries lesion can be defined as including ultra-conservative or minimal absence of treatment, cavitation occurs.1-3
a primary lesion which has not reached intervention dentistry. High evidence-level studies are in
the stage of an established lesion with The detection of carious lesions at an agreement that the ideal tool for detection
cavitation. It is therefore amenable to early stage is necessary in order to imple- of the initial lesion, the ‘gold standard,’
ment preventive and interceptive treatment has not yet been identified. Such a tool
strategies. In daily practice, the diagnosis should have both a high level of sensitiv-
MINIMAL INTERVENTION
of initial lesions is not always simple; it ity (the ability to detect disease when it
DENTISTRY
is often subjective and based on the clini- exists) and a high level of specificity (the
1. From ‘compulsive’ restorative dentistry to cian’s clinical sense. For this reason, the ability to confirm the absence of disease).
rational therapeutic strategies
search is on for more specific and sensitive The conventional and validated tools for
2. Caries risk assessment in adults
tools, using new technologies, to help the detecting early carious lesions include vis-
3. Paediatric dental care – prevention and
management protocols using caries risk practitioner diagnose initial caries lesions ual and tactile examination and radiogra-
assessment for infants and young children as precisely as possible. The purpose of phy (bitewings). These methods have good
4. Detection and diagnosis of initial this paper is to review the recommended specificity but only moderate sensitivity
caries lesions
clinical methods for diagnosing initial car- and are relatively ‘operator-dependent’.4-6
5. Atraumatic restorative treatment (ART) – 
a minimum intervention and minimally ies lesions and to examine recent tools for The combination of clinical examination
invasive approach for the management early detection of these lesions. and bitewing radiographs nevertheless
of dental caries
allows diagnoses with improved sensitiv-
6. Caries inhibition by resin infiltration BACKGROUND ity and specificity. Some new technolo-
7. Minimally invasive operative caries
management – rationale and techniques The initial enamel lesion results from an gies are appearing and it is of interest to
This paper is adapted from: Guerrieri A, Gaucher C, Bonte E, imbalance between the processes of dem- link them with standard clinical practices,
Lasfargues J J. Détection et diagnostic des lésions carieuses
initiales. Réalités Cliniques 2011; 22: 233–244 ineralisation and remineralisation. The with a view to improving caries detection
first changes in enamel appear at those and diagnosis.3
sites where there is plaque biofilm reten-
tion and stagnation. The demineralisation THE STANDARD
Faculté de Chirurgie Dentaire, Université PARIS CLINICAL APPROACH
1-4

DESCARTES (1 rue Maurice Arnoux, 92120 Montrouge) alters the enamel surface, which becomes
et Service d’Odontologie, Hôpital Bretonneau, APHP
(2 rue Carpeaux, 75018 Paris), France.
micro-porous, and with an opaque and Systematised caries diagnostic procedures
*Correspondence to: Professor Jean-Jacques Lasfargues matt appearance, characteristic of a white consist of three stages: the detection of a
Email: jean-jacques.lasfargues@brt.aphp.fr;
Tel: +33 1 53 11 14 30
spot lesion. Acid penetration along the lesion, evaluation of its severity (depth)
sheath of the enamel prism leads to the and its level of activity.7,8 Before an exam-
Accepted 21 June
DOI: 10.1038/sj.bdj.2012.1087
dissolution of crystalline spaces adja- ination, the practitioner will have noted
© British Dental Journal 2012; 213: 551-557 cent to the lesion and progressing to the the general context of caries activity. The

BRITISH DENTAL JOURNAL VOLUME 213 NO. 11 DEC 8 2012 551


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

principle general risk factors should be


noted: age group, health state and use of General context of caries
medications, lifestyle, oral hygiene, nutri- activity (diet, life-style Initial interview
and habits)
tion and use of fluorides (Figs  1 and 2).
Evaluation of individual caries risk cannot
Initial clinical examination
be separated from the actual diagnosis of
carious lesions. It is essential to categorise
a patient as being at low or high risk of Obvious lesions Suspect sites
caries for the correct choice of preventive,
interceptive, or therapeutic care.
Probe collects plaque Gingival bleeding on probing
INITIAL CLINICAL EXAMINATION = active site = active site

The purpose of the examination is to


detect visually changes of colour, trans- Cleaning and drying
of tooth surfaces
lucency and structure of the enamel. An
initial inspection, tooth by tooth, on wet
In-depth clinical examination
surfaces can spot cavities and brown or
white stains. Periodontal status and resto-
rations may also be checked initially. At this Complimentary tools Optical aids
stage, caries activity must be evaluated by (Diagnodent®, LED camera)

checking the build-up of plaque biofilm and


the gingival pathology at suspect sites. A Visual criteria Radiographic examination
(ICDAS II) (bitewings)
blunt/rounded probe (a periodontal probe is
appropriate) may be used, with gentle force
(Fig. 3). Clinical parameters that indicate SiSta Classification
and quantify the activity state of a single
carious lesion are, according to Ekstrand:8
Caries risk
• The appearance of the lesion, correlated Low to moderate Treatment decision
High
with its severity (extension, depth)
• The position of the lesion (in an area
in favouring plaque build-up or not) Fig. 1 Flow-chart of the practical approach to assessment of initial carious lesions (from
Lasfargues and Colon, 2010)3
• Tactile perceptions on probing (used to
assess the presence of surface deposits
and the roughness of the enamel) are changes in colour and translucency
• The status of the gingival margin that indicate the state of demineralisation
in relation to the areas of interest of surfaces and sub-surface zones com-
(assessed by the absence or presence of pared with adjacent healthy areas. These
bleeding caused by a careful probing). visible signs indicating caries have been
rationalised in a classification system,
EXTENSIVE CLINICAL the International Caries Detection and
OBSERVATION Assessment System (ICDAS).11 The classi- Fig. 2a Young patient presenting with a high
caries risk, as evidenced by the presence of
Observation is used to classify each fication includes six codes. Initial lesions multiple white-spot demineralisations and
lesion according to its site and its stage are mainly covered by codes 1 and 2. severe gingivitis
of advancement, with a view to therapy.3 • ICDAS II Code 0: the tooth is healthy
Pre-cleaning is fundamental to the qual- • ICDAS II Code 1: the tooth has a lesion
ity of diagnosis, both for the direct visual visible only after drying and histology
examination and for the use of comple- reveals that the lesion is limited to the
mentary diagnostic aids such as fluores- external half of enamel
cence-based techniques.9 Undertaken with • ICDAS II Code 2: the lesion penetrates
a rotating brush and prophylactic paste, the full thickness of enamel. Clinically,
or by air-polishing, the aim is elimination an opacity or discoloration distinctly
of the surface biofilm and deposits. Once visible without air-drying is apparent Fig. 2b Close-up of area of plaque retention,
indicating high disease activity
cleaned, the suspect sites are dried and but without cavitation (Fig. 4).
inspected individually. The use of visual
aids (magnifying loupes, minimum × 2.5) A statistically significant correlation visual signs.12 Carious lesions thus identi-
greatly improves the detection rate of ini- exists between the anatomical and his- fied are classified on the ICDAS system
tial carious lesions.10 The signs to look for tological stages of lesions and the major according to the site: occlusal (site 1),

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PRACTICE

Table 1 Criteria for visual detection of carious lesions (ICDAS) and SiSta classification; from
Lasfargues and Colon, 20103
ICDAS Criteria for visual Degree of severity SiSta* Therapeutic options
Code lesion detection of lesion stage
0 Sound surface Not necessary
1 Earliest optical change, Demineralisation in outer
visible on drying enamel third of enamel Minimal intervention;
2 Clear enamel change; white Demineralisation reaching 0 non-invasive care,
or brown blemishes, visible the inner third of enamel, remineralisation or sealant
Fig. 3a Detection of a proximal carious without drying possibly the ADJ
lesion. Identification of a suspected site of
3 Localised break in enamel Demineralisation of outer
carious activity distal to 36 third of dentine
Minimal intervention;
4 Dentine not visible Demineralisation of
1 and 2 adhesive ultra conservative
middle third of dentine,
restoration
no weaken­ing of dental
crown structure
5 Enamel opaque or greyish, Demineralisation of middle
suggestive of an underlying third of dentine, weakening
dentine lesion, with or of dental crown structure Operative dental care;
without enamel cavitation functional crown
3 and 4
6 Dentine cavity Demineralisation of inner restoration with or
third of dentine, without cusp coverage
undermining of cusp
Fig. 3b Carious activity confirmed by the structure and support
presence of bleeding on probing with the SiSta = Site and Stage
periodontal probe, allowing the severity of
the lesion to be evaluated
not improve the diagnostic sensitivity of NEW DIAGNOSTIC AIDS
visual examination, especially in detect- None of the new caries detection tech-
ing lesions in pits and occlusal fissures. niques developed in recent years is 100%
Indeed, the result of this subjective method reliable when used alone. They comple-
depends on the size of the probe tip, the ment the systematic approach already
resistance of the enamel and the force described, with, for the most validated,
exerted by the probe. Furthermore, prob- an increase in detection sensitivity
ing can cause iatrogenic damage to enamel when combined with conventional tech-
(and loss of the possibility of reminerali- niques.14,15 Their development is based
sation) so favouring lesion progression.13 on the need for increased detection sen-
Probing with a sharp dental explorer can- sitivity to allow lesions to be identified
Fig. 3c Bitewing showing SiSta classification not be considered a reliable technique for as early as possible (particularly before
Stage 2
detection of carious lesions. invasive restoration becomes necessary).
Today the treatment of initial lesions is
RADIOGRAPHIC EVALUATION well understood,16 as is the need for early
Bitewing radiographs are the method caries lesion detection and diagnosis.
of choice for early detection of carious The new diagnostic tools are classified
lesions, especially on proximal surfaces. on the basis of the physical principles that
Radiographic examination reveals, on underpin them.17 The most prominent include
average, twice as many proximal lesions transillumination (Diagno.cam, Kavo®), and
extending into dentine as simple visual fluorescence systems (DIAGNOdent, Kavo®;
examination. Radiographic examination CS 1600 Kodak; VistaCam iX, DürrDental®;
Fig. 4 Multiple ICDAS II score initial lesions also allows the depth of a carious lesion SoproLife, Acteon®).
(breach of any thickness of cervical enamel).
Note the white areas, clearly visible without to be estimated, useful for care planning.
drying In the permanent dentition, two bitewing OPTICAL TECHNIQUES
radiographs are recommended to cover Optical aids
proximal (site 2), and cervical (site 3), then directly and tangentially all proximal
according to their stage (Table 1). surfaces of the molar-premolar segment. The visual examination requires optical
The technique involves using a specific magnification to be properly conducted.
VISUAL EXAMINATION ASSISTED film holder with a guide rod and a col- This is not a matter of a microscope for
BY PROBING limator ring (Rinn angulator). This system clinical use for the detection of early cari-
Tactile sensation has long been the prin- allows radiographs to be reproduced at ous lesions. The use of Galilean loupes
cipal diagnostic tool in cariology, involv- time intervals appropriate for the proper (magnification  ×  2‑5) is satisfactory for
ing the use of a sharp dental explorer. It longitudinal follow-up (control) of incipi- daily practice. The practitioner may choose
has been demonstrated that probing does ent carious lesions. the most ergonomically appropriate type

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

(glasses, headband, helmet), coupled


ideally to an integrated halogen/LED
lighting system.

Scanned images
Conventional intraoral cameras allow
direct viewing of the captured image and
digital archiving is simple. Such images
are particularly useful for patient teaching
Fig. 5d An air-polisher, here the Air Max™ by
and motivation purposes but their quality Satelec. It uses a 250 μm grain powder in a wet
a
is not always satisfactory for diagnosis.17 environment (it is possible to choose the flavour)

Fluorescence systems
Fluorescence 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
e
make up the enamel and dentine matrices.
It may also occur when bacterial metabo- b
lites from the carious process, plaque,
Fig. 5 Use of modern caries diagnosis
composite resins or prophylactic paste tools: (a) diagnostic systems such as the
residue absorb high energy light. Before SoproLife® camera (Acteon) and the
using devices based on fluorescence, it is DIAGNODENT® pen (Kavo) should be used
with (b) an air-polishing system to pre-
important to undertake meticulous clean- clean surfaces
ing, rinsing and drying of the surfaces to
f
be studied so as to eliminate as much as
possible matter which could cause confu-
sion (Fig. 5).

Infrared laser
The DIAGNOdent® and DIAGNOdent pen®
were developed following the work of
Hibst and Paulus on dental fluorescence
in response to absorption of red light, in g
the late 1990s. The red light and the sub-
sequent fluorescence emissions are car-
ried via optical fibres. The return signal Fig. 5c Clinical examination reveals stained
is filtered and modulated to indicate the fissures, often considered as affected and
treated as carious lesions
degree of mineralisation of the examined
surface on a scale from 1 to 99, displayed
on a screen. Some authors agree that this Quantitative light fluorescence
system has better sensitivity than visual (QLF)
h
or radiographic examination.18-21 Its spec- This technique uses an intraoral camera
ificity is acceptable but its reproducibil- with CCD technology linked with system Fig. 5e After cleaning and drying, the
ity remains controversial.22-24 Using the for emitting light in the blue/blue-green DIAGNOdent® does not indicate the presence
of a lesion nor does (f) the fluorescence
DIAGNOdent pen® is easier than its prede- wavelengths. The fluorescence of the teeth
camera used in diagnostic mode with (g) white
cessor because the hand piece is no longer is rendered on a screen after the blue light light or (h) polarised light (SoproLife®, Acteon)
connected to a monitor by an optical cord. is filtered out, leaving green light for the
On the other hand, its use requires some image. Demineralisation greater than 5%
precautions: the tips must be aligned cor- results in a dark spot against the healthy with visual examination results in signifi-
rectly on the test surfaces, thorough clean- enamel, which is green coloured. This sys- cantly increased detection sensitivity of
ing and drying without dehydration and tem has been considered to be superior to initial lesions. The extended time required
careful scanning of the entire surface with visual examination for detection of initial for acquisition of the images makes the
the repeating beep pulses indicating good carious lesions but confounding factors use of this technology impractical in daily
signal reception. must be taken into account. Linking QLF practice.14,17,25,26

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PRACTICE

Fig. 6a Using the SoproLife® camera Fig. 7a Facial view of the patient, Mrs A, e
(Acteon) for the diagnosis and treatment of who attended for a dental assessment before
SiSta 1.1 lesions. After cleaning and drying orthodontic treatment
the tooth surfaces, visualisation of the lesion
in diagnostic mode with fluorescence

Fig. 7b Frontal view of the anterior dentition Figs 7e and f Checking the accumulation
of plaque and gingival conditions at the
25‑26 and 15‑16 embrasures

Fig. 6b Visualisation of the lesion in


diagnostic mode without fluorescence

Fig. 7c Occlusal view of the maxillary arch

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

LED cameras Demineralised enamel appears blue and den- mode, the range of red is amplified to guide
The newest detection system for carious tine is yellow to red, depending on the sever- the practitioner in his elimination of carious
lesions is the use of intraoral cameras with ity of the demineralisation.27 This device was tissue (Fig. 6).28 Finally, there is a ‘day light’
LED technology. These systems illuminate recently improved (VistaCam iX®). mode that allows intraoral photographs and
the tooth, record the fluorescence of the The fluoLED camera Sopro-Life® offers videos to be made.
dental tissue and enhance the image using fluorescence images in two modes: a diag- Research and development of these
dedicated software. Clinical studies are nostic mode and processing mode. Healthy new technologies should lead to further
underway to confirm their usefulness. The tissues appear green (blue in areas with very improvements in their sensitivity, specific-
Vista Proof® camera is used with DBSWIN thick enamel) and carious tissue is light ity and reproducibility to facilitate the reli-
software (Dürr Dental AG) which can also to very dark red. In diagnostic mode, the able and objective quantitative diagnosis
analyse digital radiographs. As with QLF distribution of colours is limited to those of carious lesions. Beyond the pre- and
systems, the healthy enamel appears green. observed on the tooth while, in processing during-operative diagnostic stages, the

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© 2012 Macmillan Publishers Limited. All rights reserved.
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.
Fig. 7k Bitewings of right premolar area

CLINICAL CASE
Mrs 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
Fig. 7h Clinical details of Quadrant 2
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 Fig. 7l Bitewing of right molar area
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 Fig. 7m Bitewing of left premolar area
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
Fig. 7i Clinical details of Quadrant 3 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 Fig. 7n Bitewings of left molar area
marginal ridge of 47 (Fig. 7j) indicated a den-
tinal lesion with undermined enamel (ICDAS risk requiring management and follow-up
code 4). At this stage, bitewing radiographs every three months (Table 2). The follow-
in these two regions was deemed necessary ing treatment objectives were proposed for
to confirm the presence or absence of lesions this patient:
and, if present, their extent. The radiographs • Control caries disease by lowering
indicated initial caries in the right sector: caries risk (plaque control and
SiSta 2.0 on 15 D and 14 D as well as 44 D dietary advice)
and 45 D, and SiSta 2.2 on 47 M and, in the • Treatment of non-cavitated lesions
left sector: SiSta 2.0 on 24 M, 25 D, 26 M using non-operative methods
and SiSta 2.0 on 36D and 37M. (remineralisation or resin impregnation)
• Treatment of cavitated lesions with
Ultraconservative minimal adhesive restorations (composite)
intervention dentistry • Replacement of defective amalgam
Analysis of all risk factors and predictors restorations by long-lasting
Fig. 7j Clinical details of Quadrant 4; note revealed by the dietary diary and the clini- provisional adhesive restorations
the lesion on mesial surface of 47
cal examination, indicated a high caries • Prevention of recurrent caries during

556 BRITISH DENTAL JOURNAL VOLUME 213 NO. 11 DEC 8 2012


© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

7. Pitts N B. Modern concepts of caries measurement.


Table 2 Evaluation of caries risk of Mrs A J Dent Res 2004; 83: C43‑C47.
8. Ekstrand K R, Martignon S, Ricketts D J, Qvist V.
Detection and activity assessment of primary
Risk factors and predictors Present Absent
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New carious lesions Dent 2007; 32: 225–235.
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New active lesions in the past 3 years 9 lesions of professional cleaning and drying of occlusal
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Restorations placed in the past 3 years X 2005; 39: 284–286.
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the detection of occlusal caries lesions. Oper Dent
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(ed) Proceedings of the 7th Indiana Conference,
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Increased counts, Lactobacillus and S. mutans Not done
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and new methods for the detection of occlusal
caries in deciduous teeth. Caries Res 2003; 37: 2–7.
orthodontic treatment by active is yet proven, so there is still no abso- 19. Lussi A, Hellwig E. Risk assessment and preventive
measures. Monogr Oral Sci 2006; 20: 190–199.
maintenance. lute substitute for the traditional clinical 20. Shi X, Traneaeus S, Angmar-Månsson B.
examination and radiographic bitewing Fluorescence methods. In Wilson N H F (ed)
CONCLUSIONS examination. The technologies, particu-
Minimally invasive dentistry. The management of
caries. pp 40–46. UK: Quintessence Books, 2007.
In recent years, methods of detection of larly those based on fluorescence, may 21. Rodrigues J A, Hug I, Diniz M B, Lussi A.
Performance of fluorescence methods, radiographic
early carious lesions have evolved consider- nevertheless assist in raising the awareness examination and ICDAS II on occlusal surfaces
ably, moving firstly towards the identifica- and motivation of patients; they are also in vitro. Caries Res 2008; 42: 297–304.
22. Lussi A, Hack A, Hug I, Heckenberger H, Megert B,
tion of the earliest mineral changes and then interesting for their monitoring potential Stich H. Detection of approximal caries with a
to controlling the demineralisation process and controlling the process of regression/ new laser fluorescence device. Caries Res 2006;
40: 97–103.
using non-operative procedures. Previously progression over periodic intervals. 23. Spiguel M H, Tovo M F, Kramer P F, Franco K S, Alves
K M, Delbem A C. Evaluation of laser fluorescence
an indiscriminate routine task, caries diag- The authors would like to thank Claudie in the monitoring of the initial stage of the de-/
nosis has become a fully-fledged, codified Damour — Terrasson, President and publishing remineralization process: an in vitro and in situ
director of the Groupe ID Espace — L’Information study. Caries Res 2009; 43: 302–307.
discipline which demands of the practitioner Dentaire, Paris France, for the authorisation of 24. Ghaname E S, Ritter A V, Heymann H O, Vann W F
precise knowledge, rigor and time. In addi- translation and publication of the series in the BDJ. Jr, Shugars D A, Bader J D. Correlation between
laser fluorescence readings and volume of tooth
tion to the identification of risk factors and 1. Haikel Y. Carie dentaire. In Piette E, Goldberg M preparation in incipient occlusal caries in vitro.
the early detection of lesions, it is essential (eds) La dent normale et pathologique. pp 99–124. J Esthet Restor Dent 2010; 22: 31–39.
Bruxelles: De Boeck Supérieur, 2001. 25. Kuhnisch J, Heinrich-Weltzien R. Quantitative light-
to evaluate the extent of each lesion (non- 2. Fejerskov 0, Kidd E A M. Dental caries. The disease induced fluorescence (QLF) ‑ a literature review. Int
cavitated vs cavitated) and its status (active and its clinical management. Copenhagen: J Comput Dent 2004; 7: 325–338.
Blackwell Munksgaard. 2003. 26. Kühnisch J, Bücher K, Henschel V, Hickel R.
or arrested) so as to establish a monitor- 3. Lasfargues J J, Colon P. Odontologie conservatrice Reproducibility of DIAGNOdent 2095 and DIAGNOdent
ing procedure and predict the outcome, as et restauratrice. Tome 1: une approche médicale Pen measurements: results from an in vitro study on
globale. France: Wolters Kluwer, 2010. occlusal sites. Eur J Oral Sci 2007; 115: 206–211.
for any other disease. Such a systematic 4. Bader J D, Shugars D A, Bonito A J. Systematic 27. Eberhart J, Frentzen M, Thoms M et al. New optical
reviews of selected dental caries diagnostic and techniques for caries detection. Fluorescence-based
approach should lead to a care plan for management methods. J Dent Educ 2001; systems to identify non-cavitated lesions. Paris:
caries, based on prophylactic measures with 65: 960–968. Dürr Dental Publication, 2007.
5. Selwitz R H, Ismail A I, Pitts N B. Dental caries. 28. Terrer E, Koubi S, Dionne A, Weisrock G, Sarraquigne
minimal use of restorative measures, leading Lancet 2007; 369: 51–59. C, Mazuir A, Tassery H. A new concept in restorative
to better patient oral health. 6. Ewoldsen N, Koka S. There are no clearly superior dentistry: light-induced fluorescence evaluator
methods for diagnosing, predicting, and noninva- for diagnosis and treatment. Part 1: diagnosis and
None of the new tools designed to sively treating dental caries. J Evid Based Dent Pract treatment of initial occlusal caries. J Contemp Dent
enhance and facilitate caries diagnosis 2010; 10: 16–17. Pract 2009; 10: E086–E094.

BRITISH DENTAL JOURNAL VOLUME 213 NO. 11 DEC 8 2012 557


© 2012 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Describes the clinical aspects of the
part 5. Atraumatic restorative atraumatic restorative treatment (ART)

PRACTICE
approach.
• Stresses the importance of following the
treatment (ART) – a minimum treatment protocol to ensure reliable
results and reviews the evidence base
supporting its use.

intervention and minimally • Suggests ART should be considered as a


therapeutic option especially in children,
anxious patients and those with special

invasive approach for the needs.

management of dental caries


C. J. Holmgren,1 D. Roux2 and S. Doméjean3

VERIFIABLE CPD PAPER

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.

MINIMAL INTERVENTION INTRODUCTION 2. Describe the clinical aspects of ART


DENTISTRY Atraumatic restorative treatment (ART) 3. Review the evidence base for
1. From ‘compulsive’ restorative dentistry to
was developed in the 1980s but embodies supporting the use of ART
rational therapeutic strategies all the principles of an alternative philoso- 4. Describe the indications for ART.
2. Caries risk assessment in adults phy of dental care that was ultimately to
3. Paediatric dental care – prevention and become known as minimal (or minimum) WHAT ARE ART SEALANTS
management protocols using caries risk
intervention dentistry.1,2 Minimal inter-
AND RESTORATIONS?
assessment for infants and young children
4. Detection and diagnosis of initial vention management of caries attaches Over the past 20 years some confusion has
caries lesions importance to the diagnosis and evalua- arisen as to what constitutes the atrau-
5. Atraumatic restorative treatment (ART) –  tion of caries risk and includes prevention, matic restorative treatment (ART) approach
a minimum intervention and minimally
invasive approach for the management stabilisation and healing (remineralisation) since a number of authors use the term to
of dental caries of early lesions and minimally invasive describe procedures that are not considered
6. Caries inhibition by resin infiltration restorative treatment for cavitated den- to be ART. To avoid confusion a recent def-
7. Minimally invasive operative caries tine lesions with selective excavation of inition by Frencken and van Amerongen
management – rationale and techniques
destroyed tissue combined with maximal should be adopted as follows: ‘ART is a
This paper is adapted from: Holmgren CJ, Roux D, Doméjean
S. Traitement restaurateur atraumatique (ART). Une approche preservation of healthy tissues. While minimally invasive approach to both pre-
a minima de la prise en charge des lésions carieuses. Réalités
Cliniques 2011; 22: 245–256. developed originally in response to a vent dental caries and to stop its further
need to provide effective restorative and progression. It consists of two components:
preventive treatment in underserved com- sealing caries prone pits and fissures and
Aide Odontologique Internationale, Paris, France;
1* munities, over the past two  decades the restoring cavitated dentin lesions with seal-
2
Senior lecturer, Hospital consultant, CHU Clermont- ART approach has become a worldwide ant-restorations. The placement of an ART
Ferrand, Service d’Odontologie, Hôtel-Dieu, F‑63001
Clermont-Ferrand, France and Univ Clermont 1, phenomenon. ART can be considered to sealant involves the application of a high-
UFR d’Odontologie, F‑63000 Clermont-Ferrand,
France; 3Professor, Hospital consultant, Centre de be a cornerstone of minimal intervention viscosity glass-ionomer that is pushed into
Recherche en Odontologie Clinique, EA4847; caries management in combining preven- the pits and fissures under finger pressure.
CHU Clermont-Ferrand, Service d’Odontologie, Hôtel-
Dieu, F‑63001 Clermont-Ferrand, France and Univ tion and minimal invasion. An ART restoration involves the removal
Clermont1, UFR d’Odontologie, F‑63000 Clermont- The objectives of this paper are to: of soft, completely demineralised carious
Ferrand, France
*Correspondence to: Dr Christopher Jonathan Holmgren 1. Describe the philosophy of the ART tooth tissue with hand instruments. This is
Email: oralhealth@chrisholmgren.org;
Tel: +33 254 371951 approach within the overall concept followed by restoration of the cavity with
of minimal intervention and minimal an adhesive dental material that simultane-
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2012.1175 invasion for the management of ously seals any remaining pits and fissures
© British Dental Journal 2013; 214: 11-18 dental caries that remain at risk’.3

BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013 11


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

This definition implies that if any other term ‘cavity preparation’ is better named
method is used to prepare the cavity, for ‘cavity cleaning’ since it emphasises the
example, use of rotating instruments to more biological approach that ART and
open a cavity or the use of non-adhesive other minimal invasive approaches adopt
restorative material this cannot be consid- over purely mechanistic approaches.
ered as ART nor should the term ‘modi- Over 50  years ago, Fusayama and
fied ART’ be used since this may lead Massler independently showed that the
to confusion.4 dentine caries lesion could be divided
into two  layers.12–14 The layer closest to
The philosophy and science the opening into the cavity defined as
behind the ART approach ‘outer carious dentine’ or ‘infected den-
Inner “affected” dentine Outer “infected” dentine
The sealing of fissures with sealants has tine’ is a soft, infected biomass that has no • few bacteria • bacterial invasion
been shown to be an effective approach sensation and is largely incapable of being • remineralisable • unmineralisable
• vital • dead
both for the prevention of fissure caries remineralised. As such it is of no further • sensitive • without sensation
• useful • not useful
lesions de  novo and for the prevention structural use to the tooth and therefore
of the progression of early lesions in this should be removed (Fig. 1). The deeper part Fig. 1 Layers of a dentine caries lesion. The
‘outer carious dentine’ or ‘infected dentine’ is
site.5-8 As such, sealants, including ART of the dentine caries lesion, that which is soft and infected and should be removed. The
sealants that use a high-viscosity glass- more distant from the opening of the cav- ‘inner carious dentine’ or ‘affected dentine’
ionomer cement (GIC), play an essential ity, is harder since the mineral content is can remineralise and should be retained
role in a minimal intervention and non- higher. This is called ‘inner carious dentine’
invasive approach.9 or preferably ‘affected dentine’. This often
The principle by which preventive and darker and stained layer is vital, minimally
therapeutic sealants function is by pro- affected with bacteria and has the potential
viding a physical barrier that excludes to remineralise. It is therefore logical to
bacteria and their nutrients from pits and retain this layer. If rotary instrumentation
fissures that cannot be cleaned and that is used to clean (prepare) the cavity, tac-
have minimal access to saliva and fluo- tile feedback that enables the distinction
ride. There is no reason why this principle between the softer infected dentine and the
shouldn’t be extrapolated to situations harder affective dentine is compromised. Fig. 2 A small enamel hatchet used to open
where the caries process has extended This often leads to excessive cavity prepa- access to underlying softened dentine
into the dentine resulting in frank cavi- ration and unnecessary removal of sound
tation but without pulpal involvement. tooth tissue or that which has the poten-
Here, the major constraint of a cavitated tial to remineralise.15,16 While a number
caries lesion is that in order to achieve a of alternatives to rotary instrumentation
seal to the cavity and to render the exter- for cavity cleaning exist, the best com-
nal surface cleansable, there is a need to promise between effectiveness of caries
place a restoration, preferably with an removal and efficiency has been shown
adhesive material.10,11 to be the use of hand-excavators.15,16 These
If a restoration is required for caries are used for cavity cleaning in the ART
control in cavitated lesions then the next approach since they are readily available
question is how best to restore the cavity. and, as they do not rely on electricity or Fig. 3 Two spoon-shaped excavators,
one small with a spoon approximately 1 mm
Ideally the objectives should be to retain running water, can be used both in the
across, another slightly larger are used to
a maximum amount of sound tooth tissue traditional dental clinic environment and excavate soft dentine
for strength, make the restoration as small for outreach situations where dental facili-
as possible so it is long lasting and to seal ties do not exist.
the adjacent pits and fissures that are of It is important to emphasise that the
high caries risk (placement of a sealant res- ART approach to manage cavitated car-
toration). Adhesive restorative materials, ies lesions does not intentionally leave
namely composites and GIC, have revolu- soft, infected dentine behind in the cavity.
tionised cavity restoration since the need The sole exception might be in deep car-
to destroy sound tooth tissue to achieve ies lesions where there is a risk of pulpal
mechanical retention, as was the case exposure. As is now becoming common
for amalgam, has been greatly reduced. practice, in such cases soft dentine is
Furthermore, a better understanding of retained deliberately and the cavity filled
the histopathology of the dentine caries and sealed with a sealant restoration. The Fig. 4 A small flat plastic instrument is used
lesion means that a minimally invasive deliberate leaving of soft dentine car- for applying the GIC and for shaping the
restoration. An ‘Ash 6 special’ is shown here
cavity preparation can safely be used. The ies in a cavity is contrary to traditional

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


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

real dangers of complete removal of all dentine conditioner will be required. Fuji
soft infected dentine in deep lesions, which IX™ (GC International), Ketac™ Molar (3M
have been shown to lead to an increased ESPE) and Chemflex™ (Dentsply) have
number of pulpal exposures.19,28 It is there- been validated for use for ART. Other GIC
fore not only logical but also good practice that purport to be suitable for ART should
to retain some soft caries on the pulpal only be used if there is evidence that they
floor of deep caries lesions when there is a are effective.
likelihood of causing a pulpal exposure in
a vital and otherwise symptomless tooth, ART RESTORATIONS STEP-BY-STEP
irrespective of the restoration method used. For experienced dentists the ART approach
Fig. 5 An Enamel Access Cutter (EAC) can might at first appear simple and straight-
be used to access the cavity when the enamel PRACTICAL CONSIDERATIONS
hatchet is too large forward. However, reliable outcomes can
WHEN USING ART only be achieved if the following steps are
Instruments required rigorously adhered to.

Under normal situations no special instru- Step 1. Preparation of the ART


ments are needed to perform ART since
instruments and materials
before the clinical procedure
most can be found in a normal den-
tal clinic. The instruments required are Before starting the clinical procedure
as follows: ensure that all the instruments and con-
• Mirror, probe and tweezers sumable materials are laid out in a logi-
• A small enamel hatchet to open access cal and ordered manner. They should be
Fig. 6 The instruments are laid out in the
sequence that they are going to be used to underlying softened dentine (Fig. 2) arranged in the sequence that they are
• Two spoon-shaped excavators, going to be used (Fig.  6). Since cotton
one small with a spoon approximately wool pellets are used for many steps in the
1 mm across, another slightly larger ART approach, it saves time to separate an
(Fig. 3). These are used for the removal adequate number of these into individual
of soft dentine. The larger excavator pellets of suitable size beforehand.
can also be used for packing filling
material under enamel and for the Step 2. Isolation of the
removal of excess filling material
operating site
• A small flat plastic instrument for As for all restorations, isolation is impor-
applying the GIC and for removing tant since contamination of the operating
Fig. 7 The tooth surface is cleaned by excess filling material and for shaping site with saliva or blood will affect bond-
rubbing with a damp cotton wool pellet and
then dried with a dry pellet or a triple syringe the restoration. An ‘Ash 6 special’ is ing of the GIC to the tooth surface. For
ideally suited to this purpose (Fig. 4). ART, a rubber dam is not necessary since
isolation with cotton rolls is adequate.
dictum but there is little evidence that In addition to this basic set of instru- These must be changed as soon as they
infected dentine must be removed before ments, a special instrument might be nec- are saturated with saliva.
sealing the tooth with a restoration.17–19 essary. The ‘Enamel Access Cutter’ (EAC)
Conversely, there is now a substantial evi- has been developed to access smaller cavi- Step 3. Examining the
dence base from long-term studies that ties where the blade of the enamel hatchet
cavitated tooth
caries lesions that are sealed in place do might be too large (Fig. 5). To reduce hand Once the operating site has been correctly
not progress and might even regress.11,20–22 fatigue it is recommended that the instru- isolated, the tooth and the extent of car-
This is consistent with the principles of ments have a wide handle. ies lesion can be examined more easily.
therapeutic sealing since if cariogenic To assist in this task, carefully remove
bacteria are isolated from their source of Materials required any plaque or food debris from the pits
nutrition they either die or remain dor- In addition to the normal consumable and fissures with a dental explorer, tak-
mant and therefore cannot result in caries materials that are found in a dental prac- ing care not to create additional cavita-
lesion progression.23–27 tice, for example, cotton wool rolls, petro- tion. The tooth surface is then cleaned
While the notion of intentionally leav- leum jelly (Vaseline) etc, the only other by rubbing with a damp cotton wool
ing a limited amount of soft, infected requirement is a high-viscosity, high- pellet, followed by drying the surface
dentine behind in a cavity to be restored strength GIC. Encapsulated GIC gener- with a dry pellet or gently with a triple
might be totally contrary to what has been ally produce a more consistent mix but syringe (Fig.  7). Discoloured or translu-
taught in dental schools over the years, are usually more expensive than hand- cent enamel usually indicates deminerali-
the unsubstantiated dangers of such an mixed GIC. Furthermore, if an encapsu- sation where the enamel might be weak
approach must be balanced against the lated GIC is to be used then a separate and where the caries process might have

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© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

spread laterally along the enamel-dentine off with the blade of the hatchet along the
junction (EDJ). line of the enamel prisms (Fig. 10).
Note: unlike for conventional restora- Note: there is no danger in leaving
tions, a local anaesthetic is very rarely sound, ‘unsupported’ enamel since it effec-
required since only necrotic tooth tissue tively becomes ‘supported’ when the cavity
is being removed during cavity cleaning. is restored with GIC.
However, an anaesthetic can be given at Soft dentine from the rest of the cavity
the request of the patient. is now removed with the larger excava-
tor as access permits. Care must be taken Fig. 8 The corner of the hatchet is placed in
Step 4. Gaining adequate in deep cavities where there is danger of the entrance of cavity, usually in the deepest
access to the caries lesion exposing the pulp. It is advisable not to part of the pit or fissure for the occlusal
surface and the instrument tip rotated
In small caries lesions, where the opening exert excessive pressure on the pulpal floor
backwards and forwards while maintaining
into the cavity is small, it is often neces- with a small excavator since this increases slight pressure
sary to widen the access. A dental hatchet the likelihood of exposure. For deep cavi-
is used ensuring that the instrument is ties close to the pulp it is better to leave
correctly stabilised using an appropriate some soft dentine on the pulpal floor than
finger rest. The corner of the hatchet is risk exposing the pulp. The resultant cavity
placed in the entrance of the cavity, usu- is then washed and gently dried. In out-
ally in the deepest part of the pit or fissure reach situations a wet cotton wool pellet
for the occlusal surface, and the instru- is used and the cavity dried with a dry
ment tip rotated backwards and forwards pellet. Note, that since a local anaesthetic
while maintaining slight pressure (Fig. 8). is not routinely used, luke-warm water for
This fractures off the weak demineralised rinsing is preferable to reduce tooth sensi-
enamel surrounding the cavity entrance, tivity during this stage. The use of a triple Fig. 9 The smallest excavator is used to
permitting adequate access to the dentine syringe is not recommended. The cavity remove soft dentine from the enamel
caries for the smallest excavator. As men- is then examined carefully and additional dentine junction by making circular scooping
movements under the enamel
tioned above, an EAC can also be used cavity cleaning is undertaken if necessary.
to improve access to a caries lesion. This It is important that stained or discoloured
instrument is placed in the cavity opening dentine that is hard should be retained.
and rotated in a similar way as the hatchet There is normally no indication to use
to fracture off weak demineralised enamel. a lining material for an ART restoration
The EAC has two pyramidal shaped work- except in the deepest of cavities. Here a
ing tips, one  large and one  small. The setting calcium hydroxide liner can be
largest tip can be used when the cavity used but only at the spot closest to the
opening is relatively wide, but needs to be pulp. Excessive use of lining material will
opened further; the smaller tip being used reduce the surface area available for bond-
in small openings where there might be ing of the GIC. Fig. 10 Where more access is required, some
difficulty in using the hatchet. of the enamel can be gently fractured off
Note: the EAC should not be used for Step 6. Conditioning the cavity with the blade of the hatchet along the line
creating cavities where they do not exist.
and adjacent pits and fissures of the enamel prisms

If in doubt about the presence of a pos- The use of hand instruments on the dentine
sible lesion it is better to place a thera- surface results in a smear layer. In order powder-liquid GIC is used the liquid com-
peutic sealant without any mechanical to improve the chemical and mechanical ponent of the GIC can be used as the con-
preparation. bonding of the GIC to the tooth tissues ditioner. The concentration is often too
this smear layer must be removed by the high and needs to be reduced. This can be
Step 5. Cavity cleaning use of a dentine conditioner. When using achieved easily by dipping a cotton wool
Hand excavators are used to remove soft, encapsulated GIC it will be necessary to pellet in water, removing excess on a paper
infected dentine. Cavity cleaning starts use a separate dentine conditioner spe- towel and then dipping this moist cotton
with the removal of soft dentine from cially developed for this purpose. This wool pellet in a drop of the liquid compo-
the EDJ. Here the smallest excavator is differs from the liquid used for acid- nent of the hand-mixed GIC.
used making circular scooping move- etching for composites since a dentine Note: the liquid component of GIC can
ments under the enamel (Fig. 9). This so conditioner usually contains a solution only be used for conditioning if it contains
called ‘unsupported’ enamel only needs to of between 10‑40% polyacrylic, tartaric the acid component of the GIC. There are
be removed if it is thin and weak or if and/or maleic acid. Because of the differ- some brands of GIC where the liquid com-
additional access is required to complete ence in dentine conditioners available, it ponent consists of demineralised water only,
removal of soft dentine at the EDJ. Here, is important to carefully follow the man- the acid being in the powder in a freeze-
some of the enamel can be gently fractured ufacturer’s instructions. If a hand-mixed dried form. Under such circumstances a

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© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

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
Fig. 11 The GIC is inserted into the cavity in fissures adjoining the cavity (Fig. 12).
Fig. 14 The excess GIC is displaced to the
small increments using the rounded end of the outer margins of the occlusal surface and will Rub a small amount of petroleum jelly
applier/carver instrument. Where possible, pack need to be removed as soon as possible with on the gloved index finger. Spread the
the GIC under any overhanging enamel first, the carver or large excavator taking care not petroleum jelly thinly over the tip of the
before filling the central portion of the cavity to dislodge the restoration
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-
Fig. 15 The finished restoration is then rial from lifting out of the cavity or pits
Fig. 12 Slightly overfill the cavity and then covered with petroleum jelly or varnish and and fissures. The press-finger technique
place additional GIC in any pits and fissures the patient advised not to eat for at least results in excess GIC being displaced to
adjoining the cavity one hour
the outer margins of the occlusal surface.
Remove this excess as soon as possible
a negative effect on the bonding of the GIC with either the carver instrument or the
to dentine and enamel. Therefore, if the large excavator, taking care not to dislodge
conditioned tooth surface becomes con- the restoration (Fig.  14). Ensure that the
taminated it is essential to wash and dry it, proximal areas are clear of excess GIC.
recondition, wash and dry it again. Note: in the event that insufficient GIC
has been mixed to ensure the cavity and
Step 7. Mixing GIC fissures are completely filled, pack this first
A consistent and correct mix of GIC is essen- mix into the cavity with the applier but DO
tial for reliable results. Always follow the NOT use the press-finger technique at this
Fig. 13 The tip of the index finger is manufacturers’ instructions. This involves stage. While maintaining good moisture
then placed onto the central part of the following recommendations for mixing control, a second batch of GIC is mixed
restorations to enable the GIC to be pressed time and finishing the restoration within that can then be used to completely fill the
firmly into the cavity, pit and fissures
the specified working time. For hand-mix cavity and pits and fissures.
GIC, the correct powder to liquid ratio must
separate dentine conditioner must be used. be maintained since too much powder or too Step 9. Finishing the
The conditioner is applied to the cavity much liquid can result in a weaker restora-
ART restoration
and pits and fissures using a cotton wool tion.29 If a hand-mix GIC is used, those for Before the GIC becomes too hard, the
pellet for 15‑20 seconds or for the period ART have a high powder-to-liquid ratio and occlusion is checked with articulating
of time specified by the manufacturer. are usually more difficult to mix than other paper. Any parts of the restoration that
Bond strength is affected if insufficient or GICs, thus special care needs to be taken. are too high can be adjusted using the
too long a time is allowed for conditioning. The consistency of the final mix does, how- carver instrument or the large excavator.
Wash the cavity and pits and fissures with ever, vary between different manufacturers. The finished restoration is then covered
pellets dipped in clean, luke-warm water with petroleum jelly or varnish (Fig. 15).
and then dry carefully. If a triple-syringe is Step 8. Restoring the cavity Ask the patient to avoid eating for at least
used, take care not to over-dry the cavity
and filling the pits and fissures an hour.
since this will tend to reduce the chemical The mixed GIC must be used promptly Note: the dentist can adapt the clinical
bonding of the GIC to the dentine. since any delay will compromise bonding procedures according to the equipment
Note: At this stage proper isolation is to the tooth surface. The GIC is inserted available and his normal working practice.
essential. Contamination of the conditioned into the cavity in small increments using For example, a local anaesthetic can be
tooth surface with saliva or blood will have the rounded end of the applier/carver used, a rubber dam can be placed, and a

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© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

rotary instrument instead of a hatchet can d’Evidence Based Dentistry, which has
be used to gain minimal access to the body started to make some Cochrane reviews
of the lesion. The use of rotary instruments available in French, there remains a dearth
is, however, specifically not part of the clas- of information in the French language.
sic ART approach. Since the ART approach, Since its early development, ART has
as has been described above, provides sat- constantly been subject to research evalua-
isfactory clinical results (see our section tion and remains one of the most researched
on the evidence base), there is no need to minimal intervention approaches with
overload the clinical procedures with meth- currently over 200  publications on the
ods or equipment that may raise anxiety in subject. With respect to the effectiveness
patients (eg rotary instruments are often not of the approach a number of systematic
accepted by children and dental phobics). reviews and meta-analyses have been
undertaken. The first meta-analysis of the
ART SEALANTS STEP-BY-STEP effectiveness of single-surface ART res-
Fig. 16 A completed ART sealant
The only difference between placing an torations in the permanent dentition was
ART restoration and an ART sealant is that published by Frencken et al. in 2004.32 This
with the latter there is no cavity to clean study, based on an analysis of five studies in the permanent dentition, the survival of
and restore. Otherwise all the other steps reported no difference in survival results ART restorations is equal to or greater than
and materials remain identical. over three  years between single-surface that of equivalent amalgam restorations
The same high-viscosity GIC is used but ART restorations and amalgam restora- for up to 6.3 years and is site-dependent.35
cavity preparation is not undertaken. Thus, tions. It also indicated that results were In primary teeth no difference in survival
techniques of isolation, cleaning, condi- better from the then more recent studies outcomes between the two types of resto-
tioning and filling of the pits and fissures as the ART approach evolved and better ration was observed.
remain identical. The steps are therefore restorative materials became available. ART has also been used in institutional-
summarised as: The interest in the ART approach led ised elderly populations for treating root
• Step 1. Preparation of the ART to a substantial number of research pub- surface caries where short-term results
instruments and materials before the lications on the subject during this time suggest that ART restorations compare
clinical procedure that permitted a second more compre- favourably with traditional approaches
• Step 2. Isolation of the operating site hensive meta-analysis to be undertaken to treat such lesions.36 In this context, an
• Step 3. Cleaning the pits and fissures in 2006.33 Here, 28 studies were included earlier study where ART restorations were
and examination of the tooth in the analysis. The high mean survival provided for housebound Finnish elderly
• Step 4. Conditioning the pits and fissures rates for single-surface ART restorations also showed high success rates.37
• Step 5. Mixing the GIC using high-viscosity GIC in permanent With respect to the evidence base for
• Step 6. Filling the pits and fissure dentitions found in the previous meta- ART sealants, the meta-analysis of van’t
• Step 7. Press-Finger analysis was confirmed and a survival Hoff et al. in 2006 found that the number
• Step 8. Finishing the ART sealant rate of 72% over a period of six  years of studies reporting on the retention and
(Fig. 16). was reported.32 Similarly, in primary teeth caries preventive effect of ART sealants was
single-surface ART restorations using low but based on available evidence the
THE EFFECTIVENESS OF ART – high-viscosity GIC had a high mean sur- mean survival rate for partially and fully
WHAT IS THE EVIDENCE BASE? vival rate of 95% after one year and 86% retained ART sealants in permanent denti-
Ideally all dental care decisions and treat- after three  years. The survival rates of tions using a high-viscosity GIC was of the
ments should be based on a sound research multiple-surface ART restorations in the order of 72% after three years.33 In terms of
evidence base, this being the basis of evi- primary dentition were low with a mean effectiveness in preventing caries over this
dence-based dentistry. This helps to ensure annual failure rate of 17%. time period, 97% of sealed teeth remained
that dental care is both safe and effective. The most recent meta-analysis of ART sound. The more recent meta-analysis by
Unfortunately, the evidence base to sup- survival based on 29 publications reported de Amorim et al.34 showed that the caries
port the effectiveness of many of the com- that for single-surface ART restorations in prevention effect of ART sealants was high.
monly performed treatments in dentistry permanent teeth over the first three and A summary of the evidence base for ART
is limited both in quantity and quality.30,31 five years the mean survival rates were 85% is that:
Gradually, properly conducted systemic and 80% respectively and 86% for multi- • Single-surface ART restorations using
reviews of dental treatment approaches ple-surface ART restorations in permanent high-viscosity GIC in both primary and
are appearing in the literature and there teeth over one year.34 The survival rates of permanent teeth show high survival
are attempts by a number of organisations single and multiple-surface ART restora- rates and can therefore be safely used
to sensitise and educate the dental pro- tions in primary teeth over two years were • The survival rate for multiple surface
fession (Cochrane, NICE, American Dental 93% and 62% respectively. A systematic ART restorations in primary teeth is
Association, etc). Despite initiatives by review comparing the longevity of ART rather low
organisations such as the Centre Français and amalgam restorations concluded that, • ART restorations have the ability to

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


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

outperform amalgam restorations in decayed teeth are restored.39 The reasons lower the likelihood of future complex
terms of survival for this lack of care is obviously multifac- restorations.8,43 ART sealants made using
• ART sealants have a high caries torial but demands the question whether a high-strength high-viscosity GIC have
preventive effect. other models of delivery of oral care using the advantage over resin-based sealants
approaches such as ART could be explored in that they can be used where moisture
INDICATIONS FOR in France, for instance providing preven- control is less than optimal, for instance,
THE ART APPROACH tion and caries management within the in erupting teeth in high caries risk indi-
As with all preventive and restorative schools as is done in other countries.40 viduals or in younger children.
approaches ART must not be considered a Likewise, non-mobile elderly or physi- Irrespective of the type of sealant used,
panacea and therefore careful case selec- cally and mentally handicapped peo- be it ART or resin-based, its placement is
tion is essential. The indications for ART ple might not easily be able to access non-invasive. Therapeutic sealants can
are based on the strengths of the approach the dental clinic. Although oral health effectively halt the progression of initial or
for certain situations combined with the data for the elderly in France is limited, incipient caries lesions. Conversely, even if
evidence base for its effectiveness. Thus, a report by the Haute Autorité de Santé a minimal invasive approach is used to treat
the indications can largely be divided into (HAS) showed that elderly people have lit- such a lesion, the tooth is condemned for
two levels, the patient and the tooth. tle access to dental care and that between life to the repeat restoration cycle.43 Thus,
30-60% require restorative treatment.41,42 therapeutic sealants using resins or ART
Indications at the patient level Here some extractions and restorative care can preserve tooth structure and lower the
At the patient level, one of the major using the ART approach could be delivered likelihood of future complex restorations.8
strengths of the ART approach is that it is in their homes without resort to expensive
well accepted by patients. The high accept- portable dental equipment.36,37 REPAIR OF ART RESTORATIONS
ance is because, unlike most traditional An important element of the minimal inter-
restorative treatment of vital teeth, ART Indications at the tooth level vention approach is the repair of defective
rarely requires a local anaesthetic. This is The indications at the tooth level are based restorations rather than their total replace-
largely because of the minimally invasive on the best evidence from clinical studies. ment.9 Replacement of defective restora-
nature of the approach where only necrotic There is now evidence to show that ART tions is accompanied by a risk of increasing
tissue is removed and where remaining single-surface restorations using high- the size of the cavity thereby weakening the
sound tissue is retained. Moreover, since viscosity GIC have a high survival rate in tooth if the defective restoration is removed
rotary instrumentation is not used with ART, both primary and permanent teeth that is in its entirety. Tyas et al.9 discuss at length
the threatening sound from this and the comparable to, if not better than, traditional the decision-making process as to whether
necessary high-volume suction is absent. In amalgam restorations.34,35 Taken that ART to leave, repair or replace what is deemed
this respect, a recent review on dental anxi- restorations are both minimally invasive to be a defective restoration. Alternative
ety and pain relating to the ART approach and caries protective when compared to treatments to replacement of both defective
concluded that the ART approach has been other traditional restorative methods, ART amalgam and resin-based composite resto-
shown to cause less discomfort than other restorations might therefore be considered rations using refinishing, sealing of defec-
conventional approaches and is, therefore, a treatment of choice for single-surface car- tive margins or repair, show the viability
considered a very promising ‘atraumatic’ ies lesions. The evidence suggests that ART of this approach in the long term.44,45 These
management approach for use in carious restorations can be used for multiple surface principles can also be applied to ART resto-
lesions in children, anxious adults and pos- caries lesions in primary teeth but that, as rations and sealants made with GIC. Indeed
sibly dental-phobic patients.38 for other multiple-surface restorations in Christensen positively encourages the use of
The other major strength of the ART primary teeth, the survival rates are lower GIC for the repair of defective restorations.46
approach is that it can be used equally well than those for single-surface restorations.
in a dental practice setting as in an out- There are limited data on the use of ART CONCLUSIONS
reach environment such as in schools or in restorations for multiple-surface lesions in Over the past two decades ART, as a mini-
old people’s homes. The concept of deliver- permanent teeth and therefore additional mal intervention and minimal invasion
ing care outside the dental practice setting research is required on this aspect. approach for the management of den-
is largely alien to the dental profession. In With respect to the use of sealants tal caries, has proven to be a success in
France, as in many developed countries, generally, their use should be targeted to both developed and developing countries.
little dental care is delivered outside the individuals and teeth that are at high risk There is now a strong evidence base to
traditional dental clinic environment. This of developing caries and to teeth that are show that ART is a quality approach to
does, however, limit the coverage of dental already exhibiting early caries lesions. control caries that is reliable and effec-
care to those persons who can easily access This means that instead of adopting an tive. As with many developments in oral
a dental clinic or are adequately motivated invasive approach for initial or incipi- health, but especially minimal interven-
to do so. As an example, in France for ent caries lesions, the placement of seal- tion and minimal invasion approaches, the
children at age six, two  thirds of dental ant can effectively halt the progression dental profession and the dental education
cavities in primary teeth are not treated. of these lesions. Such an approach can system has been very slow to take these
Similarly, in 12-years olds, only half the potentially preserve tooth structure and on board even though there is a strong

BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013 17


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

evidence base for these approaches. Thus dentistry. Aust Dent J 1992; 37: 205–210. 27. Gruythuysen R J, van Strijp A J, Wu M K. Long-term
3. Frencken J E, van Amerongen W E. The Atraumatic survival of indirect pulp treatment performed in pri-
the concepts that are described in this arti- Restorative Treatment approach. In Fejerskov mary and permanent teeth with clinically diagnosed
cle might be alien and hard to accept by O, Kidd E (eds) Dental caries: the disease and its deep carious lesions. J Endod 2010; 36: 1490–1493.
clinical management. 2nd ed. pp 427–442. Oxford: 28. Bjørndal L, Reit C, Bruun G et al. Treatment of deep
many dental practitioners who have had a Blackwell Munksgaard, 2008. caries lesions in adults: randomized clinical trials
traditional, rhetorical-based dental educa- 4. Frencken J E, Leal S C. The correct use of the ART comparing stepwise vs. direct complete excavation,
approach. J Appl Oral Sci 2010; 18: 1–4. and direct pulp capping vs. partial pulpotomy. Eur J
tion. This is consistent with what is known 5. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä Oral Sci 2010; 118: 290–297.
as the research-application gap. In France, M, Worthington H V. Pit and fissure sealants for 29. Dowling A H, Fleming G J. Is encapsulation of
preventing dental decay in the permanent teeth of posterior glass-ionomer restoratives the solution to
it appears that very few practicing dentists children and adolescents. Cochrane Database Syst clinically induced variability introduced on mixing?
or dental academics are aware of the ART Rev 2008; 4: CD001830. Dent Mater 2008; 24: 957–966.
6. Beauchamp J, Caufield P W, Crall J J et al. Evidence- 30. Butani Y, Levy S M, Nowak A J et al. Overview of
approach or other minimal intervention based clinical recommendations for the use of the evidence for clinical interventions in pediatric
and minimal invasion approaches and the pit‑and‑fissure sealants: a report of the American dentistry. Pediatr Dent 2005; 27: 6–11.
Dental Association Council on Scientific Affairs. 31. Glick M, Meyer D M. Evidence or science based?
opportunities they can afford. Failure of J Am Dent Assoc 2008; 139: 257–268. There is a time for every purpose. J Am Dent Assoc
the dental profession and the dental edu- 7. Gooch B F, Griffin S O, Gray S K et al. Preventing 2011; 142: 12–14.
dental caries through school-based sealant pro- 32. Frencken J E, Van’t Hof M A, Van Amerongen W E,
cation system to embrace these approaches grams: updated recommendations and reviews of Holmgren C J. Effectiveness of single-surface ART
results in the oral health of our patients evidence. J Am Dent Assoc 2009; 140: 1356–1365. restorations in the permanent dentition: a meta-
8. Griffin S O, Oong E, Kohn W et al. The effectiveness analysis. J Dent Res 2004; 83: 120–123.
being placed at a disadvantage. of sealants in managing caries lesions. J Dent Res 33. Van’t Hof M A, Frencken J E, van Palenstein Helderman
2008; 87: 169–174. W H, Holmgren C J. The atraumatic restorative treat-
9. Tyas M J, Anusavice K J, Frencken J E, Mount G J. ment (ART) approach for managing dental caries: a
ADDITIONAL NOTE Minimal intervention dentistry ‑ a review. FDI meta-analysis. Int Dent J 2006; 56: 345–351.
Commission Project 1–97. Int Dent J 2000; 50: 1–12. 34. de Amorim R G, Leal S C, Frencken J E. Survival of
The indications for ART at the patient level 10. Fejerskov O, Kidd E, Bente N. Dental caries: the dis- atraumatic restorative treatment (ART) sealants
mentioned in this article relate to the situa- ease and its clinical management. 2nd ed. Oxford: and restorations: a meta-analysis. Clin Oral Investig
Blackwell Munksgaard, 2008. 2012; 16: 429–441.
tion in France with country-specific exam- 11. Alves L S, Fontanella V, Damo A C, Ferreira de 35. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic
ples given. For example, while in France for Oliveira E, Maltz M. Qualitative and quantitative restorative treatment versus amalgam restoration
radiographic assessment of sealed carious dentin: a longevity: a systematic review. Clinical Oral Investig
children at age six, two-thirds of primary 10-year prospective study. Oral Surg Oral Med Oral 2010; 14: 233–240.
teeth with cavities are not restored, this fig- Pathol Oral Radiol Endod 2010; 109: 135–141. 36. Lo E C, Luo Y, Tan H P, Dyson J E, Corbet E F. ART
12. Fusayama T, Okuse K, Hosoda H. Relationship between and conventional root restorations in elders after
ure is even worse in the United Kingdom hardness, discoloration, and microbial invasion in 12 months. J Dent Res 2006; 85: 929–932.
where, according to the 2003 survey of chil- carious dentin. J Dent Res 1966; 45: 1033–1046. 37. Honkala S, Honkala E. Atraumatic dental treatment
13. Massler M. Pulpal reactions to dental caries. Int among Finnish elderly persons. J Oral Rehabil 2002;
dren’s dental health in the United Kingdom, Dent J 1967; 17: 441–460. 29: 435–440.
for children age five, only one  eighth of 14. Fusayama T, Terachima S. Differentiation of two 38. Leal S C, Abreu D M, Frencken J E. Dental anxiety and
layers of carious dentin by staining. J Dent Res pain related to ART. J Appl Oral Sci 2009; 17: 84–88.
decayed teeth are restored on average. This 1972; 51: 866. 39. Hescot P, Rolland E. La santé dentaire en France.
does not imply that the authors advocate 15. Banerjee A, Kidd E A, Watson T F. In vitro evaluation Paris, France: UFSBD, 2006.
of five alternative methods of carious dentine 40. Hermosillo V H, Quintero L E, Guerrero N D, Suárez
that all decayed primary teeth be restored.47,48 excavation. Caries Res 2000; 34: 144–150. D D, Hernández M J, Holmgren C J. The imple-
With respect to 12-year-old children the sit- 16. Celiberti P, Francescut P, Lussi A. Performance of mentation and preliminary evaluation of an ART
four dentine excavation methods in deciduous strategy in Mexico: a country example. J Appl Oral
uation appears better in the United Kingdom teeth. Caries Res 2006; 40: 117–123. Sci 2009; 17: 114–121.
than in France since over half the decayed 17. Kidd E A. How ‘clean’ must a cavity be before 41. Haute Autorité de Santé. Stratégies de prévention
restoration? Caries Res 2004; 38: 305–313. de la carie dentaire. HAS, 2010. Online informa-
permanent teeth are filled.47,48 In common 18. Ricketts D N, Kidd E A, Innes N, Clarkson J. tion available at http://www.has-sante.fr (accessed
with France, access to oral dental care in the Complete or ultraconservative removal of decayed November 2012).
tissue in unfilled teeth. Cochrane Database Syst Rev 42. Montal S, Tramini P, Triay J A, Valcarcel J. Oral
United Kingdom is difficult for the elderly or 2006; 3: CD003808. hygiene and the need for treatment of the depend-
handicapped.49 For example, in one survey of 19. Thompson V, Craig R G, Curro F A, Green W S, Ship ent institutionalised elderly. Gerodontology 2006;
J A. Treatment of deep carious lesions by complete 23: 67–72.
nursing home residents in Avon, 63% were excavation or partial removal: a critical review. J Am 43. Elderton R J. Preventive (evidence-based) approach
found to have root caries.50 The commonal- Dent Assoc 2008; 139: 705–712. to quality general dental care. Med Princ Pract
20. Handelman S L, Leverett D H, Espeland M A, Curzon 2003; 12: 12–21.
ity of untreated dental caries in both France J A. Clinical radiographic evaluation of sealed 44. Moncada G, Martin J, Fernández E, Haempel M C,
and the United Kingdom points to the need carious and sound tooth surfaces. J Am Dent Assoc Mjör I A, Gordan V V. Sealing, refurbishment and
1986; 113: 751–754. repair of Class I and Class II defective restorations:
to explore new approaches to the delivery of 21. Mertz-Fairhurst E J, Curtis J W Jr, Ergle J W, a three-year clinical trial. J Am Dent Assoc 2009;
oral care. Atraumatic restorative treatment Rueggeberg F A, Adair S M. Ultraconservative and 140: 425–432.
cariostatic sealed restorations: results at year 10. 45. Gordan V V, Garvan C W, Blaser P K, Mondragon
might be one of a number of approaches that J Am Dent Assoc 1998; 129: 55–66. E, Mjör I A. A long-term evaluation of alternative
could lead to an improvement of oral health 22. Massara M L, Alves J B, Brandão P R. Atraumatic treatments to replacement of resin-based compos-
restorative treatment: clinical, ultrastructural and ite restorations: results of a seven-year study. J Am
in our populations. chemical analysis. Caries Res 2002; 36: 430–436. Dent Assoc 2009; 140: 1476–1484.
23. Jeronimus D J Jr, Till M J, Sveen O B. Reduced viabil- 46. Christensen G J. Restorative dentistry for times of eco-
The authors would like to thank Dr Jo Frencken for ity of microorganisms under dental sealants. ASDC nomic distress. J Am Dent Assoc 2009; 140: 239–242.
reviewing the manuscript and for kindly providing J Dent Child 1975; 42: 275–280. 47. Pitts N B, Harker R. Children’s dental health in the
Figures 6 to 15 and Claudie Damour-Terrasson, 24. Jensen O E, Handelman S L. Effect of an autopolym- United Kingdom 2003: obvious decay experience.
publishing director of the Groupe Information erizing sealant on viability of microflora in occlusal London: Office for National Statistic, 2005.
Dentaire, Paris, France, for authorising the transla- dental caries. Scand J Dent Res 1980; 88: 382–388. 48. Pitts N B, Chestnutt I G, Evans D, White D, Chadwick
tion and publication of the series in the BDJ. 25. Wambier D S, dos Santos F A, Guedes-Pinto A C, B, Steele J G. The dentinal caries experience of chil-
Jaeger R G, Simionato M R. Ultrastructural and dren in the United Kingdom, 2003. Br Dent J 2006;
1. Dawson A S, Makinson O F. Dental treatment and microbiological analysis of the dentin layers affected 200: 313–320.
dental health. Part 1. A review of studies in support by caries lesions in primary molars treated by mini- 49. Simons D. Who will provide dental care for house-
of a philosophy of Minimum Intervention Dentistry. mal intervention. Pediatr Dent 2007; 29: 228–234. bound people with oral problems? Br Dent J 2003;
Aust Dent J 1992; 37: 126–132. 26. Oong E M, Griffin S O, Kohn W G, Gooch B F, 194: 137–138.
2. Dawson A S, Makinson O F. Dental treatment and Caufield P W. The effect of dental sealants on 50. Frenkel H, Harvey I, Newcombe R G. Oral health
dental health. Part 2. An alternative philosophy bacteria levels in caries lesions: a review of the care among nursing home residents in Avon.
and some new treatment modalities in operative evidence. J Am Dent Assoc 2008; 139: 271–278. Gerodontology 2000; 17: 33–38.

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


© 2013 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Suggests the inhibition of caries
part 6. Caries inhibition progression by resin infiltration should

PRACTICE
now be considered an alternative to
invasive restorations.

by resin infiltration • Describes the principle and protocol of


resin infiltration of carious lesions.

J. J. Lasfargues,*1,2 E. Bonte,1,2 A. Guerrieri1,2 and L. Fezzani1,2

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.

INTRODUCTION invasive restoration.1 In this context a has been a lack of effective procedures
In recent decades, the management of new technique to stop the progression of for stopping initial lesions in one  ses-
carious lesions has shifted the paradigm initial caries without the use of drilling sion. This applies particularly to proximal
of drilling and filling into the paradigm has been proposed: the inhibition of caries carious lesions and the buccal and lingual
of prevention, control and minimally by resin infiltration, that is, stopping the smooth surfaces.
active carious process at its site without Resin infiltration of carious lesions rep-
any invasive procedure.2 resents an approach to the treatment of
MINIMAL INTERVENTION Remineralisation of enamel deminer- non-cavitated lesions on proximal and
DENTISTRY
alised by acids from the cariogenic bio- smooth surfaces of primary and perma-
1. From ‘compulsive’ restorative dentistry to film can be achieved principally through nent teeth. The principal feature of this
rational therapeutic strategies
the application of topical fluorides and technique is that it is non-invasive, pre-
2. Caries risk assessment in adults
remineralising agents3,4 by the use of fis- serves tooth structure and can be com-
3. Paediatric dental care – prevention and
management protocols using caries risk sure sealants or by repair of the lesion pleted in a single visit. The concept was
assessment for infants and young children using bioactive materials.5 In all cases first developed in Germany, at the Charité
4. Detection and diagnosis of initial the goal is to stop lesion progression. University Hospital in Berlin, from in vitro
caries lesions
Remineralisation by topical application studies on the penetration of resin into
5. Atraumatic restorative treatment (ART) – 
a minimum intervention and minimally of fluoride requires multiple treatment caries9-11 and marketed under the brand
invasive approach for the management sessions and strict long-term follow-up, name of Icon® (DMG America Company,
of dental caries
which implies strong cooperation from the Englewood, NJ).
6. Caries inhibition by resin infiltration
patient and is often difficult to obtain. In
7. Minimally invasive operative caries PRINCIPLE OF RESIN INFILTRATION
management – rationale and techniques addition, monitoring systems for assessing
This paper is adapted from: Lasfargues JJ, Bonte E, Guerrieri A, the status of the lesions over time are still
OF CARIOUS LESIONS
Fezzani L. Inhibition carieuse par infiltration résineuse. Réalités
Cliniques 2011; 22: 257–267. being studied and are difficult to apply The principle of resin infiltration is to per-
in every-day clinical practice.6 Sealing fuse porous enamel with resin by capillary
techniques using resin or glass-ionomer action, thereby stopping the process of
cements are primarily intended for initial demineralisation and stabilising the carious
1
Faculté de Chirurgie Dentaire, Université Paris
carious lesions in the pits and fissures on lesion. The principle can be compared with
Descartes, 1 rue Maurice Arnoux, 92120 Montrouge, occlusal surfaces of erupting posterior the saturation of a sugar cube or sponge
France; 2Service d’Odontologie – Hôpital Bretonneau –
APHP, 23 rue Joseph de Maistre, 75018 Paris, France
teeth. They have been proven to prevent with a liquid (Fig. 1). The infiltration takes
*Correspondence to: Professor Jean-Jacques Lasfargues tooth decay7 but their effectiveness in the place within the enamel, in contrast to pit
Email: jean-jacques.lasfargues@brt.aphp.fr;
Telephone: +33 1 53 11 14 30
sealing of carious lesions in site 1 (occlusal and fissure sealants, which forms a superfi-
surfaces) to prevent the need for a restora- cial mechanical barrier on the outer surface
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2013.54
tion of stages 0 and 1 (SiSta classification)8 of the initial lesion, depriving the bacteria
© British Dental Journal 2013; 214: 53–59 remains controversial. Thus, hitherto there that colonise the surface of the lesion of

BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013 53


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

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
c (CLSM) in dual fluorescence (DF) and combined transparent fluorescence (CTF) modes, and
Fig. 1 Illustration of the concept of by transversal microradiographs (TMR) and scanning electron microscopy (SEM). With the
infiltration by a low viscosity resin: direct technique, areas infiltrated by the resin are not all identified by red fluorescence. With
coffee plays the role of ‘infiltrating’ the the indirect technique, the images obtained by CLSM infiltration DF are a good fit with the
sugar cube, analogous to porous enamel different reference methods. (Figure reproduced courtesy of the Journal of Microscopy Research
(a); Clinical application of the concept: and Technique, John Wiley Publishing)18
the infiltration by resin is achieved
by depositing the liquid resin on the nutrients from the biofilm (Fig. 2). Bacteria and their capacity to obstruct
demineralised enamel using a specially
developed method (b) and then the resin in
that have penetrated the demineralised caries progression.
the saturated area (c) is light-cured enamel are trapped in the infiltrating resin The results indicate that the inhibition
once it has been cured. of caries progression is achieved by the
It has been shown that bacteria can sequential effects of 15% hydrochloric acid
physically cross the outer, macroscopi- gel applied for two minutes, followed by
cally intact or slightly damaged enamel the application of a low viscosity resin of
of non-cavitated lesions.12 The presence type TEGDMA (tri-ethylene glycol dimeth-
of these trapped bacteria does not pre- acrylate) with a sufficiently high (>200 cm/
vent the resin infiltrating and does not sec) penetration coefficient. Studies by
warrant operative treatment by surgical confocal laser microscopy19 have produced
a tissue removal and restoration.13 To pen- images demonstrating the penetration of
etrate the entire thickness of the enamel, the resin, thus allowing the depth of the
to seal its pores, to block the diffusion of lesion and its non-progression after resin
nutrients and to stop caries progression infiltration to be checked (Fig. 3).
it is essential that the infiltrating agent
has a high penetrative ability. Despite the INDICATIONS FOR RESIN INFILTRA-
novelty of this technique several research
TION OF CARIOUS LESIONS
studies both in vitro and in vivo14-18 have The erosion/infiltration technique has been
b tested the: proposed for hiding white spots associated
Fig. 2 Sealing and infiltration of initial • Erosive potential of different etching with non-carious conditions such as fluo-
caries lesions at Site 1 and Site 2 (a) are agents, including hydrochloric acid, on rosis20,21 and it appears to give satisfactory
two different therapeutic concepts; (b) at the ‘compact’ layer and the ‘pseudo- aesthetic results in patients (Fig. 4). This
Site 1, the sealant forms a physical surface
barrier which deprives bacteria of nutrients. intact’ enamel surface to permit resin use of the technique will not be discussed
At Site 2, infiltrating the enamel with resin impregnation of the enamel further in this article.
traps the bacteria that have penetrated the • Ability of different adhesive systems Infiltration of carious lesions may be
body of the lesion and the outcome is a
and low viscosity resin fluids to indicated in all age groups- children, ado-
hybrid resin enamel
penetrate the enamel subsurface lescents and adults, for all initial lesions

54 BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

Prevention Restoration
(No invasive care) (Invasive care)

EI EII DI

Fig. 4a Preoperative situation showing


non-carious white spot on 11 and 21, in an
18-year-old patient

Fluoridation Infiltration Infiltration?


Resin infiltration
(Micro-invasive care)

Fig. 5 Schematic representation of comparative indications for remineralisation by fluoride, by


Fig. 4b Situation during the procedure: resin infiltration and minimal intervention dentistry. These treatment options are offered for
application of infiltrating resin after etching guidance, given the difficulty of creating a categorical decision based on the radiographs alone
with hydrochloric acid
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. 4c Result three months after treatment;


the aesthetic result obtained after the
infiltration procedure is maintained and a c
continues to satisfy the patient
Fig. 6 White spot demineralisation after
where the depth does not exceed the outer orthodontic care, before treatment:
(a) processing by resin infiltration; (b)
third of dentine, that is, SiSta stages 0 and condition after etching with hydrochloric
1 (Fig. 5). The technique is aimed primarily acid, dried with ethanol; (c) result after
at initial proximal lesions. Below a thresh- six months
old depth estimated at 800  microns2 the
tissue lost by demineralisation is replaced
by infiltrated resin, creating an internal b
barrier to the diffusion of sugars and
organic acids which would otherwise colo-
nise the proximal embrasure. This barrier in a high caries risk oral environment, pro- (Fig 7). The nozzle itself consists of a dou-
stabilises and freezes the lesion without vided that they are not cavitated and are ble film of superfine transparent plastic,
affecting the anatomical shape of the tooth surrounded by intact enamel. In addition perforated on one side for the delivery of
since the surface is not directly concerned. to stabilising the lesion, the appearance the agents and simultaneously protecting
Thus, the interproximal physiology is not of the tooth is generally improved by the the neighbouring surface from them. These
disturbed, provided that the excess resin is technique (Fig. 6). tips can be rotated 360°, which facilitates
carefully removed in accordance with the application from all angles. Two  screw
application procedure (see protocol). OPERATING PROTOCOL syringes are used to control extrusion of
The second indication for the technique All the necessary elements are included acid gel and the infiltration resin respec-
is for carious lesions on non-proximal in the proximal treatment kit, including tively. Interdental wedges can be used to
smooth surfaces, such as opaque white syringes with special tips for delivering separate the surface to be treated and the
lesions around orthodontic devices used in situ the acid gel and infiltration resin contiguous surface.

BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013 55


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

a Fig. 8f Drying with air syringe

Fig. 8a Operative Protocol. Initial clinical


view of the segment 14‑16

Fig. 8g Dehydration with 99% ethanol (Icon


b
Dry®)
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. 8b Pre-operative bitewing showing
amalgam with marginal excess at 15 and
several proximal initial lesions, including 14
The operative steps (Fig. 8) will be illus- (D) and 15 (D)
trated by the treatment of a proximal
lesion of a maxillary premolar (distal sur- Fig. 8h Application of the infiltration resin
using the proximal nozzle
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- Fig. 8c Isolation by rubber dam and
interdental wedges (amalgam in 15 removed)
ies risk patient with numerous proximal
lesions and corroded amalgams with mar- Fig. 8i Light polymerisation of the
ginal overhangs. Given the anticipated infiltration resin from all angles for 40 s,
after withdrawing the nozzle and removing
orthodontic care and the patient’s poor excess resin with dental floss
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 Fig. 8d Etching (Icon Etch®) the
demineralised area for two minutes (15D)
by adhesive long-term temporary resto-
rations. Follow-up should confirm the
absence of recurrent caries and decisions
about prosthetic restorations should be Fig. 8j No immediate but short time recall
deferred pending decisions about ortho- radiographic examination; postoperative
dontic treatment: radiograph shows that the two lesions on
• Indications for resin impregnation 15 and 14 treated by resin infiltration have
not progressed. Replacement of the amalgam
treatment should be based on with marginal excess by a composite restoration
bitewing radiographs, showing an allows the patient to manage plaque control.
enamel stage 0 initial lesion and on Other Stage 0 lesions are treated identically.
Fig. 8e Rinsing (30 s) See: Figs 1b-c
the clinical situation

56 BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

• Before treatment, the teeth must be • A clinical and radiographic follow-up


cleaned and then isolated by rubber should be initiated to confirm that the
dam, rinsed and dried lesions do not progress and that there
• A plastic inter-dental wedge should be is no recurrence. The same protocol
inserted into the inter-dental space is recommended for the treatment of
• The transparent proximal application white spot carious lesions on buccal
nozzle should be screwed onto and palatal surfaces, using the Icon
the syringe, pre-filled with 15% ‘Smooth Surfaces ®’ kit, in which the
hydrochloric acid, and then set proximal nozzles are replaced by
up correctly positioned in the nozzles with pads suitable for buccal
interdental space or lingual surfaces (Fig. 9).
• The etching gel (Etch Icon®) should
be extruded towards the affected DISCUSSION
proximal surface and left in place for A systematic review of the literature
two minutes to make the outer layer of comparing techniques for sealing and
enamel porous infiltration in the treatment of initial
• The transparent application nozzle caries lesion, concludes, with a good
should be withdrawn occlusally level of evidence, that the sealants act
and the site thoroughly rinsed for by forming a superficial barrier against
30 seconds and again dried the penetration of bacteria and their by-
• The surface should be dehydrated with products, while infiltration techniques
99% ethanol, delivered by a metal create an internal barrier in the lesion by
tipped syringe (Icon dry®) to facilitate replacing lost minerals with low viscos-
the drying process, because the ity light-cured resin.22 Occlusion of pores
TEGDMA is hydrophobic by penetration of the resin into the body
• The proximal application nozzle of of the lesion is probably responsible for
the resin can then be screwed onto the the retention of the material, allowing an
syringe pre-filled with transparent low expectation of a stable result over time.
viscosity resin and positioned to access The durability of the result is dependent
the affected surface on the lesion’s environment. Caries inhi-
• A slight excess of infiltration bition is being maintained in a weakly
resin should be applied, directly in demineralising environment, but it is
contact with the previously etched likely that in a patient at uncontrolled
demineralised zone. It must be risk of caries demineralisation will con-
well spread over the interproximal tinue or recur at the periphery of the resin
contact area and be left in place infiltrated area. The technique does not
for three minutes so that the resin make proper management of caries risk
penetrates the pores of the lesion by and patient monitoring redundant.
capillary attraction Resin infiltration seems suited particu-
• The transparent application nozzle is larly for proximal lesions where, when
then removed, and the excess resin invasive treatment is chosen, the ratio of
is removed with dental floss. The normal tissue to carious tissue leads to a
resin is then photo-polymerised from not insignificant loss of healthy tissue in
three angles (buccal, lingual, occlusal) order to gain access to the lesion, even
for 40 seconds when applying micro-invasive methods of
• A new proximal application nozzle preparation such as sono-abrasion.23
is mounted on the preloaded syringe It is extremely difficult for the prac-
and infiltration resin is applied a titioner to locate the border between
second time. This second layer of resin the absence or presence of cavitation
infiltration is applied for one minute clinically and radiographically in the
only and light cured as before for interproximal spaces between adjacent
40 seconds posterior teeth. Initial lesions evaluated
• After removing all the equipment the as non-cavitated may nevertheless appear
interproximal space is evaluated with with broken-down surface layers.12 In a Fig. 9 Resin infiltration treatment of a
demineralisation spot on the buccal surface
dental floss and the cervical excess is recent in vitro study assessing the degree of a molar after the use of orthodontic
removed using, for example, a probe of penetration of the resin according bands
or a curved mini-CK6 to ICDAS codes it has been shown that

BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013 57


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

cavitated lesions (code 5) showed signifi- patients, in particular for children and
cantly less resin infiltration than non-cav- their parents. The benefits depend on the
itated lesions (codes 2 and 3) and the resin overall management of caries risk and
was unable to fill the cavities (Fig. 10).24 adequate follow-up. Experience is hith-
The technique is therefore not recom- erto limited. High evidence level clinical
mended for the management of cavitated trials are needed to assess the long-term
lesions and it should be borne in mind results and development is needed to
that, if a proximal cavity has not previ- simplify the system for use in ordinary
a
ously been detected, infiltration may be dental practice.
faulty and caries inhibition may fail. Here The authors would like to thank Claudie Damour-
again, the technique does not dispense Terrasson, President and publishing director of the
Groupe ID Espace- L’Information Dentaire, Paris France,
with the requirement for early detec- for the authorisation of translation and publication of
tion, thorough diagnosis and rigorous the series in the BDJ.
caries monitoring.
1. Lasfargues years Evolution des concepts en odon-
The risk-benefit ratio of this non-inva- tologie conservatrice. Du modèle chirurgical invasif
sive and aesthetic technique is favour- au modèle médical préventif. J Dent du Québec
b 1999; XXXVI: 65–77.
able but clinical experience is limited, 2. Kugel G, Arsenault P, Papas A. Treatment modalities
and questions arise about the aging of the Fig. 10 The resin did not fill the small for caries management, including a new resin infil-
tration system. Compend Contin Educ Dent 2009;
resin, even though the risk of hydrolysis carious defect, dissuading the method for
3: 1–10.
appears limited due to the hydrophobic the cavitated lesions. Initial situation (a) 3. Carvalho J C, Van Nieuwenhuysen J P, Maltz M.
and after resin infiltration (b) Traitement non opératoire de la carie dentaire.
nature of the resin. There is little informa-
Réalités Cliniques 2004; 15: 235–248.
tion on the wear resistance of the impreg- 4. Miller C, Ten Cate J, Lasfargues J J. La reminéralisa-
nated zone and on the colour stability and tion des lésions carieuses (1) Le rôle essentiel des
fluorures. Réalités Cliniques 2004; 15: 249–260.
aesthetics after infiltration. Finally, this 5. Lasfargues J J, Ten Cate J, Miller C. La reminéralisa-
technique is described as ‘without drilling tion des lésions carieuses (2) Synergies
thérapeutiques. Réalités Cliniques 2004;
and without anaesthesia’, deceptively sim- 15: 261–276.
ple and fast. The duration of full treatment 6. Guerrieri A, Gaucher C, Bonte E, Lasfargues J J.
Détection et diagnostic des lésions carieuses
of a lesion is 15‑20 minutes (rubber dam initiales. Réalités Cliniques 2011; 22: 233–244.
included) for a practitioner who masters 7. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä
M, Worthington H V. Pit and fissure sealants for
the technique. Undertaking the treatment preventing dental decay in the permanent teeth of
is relatively difficult. It requires the teeth children and adolescents Cochrane Database Syst
Rev 2008; 4: CD001830.
to be perfectly cleaned and dried and iso- 8. Lasfargues J J, Kaleka R, Louis J J. A new therapeutic
lated by the rubber dam. Passing the clear classification of cavities. Quintessence Int 2001;
32: 97.
plastic nozzle between the proximal con- 9. Meyer-Lueckel H, Mueller J, Paris S, Hummel M,
tacts is not always easy, despite the aids. Kielbassa A M. The penetration of various adhe-
Fig. 11 Excess resin expressed from the sives into early enamel lesions in vitro. Schweiz
Measuring the amount of infiltration resin Monatsschr Zahnmed 2005; 115: 316–323.
syringe and collected in the bottom of
to be placed is imprecise (Fig. 11) despite 10. Mueller J, Meyer-Lueckel H, Paris S, Hopfenmuller
the dam W, Kielbassa A M. Inhibition of lesion progression
the needle screw and excess cured resin by the penetration of resins in vitro: influence
may persist in the recess, which must be cannot be evaluated since progression of the application procedure. Oper Dent 2006;
31: 338–345.
carefully verified otherwise there is a risk of the lesion cannot be visualised at 11. Paris S, Meyer-Lueckel H, Mueller J, Hummel M,
of promoting papillary inflammation. The subsequent visits. Kielbassa A M. Progression of sealed initial bovine
enamel lesions under demineralizing conditions
application of resin should always be done in vitro. Caries Res 2006; 40: 124–129.
in two  stages to fill cracks and voids in CONCLUSIONS 12. Kielbassa A M, Paris S, Lussi A, Meyer-Lueckel H.
Evaluation of cavitations in proximal caries lesions
the first layer, observed by microscopy, Infiltrating resins have opened up an at various magnification levels in vitro. J Dent 2006;
and to obtain a better surface quality. The innovative pathway in the management 34: 817–822.
13. Parolo C C, Maltz M. Microbial contamination
state of the final surface is slightly rough of initial carious lesions, correspond- of noncavitated caries lesions: A scanning
and imperfect and does not appear to be ing with the goals of the physician to electron microscopic study. Caries Res 2006;
40: 536–541.
improved by available finishing systems, heal without causing harm. The inhibi- 14. Meyer-Lueckel H, Paris S, Kielbassa A M. Surface
such as interproximal abrasive strips.25 tion of caries progression by infiltration layer erosion of natural caries lesions with
phosphoric and hydrochloric acid gels in prepara-
The removal of the equipment (nozzle, should be considered an alternative to tion for resin infiltration. Caries Res 2007;
wedge, rubber dam) frequently leads to more invasive therapies and warrants a 41: 223–230.
15. Paris S, Meyer-Lueckel H, Kielbassa A M. Resin infil-
haemorrhage due to the inevitable com- place in the range of minimally inva- tration of natural caries lesions. J Dent Res 2007;
pression of the papilla for the duration of sive dentistry techniques. Compared 86: 662–666.
16. Meyer-Lueckel H, Paris S. Improved resin infiltration
treatment. The absence of radio-opacity, with remineralisation techniques that of natural caries lesions. J Dent Res 2008;
inherent with unfilled resin, does not may require several follow-up visits, this 87: 1112–1126.
17. Paris S, Dörfer C E, Meyer-Lueckel H. Surface
allow the result to be seen on radiograph. therapy can be undertaken in one treat- conditioning of natural enamel caries lesions in
The alleged efficacy of the treatment ment session, which is important for deciduous teeth in preparation for resin infiltration.

58 BRITISH DENTAL JOURNAL VOLUME 214 NO. 2 JAN 26 2013


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

J Dent 2010; 38: 65–71. white spot lesions by resin infiltration ‑ a clinical mini-obturations. EMC Odontologie 2006;
18. Meyer-Lueckel H, Paris S. Infiltration of natural report. Quintessence Int 2009; 40: 713–718. [23‑144‑A-10].
caries lesions with experimental resins differing 21. Tirlet G, Attal J P. L’érosion/infiltration: une nouvelle 24. Paris S, Bitter K, Naumann M, Dörfer C E, Meyer-
in penetration coefficients and ethanol addition. thérapeutique pour masquer les taches blanches. Lueckel H. Resin infiltration of proximal caries
Caries Res 2010; 44: 408–414. Inf Dent 2011; 4: 12–16. lesions differing in ICDAS codes. Eur J Oral Sci 2011;
19. Paris S, Bitter K, Renz H, Hopfenmuller W, Meyer- 22. Kantovitz K R, Pascon F M, Nobre‑dos‑Santos M, 119: 182–186.
Lueckel H. Validation of two dual fluorescence Puppin-Rontani R M. Review of the effects of infil- 25. Mueller J, Yang F, Neumann K, Kielbassa A M.
techniques for confocal microscopic visualization trants and sealers on non-cavitated enamel lesions. Surface tridimensional topography analysis of
of resin penetration into enamel caries lesions. Oral Health Prev Dent 2010; 8: 295–305. materials and finishing procedures after resinous
Microsc Res Tech 2009; 72: 489–494. 23. Decup F, Tison B, Lasfargues J J. Intervention infiltration of subsurface bovine enamel lesions.
20. Paris S, Meyer-Lueckel H. Masking of labial enamel restauratrice minimale: mini-cavités et Quintessence Int 2011; 42: 135–147.

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© 2013 Macmillan Publishers Limited. All rights reserved.
Minimal intervention dentistry: IN BRIEF
• Describes minimally invasive operative
part 7. Minimally invasive caries management techniques.

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

operative caries management: • Suggests removal of grossly softened


caries-infected dentine is recommended
in most situations along with the

rationale and techniques placement of a sealed restoration.

A. Banerjee1
VERIFIABLE CPD PAPER

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.

INTRODUCTION in the dental literature. Minimum(al) inter- 2. The chemistry/handling of the adhesive
The term MI dentistry or ‘MID’ has been vention dentistry is the holistic patient care materials used to restore the cavity
used for many years with several meanings philosophy that encompasses the complete 3. Consideration of the practical
patient-dentist team-care approach to operative techniques available to
MINIMAL INTERVENTION managing dental disease by identification excavate caries minimally.
DENTISTRY and diagnosis (including caries risk assess-
1. From ‘compulsive’ restorative dentistry to ment), prevention and control, restoration Appreciation of these factors will ena-
rational therapeutic strategies
and recall, so educating and empower- ble the dental practitioner to embrace the
2. Caries risk assessment in adults
3. Paediatric dental care – prevention and ing the patient to take responsibility for contemporary oral physician’s biological
management protocols using caries risk their personal oral health.1,2 Minimally approach to operative caries management
assessment for infants and young children
Invasive Dentistry describes contemporary as opposed to the surgeon’s mechanistic
4. Detection and diagnosis of initial
caries lesions ultraconservative operative management efforts of preparing cavities of a pre-deter-
5. Atraumatic restorative treatment (ART) –  of cavitated lesions requiring surgical mined shape, governed primarily by the
a minimum intervention and minimally intervention. It does not mean unduly properties of the chosen restorative mate-
invasive approach for the management
of dental caries early operative intervention of incipient rial as opposed to the actual histopathol-
6. Caries inhibition by resin infiltration lesions, which in most cases is unnecessary ogy of the disease process and retention of
7. Minimally invasive operative caries as more effective and appropriate non- tooth substance.3,4
management – rationale and techniques
This paper is adapted from: Banerjee A. Stratégies invasives a
invasive preventive approaches exist. It is
minima de l’éxérèse des tissus cariés. Réalités Cliniques 2011; the latter definition that will be discussed LESION HISTOLOGY
22: 141–156. The authors would like to thank Claudie Damour-
Terrasson, publishing director of the Groupe Information further in this paper. Enamel caries
Dentaire, Paris, France, for the authorisation of translation and
publication of this MI series in the BDJ.
‘Golden triangle’ of MID Long-term, repeated episodes of bacte-
1
Professor of Cariology & Operative Dentistry/Hon
Consultant, Restorative Dentistry, Conservative
A thorough understanding and apprecia- rial acid demineralisation instigated at a
Dentistry, Floor 26, Tower Wing, King’s College London tion of the interplay between three criti- susceptible tooth surface by the residing
Dental Institute, Guy’s Dental Hospital, London Bridge,
London, SE1 9RT
cal factors is required to achieve success plaque biofilm results in the growth of
Correspondence to: Professor Avijit Banerjee clinically when using a minimally inva- subsurface structural porosities, eventu-
Email: avijit.banerjee@kcl.ac.uk;
Tel/fax: +44 207 188 1577/7486
sive operative caries management strategy ally enlarging, if not controlled at the
(MI OCMS): earliest stages by remineralisation/oral
Accepted 21 June 2012
DOI: 10.1038/sj.bdj.2013.106
1. The histology of the dental substrate hygiene procedures, coalescing and ulti-
© British Dental Journal 2013; 214: 107-111 being treated mately causing cavitation. Carious enamel

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© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

with its unsupported prismatic structure affected dentine within a lesion is a rather invasive approach removing only caries-
is weak under stress from compressive/ subjective process at present. Caries-infected infected dentine will conserve more tooth
shear occlusal loads or from tensile shrink- dentine is sticky and soft to a sharp dental structure that can help retain and support
age forces from photo-cured resin-based explorer whereas caries-affected dentine is the definitive sealed restoration. The opti-
adhesive materials.5 If carious enamel is a little more tacky (‘scratchy and sticky’) in mal restorative material is natural tooth
retained at the margin of the cavity and nature and blends to the hard, scratchy con- substance and smaller cavities are easier
subsequently restored, deficiencies may sistency of deeper sound dentine.3 Propylene to manage for both the dentist and the
allow the ingress of plaque biofilm bacteria glycol-based indicator dyes were developed patient. A reduced surface area of res-
through micropores within the defective to act as a marker for that carious dentine toration with its margins in cleansable,
enamel structure - cohesive microleakage. requiring excavation, but many conflicting accessible areas will increase the patient’s
Further complications are associated with studies exist regarding their efficacy in this ability to regularly agitate and remove the
the potential of ‘secondary’ caries devel- regard.10 Latest developments include more plaque biofilm, thus reducing the risk of
oping along defective marginal interfaces specific indicators highlighting the sulphur- further onset of caries.
where plaque biofilm stagnates, further containing bacterial products indicative of
compromising tooth structure.3 the increased bacterial load present in car- Patient’s caries risk assessment
ies-infected dentine but these have yet to be The MI operative caries management strat-
Dentine caries validated in vivo. egy (OCMS) relies on close collaboration
Carious dentine can be subdivided into with successful prevention/control regimes
two histopathological zones: How much dentine caries instigated by the patient and the dental
1. The peripheral caries-infected
should be excavated? team. These can often be linked to the
zone (close to the enamel-dentine The answer to the above question is spe- overall risk assessment of the individual
junction [EDJ]), irreversibly damaged, cific to the individual tooth/lesion, oral patient as a motivated patient has the
necrotic and softened by long cavity, patient and dentist as there are greater potential to be converted to low
standing bacterial contamination and numerous inter-relating co-variables that caries risk. If these are in place MI resto-
proteolytic denaturation of collagen have to be considered. rations have a good chance of medium to
and acid demineralization of the long-term success.14,15 If, however, the car-
inorganic component Pulp status ies risk is high in less motivated patients
2. The deeper caries-affected zone, The vitality (sensibility) of the pulp must then adhesive restorations may show a
reversibly damaged by virtue of be assessed from the clinical signs and reduced long-term survival rate.16
carious process, which has the symptoms and suitable investigations (a
potential to repair under the correct combination of electrical, thermal and Clinical factors
conditions as the collagen is not radiographic). Signs of an acute, revers- Practical considerations in restoration
denatured.5-7 ible pulpitis can resolve if the carious pro- placement must play a part in deciding
cess is arrested using a sealed restoration whether MI is a feasible option for particu-
The soft, wet, necrotic nature of car- along with effective patient control meas- lar individuals. These may include:
ies-infected dentine means it is an infe- ures, tipping the histopathological balance • Suitable access for instrumentation
rior chemical and physical substrate for from the bacteria in favour of the heal- • Ability to control moisture levels
adhesion and seal formation, whereas the ing dentine-pulp complex and its acute (ideally with rubber dam isolation)
potentially repairable caries-affected den- inflammatory mediators.5,11. • Appreciation of the final position of
tine has been shown to exhibit adequate the cavity-restoration margin (supra-
adhesive bonding potential, especially Lesion depth or subgingival)
when surrounded by a periphery of sound Lesion-pulp proximity affects the level • Appropriate handling of adhesive
dentine and enamel.8 of protection afforded to the vital pulp. restorative materials by the dental team
It is important to appreciate that using Indirect pulp protection (capping) con- (for example, ensuring that dentine
the principles of minimally invasive (MI) serves caries-affected dentine close to the bonding agent bottle lids are replaced
dentistry may often lead to less carious pulp, minimising the risk of unnecessary promptly after dispensing to ensure
dentine excavation overall than past caries pulp exposure, and a suitable material minimal evaporation of any solvent
excavation rationales based on a mechanis- (for example, glass ionomer cement) with carrier; appropriate ratios of powder:
tic approach to maximise the retention and anti-bacterial properties as well as bonding liquid mixed when required etc).
physical properties of the restorative material and sealing chemically to the remaining
within the cavity.9 MI cavities will exhibit cut dentine affords a potential seal, so per- Prospective long-term randomised con-
surfaces with different qualities of enamel mitting rejuvenation of the dentine-pulp trolled clinical trials have assessed the
and dentine histology along the same cavity complex.5,12,13 validity and efficacy of minimally inva-
surface and these tissues will require han- sive caries removal with or without indi-
dling in different ways in order to optimise Extent of viable tooth structure rect pulp capping in terms of restoration
adhesive bonding. Indeed, clinically delineat- The functional and aesthetic restorability longevity and pulp status.13-15 Systematic
ing between the layers of caries-infected and of the tooth must be assessed. A minimally analysis of the results has concluded that

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PRACTICE

Table 1 Tooth-cutting/caries removal technologies, the substrates acted upon and their
mechanism of action
Mechanism Dental substrate affected Tooth-cutting technology
Sound or carious enamel
Mechanical, rotary SS, CS, diamond, TC and plastic burs*
and dentine
Mechanical, Sound or carious enamel Hand instruments (excavators, chisels), air-abrasion,
non-rotary and dentine air-polishing**, ultrasonics, sono-abrasion
Caridex™, Carisolv™ gel (amino acid-based), Papacarie®
Chemomechanical Carious dentine
gel (papain-based), pepsin-based solutions/gels
Sound or carious enamel
Photo-ablation Lasers
and dentine
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
as long as there is a suitable patient-dentist metallo-proteinases (MMPs).4,19-21 Latest in- and visible caries-infected dentine. Symptoms
team-care approach to maintaining oral vitro research indicates the potential use of were those of an early reversible pulpitis and
health, adhesive sealed restorations placed anti-MMPs in dental adhesives to block the the pulp was vital to electric pulp testing and
ethyl chloride
in ultra-conservative cavity preparations activity of the indigenous MMPs, hence
can last well in the functioning oral cav- resisting collagen degradation in the cari-
ity.9,12,17 The issue of pulp capping using ous dentine.21,22
a separate ‘lining’ or ‘base’ material has
been reviewed in the literature. In modern MINIMALLY INVASIVE
day MI OCMS, using adhesive restorative
OPERATIVE TECHNIQUES
materials, the clinical need of a separate As can be seen from Table  1, there are
layer of pulp protection has been shown several clinical technologies available for
to be unnecessary (apart from the scenario cutting teeth and removing caries. Most
where the pulp may be protected with a are not self-selective for caries-infected
thin layer of glass ionomer cement beneath dentine and involve active discriminatory
a large amalgam restoration with close action from the operator when considering
pulp proximity).18 MI OCMS.23,24 Dentists are highly trained
at using dental burs in slow speed or air
MATERIALS SCIENCE turbine handpieces as well as hand exca- Fig. 2 Radiograph of 17 showing
demineralisation extending into the inner third
A thorough understanding of the clini- vators, and although not self discrimina- of dentine towards the pulp. The pulp chamber
cal relevance of contemporary adhesive tory in favour of caries-infected dentine, a is clearly visible with a potential bridge of
dental materials science is required to good operator can still practice MI OCMS dentine between it and the advancing lesion.
There is no proximal cavitation
implement successfully the MI OCMS. The effectively using these instruments as
physico-chemical interaction of the rele- illustrated in Figures 1‑6.
vant dental substrate retained at the cavity Ultrasonic and sonic instrumentation
surface with the adhesive material must use the principle of probe tip oscilla-
be enhanced by the operator to achieve tion and micro-cavitation to chip away
medium to long-term successful out- hard dental tissues. Lasers transfer high
comes. The restoration seal is reliant upon energy into the tooth through water caus-
the integrity and morphology of mineral ing photo-ablation of hard tissues. Great
(calcium ions, micromechanical undercuts, control is required by the operator in order
supported prismatic structure in enamel) to harness this energy effectively and the
and of the collagen nano-matrix/tubular effects on the remaining enamel, dentine
structure in dentine (hybrid zone). The and pulp continue to be investigated in
clinical relevance of the individual steps terms of residual strength and bonding
in adhesive bonding (acid etch, primer capabilities. A recent systematic review
and bond) have been discussed in an concluded that laser caries removal is Fig. 3 The peripheral unsupported enamel has
been removed using a long tapered diamond
alternative publication.4 Issues regarding not yet a viable general dental practice bur in a high speed air turbine handpiece and
chemical or micro‑/nano-mechanical bond option for effective caries excavation.25 the sound margins lightly bevelled
mechanisms revolve around the longev- Enzymatic (including hypochlorite-, pep-
ity of the seal achieved, which is affected sin- and papain-based) solutions have a more self-limiting technique of remov-
adversely by physico-chemical hydrolysis and are being investigated to help further ing caries-infected dentine alone.23 Other
and potential enzymatic degradation by breakdown of collagen in already softened chemical methods include photo-acti-
indigenous, acid-activated dentine matrix carious dentine in the hope of developing vated disinfection (PAD) where tolonium

BRITISH DENTAL JOURNAL VOLUME 214 NO. 3 FEB 9 2013 109


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

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-abrasion
Air-abrasion is a 68-year-old dental oper- Fig. 7 Cavitated occlusal caries with soft
infected dentine evident
ative technique used for the removal of
enamel and dentine during cavity prepara- Fig. 4 The dentine at the periphery has been
initially excavated to a depth of caries-
tion.27,28 Air abrasion units are capable of affected dentine but flakes of very soft
minimally invasive tooth preparation using infected dentine remain over the pulpal
27 μm aluminium oxide (α-alumina).24,29,30 aspect of the cavity
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 Fig. 8 Initially clear, slightly viscous Carisolv™
requires careful education of clinicians to gel introduced into the cavity using the
mace-tip hand instrument and left for
realise its potential for minimally invasive
40 seconds before excavation
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 Fig. 5 The dentine adjacent to the enamel-
dentine junction is both scratchy and slightly
enamel and dentine and collectively these sticky to a dental probe, indicating it is
show the technique to be efficient if spe- affected histologically. The peripheral enamel
cific operating parameters (for example, margin is sound histologically
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 Fig. 9 This process is continued until the gel
indicated good patient acceptance of the has a muddy consistency when it is washed
out of the cavity and the relative hardness
technology in terms of the lack of vibra- of the remaining cavity walls tested using a
tion, no heat generation and the reduced sharp dental explorer
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 Fig. 6 The final resin composite restoration
has been placed and finished to reduce plaque
for caries detection,38 followed by the use biofilm adherence in the oral cavity
of a small head dental bur or alumina air-
abrasion for the removal of the carious, operator feedback when using these oper-
demineralised enamel. The microscopically ative technologies can result in cavity
roughened enamel surface created by alu- over-preparation. Innovation in abrasive Fig. 10 MI prepared cavity with affected
dentine retained over the pulpal aspect
mina air-abrasion is devoid of weakened powder development has resulted in the of the cavity. The peripheral margins in
prisms and is therefore better adapted production of a commercially available the case have purposely been excavated
for adhesive bonding. However, lack of bio-active glass powder capable of remov- to histologically sound dentine to aid the
restorative peripheral seal
substrate selectivity and no self-limiting ing extrinsic dental stain, desensitising

110 BRITISH DENTAL JOURNAL VOLUME 214 NO. 3 FEB 9 2013


© 2013 Macmillan Publishers Limited. All rights reserved.
PRACTICE

exposed dentine and exhibiting an intrin- judicious use of contemporary adhesives capping: a review of the literature. Oper Dent 2009;
34: 615–625.
sic selectivity towards carious, dem- with their bacteriocidal/static properties, 19. De Munck J, Van Landuyt K, Peumans M et al. A
ineralised enamel and resin composite there is little need clinically for a separate critical review of the durability of adhesion to tooth
tissue: methods and results. J Dent Res 2005;
restorations.39–41 Research is ongoing into lining/base layer to protect the pulp. A 84: 118–132.
development of a self-selective air-abra- thorough understanding of the chemistry 20. Van Meerbeek B, De Munck J, Van Landuyt K L
et al. Dental adhesives and adhesive performance.
sive powder for caries-infected dentine. of the materials and how they relate to In Curtis R, Watson T F (eds) Dental biomateri-
the histology of the tissues is necessary als: imaging, testing and modeling. pp 81–111.
Chemo-mechanical caries removal to ensure the best prognosis of a sealed, 21.
Cambridge: Woodhead Publishing, 2008.
Breschi L, Martin P, Mazzoni A et al. Use of a
After the development and subsequent adhesive restoration. specific MMP-inhibitor (galardin) for preservation
of hybrid layer. Dent Mater 2010; 26: 571–578.
demise of the Caridex™ system in the Figures 1‑6 have been reproduced with publisher’s 22. Almahdy A, Koller G, Sauro S et al. Effect of MMP
1970s, chemo-mechanical caries removal permission from Banerjee A. A large carious lesion. inhibitors incorporated within dental adhesives.
In Odell E W (ed) Clinical problem solving in J Dent Res 2012; 91: 605–611.
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mercialisation of Carisolv™ gel in the late Livingstone, 2010. of five alternative methods of carious dentine
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