Dental Caries

The Editors Ole Fejerskov, DDS, PhD, DSc (Odont), DSc (Odont) (h.c. multpl) is Professor Emeritus in the Department of Biomedicine, Faculty of Health, at Aarhus University in Denmark. Bente Nyvad, DDS, MPH, PhD, DSc (Odont) is Professor of Oral Ecology and Caries Control in the Department of Dentistry and Oral Health, Faculty of Health at Aarhus University in Denmark.

• Contributors xiPreface xiiiPart I Dental caries: What is it and what is the magnitude of the problem?Chapter 1 Dental caries – definitions and clinical features 3Ole Fejerskov and Bente NyvadThe editors’ view on dental caries and introduction to the book 3Terminology 5Examples of dental caries 6Background literature 15Chapter 2 Strategic public health considerations for caries control in populations 17Anja Heilmann and Richard G. WattIntroduction 17The global burden of dental caries 18The role of sugar in the etiology of dental caries 18Public health principles for preventive action 21Overview of upstream, midstream, and downstream strategies to prevent dental caries 27Implications for the dental profession and oral health care systems 30Conclusion 30References 31Chapter 3 Dental caries epidemiology 35Firoze Manji and Ole FejerskovIntroduction 35Probability of an outcome 36Some standard terms used in epidemiology 40Measures of central tendency: Mean, median, mode 42Types of investigation 43Problems of determining the role of specific factors 44Analysis and interpretation of data 45Drawing inferences about associations 51Age and dental caries 54International comparisons of occurrence of dental caries 54Background literature 56References 56Part II Diagnosis and detectionChapter 4 Visual–tactile caries diagnosis and the role of bitewing radiography 61Bente Nyvad, Vita Machiulskiene, and Vibeke BaelumIntroduction 62The diagnostic process 62Two differing perspectives on caries detection 63Achieving the best health outcome for the patient by classifying caries lesions according to the best management options for each lesion type 63How early should caries lesions be detected? 65What are the best visual–tactile caries diagnostic criteria? 65Commonly used visual–tactile criteria 68Differential diagnosis 74Visual–tactile caries examination: A systematic clinical approach 76Benefits and limitations of visual–tactile caries diagnosis 78Do we need radiographs for caries detection? 79Conclusion 82References 83Chapter 5 The foundations of good diagnostic practice 85Vibeke BaelumIntroduction 85The making of a dentist 86The dental examination: In the best interest of our patients 87What are we looking for? What is caries? 88The wealth of caries diagnostic methods and criteria 90The evolution in caries diagnostic methods 90Diagnostic test assessment in the essentialistic gold-standard paradigm 91Evaluating caries diagnostic methods 92Leaps in the essentialistic gold-standard reasoning 93Diagnostic test evaluation in the nominalistic caries paradigm 95Inter- and intra-examiner errors in caries diagnosis 96How do we deal with the unavoidable diagnostic uncertainty? 97The additional diagnostic yield argument 98Concluding remarks 99References 100Part III The oral environment and dental cariesChapter 6 The oral microbiome – composition, acquisition, establishment, and maturation 105Gunnar DahlénThe microbiome 105The composition of the oral microbiome 107The composition and structure of oral mucosal and tongue microbiome 116Dental plaque microbiome 117The oral microbiome and immunity 120Acquisition of the oral microbiome 123Establishment of the oral microbiome 125Maturation of the oral microbiome 125Conclusions 129Background literature 129References 129Chapter 7 Functions of the oral microbiome in caries and how they can be controlled 133Nobuhiro Takahashi and Bente NyvadIntroduction 133Bacterial metabolism and ecological factors affecting the cariogenic features of dental biofilm 134The ‘ecological plaque hypothesis’ to explain the role of dental biofilm bacteria in the etiology of dental caries 135How to control a cariogenic drift of the oral microbiome 141Clinical approaches to caries control by interference with microbial metabolism 144Prebiotics, probiotics, and synbiotics 146Concluding remarks 148References 149Chapter 8 The essential role of saliva in dental caries and erosion 153Anne Marie Lynge PedersenIntroduction 153The salivary glands and their secretion 154Neuronal regulation of salivary secretion 155Formation of saliva 157Saliva and its role in maintaining dental health 159The functions of saliva flow and its inorganic and organic electrolytes 164Saliva gland hypofunction and dental caries and erosion 170Evaluation of salivary gland function 172Management of salivary gland hypofunction 175Concluding remarks 175Background literature 176References 176Part IV What happens in the dental hard tissues and key determinants of cariesChapter 9 The process of de- and remineralization – the key to understanding clinical manifestations of dental caries 181Ole Fejerskov and Mogens Joost LarsenIntroduction 181Enamel mineral 182Stability of calcium phosphates 183Crystal dissolution 183Why is apatite solubility increased by acid? 184Effect of carbonate and fluoride on apatite dissolution and growth 185Demineralization and remineralization of the dental hard tissues 186Caries demineralization 188Remineralization of enamel 190Remineralization of dentin 192Background literature 196References 196Chapter 10 Initiation and progression of dental caries in dental hard tissues 199Ole FejerskovIntroduction 199Human dental enamel at the time of eruption 201Enamel changes during early caries lesion development 205The approximal white spot lesion 209Progression of the enamel lesion 213Arrest of the caries lesion 215Occlusal caries 216Dentin reactions to caries progression 221Pulpo-dentinal reactions 221Root surface caries 227Background literature 230References 230Chapter 11 Erosion of the teeth 233Mogens Joost LarsenIntroduction 233Clinical manifestations and diagnosis 233Histological and chemical features 236Classification by depth of the lesion 237Classification by etiology 237Erosion caused by food and drinks 237Erosion caused by stomach contents 242Erosion caused by airborne acids 243Idiopathic erosion 243Prophylaxis and treatment of erosion 244Conclusion 246Background literature 246References 246Chapter 12 Sugar, diet, and dental caries 247Cor van Loveren, Peter Lingström, and Bente NyvadIntroduction 247History 248Early ecological studies 248Experimental human studies 249Influence of fluoride on the diet – caries relationship 250Which is of more importance – amount or frequency of sugar consumption? 251Measuring cariogenicity 251Sweeteners 256Protective factors in foods 265Diet and dental erosion 266Dietary advice for dental health promotion 266References 267Chapter 13 Oral hygiene – does it matter? 273Bente NyvadIntroduction 273Some theoretical considerations 273The biological effect of tooth cleaning 274The clinical effect of tooth cleaning 274The effect of professional tooth cleaning 278The effect of dental flossing 279Does tooth cleaning matter? 279References 280Chapter 14 Fluorides in caries control 283Ole Fejerskov, Jaime A. Cury, Livia M. A. Tenuta, and Firoze ManjiIntroduction 283Fluoride in caries control 284Anticaries mechanisms of fluoride 288Dental fluorosis and metabolism of fluoride 292Fluoride dose and dental fluorosis 296Where is fluoride found in nature? 300Fluoride absorption, distribution, and elimination 300Fluoride concentration in teeth 301Pathogenesis of dental fluorosis 303The efficacy and effectiveness of fluorides in the control of dental caries: Systematic review 303Rational use of fluorides in caries control 309Background literature 310References 310Part V Caries Control in Children, Adults and ElderlyChapter 15 The caries control concept 317Bente Nyvad and Ole FejerskovWhy the caries control concept should replace caries prevention 317How caries control was managed in the past 318Arrest of active enamel caries 319Arrest of active root caries 320Arrest of active cavitated caries 321Role of fluoride in lesion arrest 324Benefits and limitations of the caries control approach – and some recommendations 324References 324Chapter 16 Caries control for the individual patient in all age groups 327Bente Nyvad and Edwina A.M. KiddIntroduction 327How are current caries activity and risk of future caries progression assessed? 328The ‘dental traffic light’ 331What non-operative, treatments are available? 332How is the individual helped to control disease progression? 337When should the patient be recalled? 337Caries control in children and adolescents 339Caries control in the frail elderly 343Failure 345References 346Part VI Intervention and treatmentChapter 17 Carious cavities – how to manage the ‘infected’ dentin and the pulpal response 351Bente Nyvad, Edwina A.M. Kidd, and Ole FejerskovIntroduction 351The caries process in dentin 352Mineral distribution in dentin caries 352Inflammatory reactions to caries in the dental pulp 354How to manage the carious dentin 355How much carious dentin needs to be removed? 355Excavation techniques 356Excavation protocols 356Excavation of deep dentin lesions 358Concluding remarks 360References 360Chapter 18 Control of dental caries by minimally invasive restorative intervention 363Sebastian Schlafer, Irene Dige, and Bente NyvadIntroduction 363The strategy for minimally invasive restorative intervention of caries 364Micro-invasive treatments 364Minimally invasive operative treatment 369Defective restorations: replacement or repair? 376A final word of caution 377References 377Part VII The Implication of Caries Control for the Dental professionChapter 19 How accurately can we assess the risk of developing caries lesions? 383Hannu HausenIntroduction 383The risk of developing caries lesions cannot be observed directly for an individual patient 384The course of a typical study for evaluating the accuracy of a prediction 385A real-life example of using a single, dichotomous predictor 387Interpretation and use of the measures of prediction accuracy 387What level of accuracy would be sufficient in everyday practice? 393What level of accuracy can be achieved? 393Social factors 395Clinical caries risk assessment: is it possible? 396How valuable are the proposed measures? 396Concluding remarks 397Background literature 397References 397Chapter 20 Oral health care – past, present, and future perspectives 401Ole Fejerskov and Firoze ManjiA brief history of the emergence of dentistry 401How many dentists are needed? 402Caries research in the last 50 years 403A possible future for oral health care in the times of COVID-19 404References 405Index 407

"a modern and thorough consideration of the disease...The authors take time to justify their position on the most debatable matters and use careful terminology throughout the book"- Gail Douglas, Chair in Dental Public Health, School of Dentistry, University of Leeds, UK.  Review published in British Dental Journal (May 25)