Minimal Intervention Dentistry

Minimal intervention dentistry:
part 1. From compulsive

restorative dentistry to
rational therapeutic strategies
IN BRIEF
Explains the differences between minimal
J.D.B. Featherstone1 and S. Domjean2

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
Cariology has advanced over the past
30 years with scientific advances in the
knowledge of the caries process in terms
MINIMAL INTERVENTION
DENTISTRY
1. From compulsive restorative dentistry to
2. Caries risk assessment in adults
3. Paediatric dental careprevention and
management protocols using caries risk
assessment for infants and young children
4. Detection and diagnosis of initial
caries lesions
5. Atraumatic restorative treatment (ART)a
minimum intervention and minimally
invasive approach for the management
of dental caries
6. Caries inhibition by resin infiltration
7. Minimally invasive operative caries
managementrationale and techniques
This paper is adapted from: Featherstone JDB, Domjean S. Le
concept dintervention minimale en cariologie. De la dentisterie
restauratrice compulsive aux stratgies thrapeutiques
raisonnes. Ralits Cliniques 2011; 22: 207212.
Office of the Dean, Box 0430, 513 Parnassus Ave,

University of California at San Francisco, San Francisco
CA 941430430, USA; 2CHU Clermont-Ferrand,
Service dOdontologie, Htel-Dieu, F63001
Clermont-Ferrand, France
*Correspondence to: Professor John D. B. Featherstone
Email: John.Featherstone@ucsf.edu;
Tel:+01 415 476 1323
1*
Accepted 21 June 2012

DOI: 10.1038/sj.bdj.2012.1007
British Dental Journal 2012; 213: 441-445
of its pathogenesis, its transmission, the

demineralisation and remineralisation continuum, the mode of action of fluoride, but
also with respect to the great technological developments in biomaterials, equipment for the detection of caries lesions
and methods for cavity preparation. This
new scientific knowledge combined with
developments both technological and technique related, impose that both medically
and ethically, the sole pertinent therapeutic
model that is relevant is one that is based
on prevention and treatment using the
least invasive of approaches. This rational
model of care is known as minimal intervention dentistry and is applicable not only
to cariology but to periodontology and all
other areas of dentistry.1-3
Studies conducted in France in the early
2000s indicated that dental practitioners
had not yet integrated this concept of
cariology into practise4-7 even though,
since the 1990s, Elderton had already
denounced traditional approaches to conservative dentistry when considered in
isolation.8-10 Indeed, traditional oral care,
which comprises largely conservative/
operative dentistry, including scaling and
polishing, has very little impact on the oral
health of patients both in children and
adults because the patient finds himself/
herself caught in a repeat restoration spiral of care, where successive replacement
Fig. 1 The limitations of traditional dental

treatment
of restorations results in the restoration

increasing in size each time the restoration
is renewed, leading to eventual loss of the
tooth.2,8,11,12 Figure1 illustrates a patient,
aged 33 at the time of the photograph,
who has, judging by the number of endodontic treatments present, been obliged to
visit the dentist on numerous occasions in
the past. The problem of oral hygiene has
not been resolved and, the caries process,
which is very aggressive, has not been
halted. Restorative and endodontic treatment do not in themselves solve the problems 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
intervention dentistry, minimally invasive

dentistry, micro-dentistry, atraumatic
restorative treatment and selective tissue
excavation.
Examines the foundations of minimal
intervention dentistry.
Considers the implementation of modern
concepts into everyday clinical practice.
PRACTICE
delay in adopting minimal intervention in
routine dental practice are certainly many,
including lack of initial training and continuous education of practitioners in this
subject area, lack of time and personnel for
its easy implementation in general practice, lack of knowledge and appreciation
of preventive and non-invasive therapeutic strategies by the public authorities and
their lack of incorporation into financial
reimbursement schemes. Adapted from a
series first published in French in Ralits
Cliniques, the BDJ offers a series of articles on the general topic of minimal intervention dentistry written by international
authors to help the dental practitioner
integrate this concept into daily clinical
practice.
WHAT ARE THE DIFFERENCES

BETWEEN MINIMAL
INTERVENTION DENTISTRY,
MINIMALLY INVASIVE DENTISTRY,
MICRO-DENTISTRY, ATRAUMATIC
RESTORATIVE TREATMENT
AND SELECTIVE TISSUE
EXCAVATION AND HOW
SHOULD EACH BE DEFINED?
A primary source of confusion for practitioners concerns the terminology used since
minimally invasive dentistry and minimal
intervention dentistry are often used interchangeably although they describe different
concepts. This first section aims to define
the terms most commonly used that are
associated with minimal intervention.
Minimal intervention dentistry

Minimal intervention dentistry is a concept
of patient care that deals with the causes
of dental disease and not just the symptoms.1,13,14 Based on biological solutions
rather than purely restorative, minimal
intervention is based entirely on prevention and control of oral disease.
Primary prevention focuses on preventing new cases of oral diseases. It uses collective prevention measures such as artificial
fluoridation of water or school oral health
programmes. At the individual level, primary prevention aims to prevent the early
colonisation of childrens teeth by cariogenic bacteria (for example, Streptococcus
mutans, one of the species associated
with the initiation of the caries process).
Prevention also includes the management
of other factors such as a cariogenic diet
442
rich in fermentable carbohydrates, coupled

with poor oral hygiene habits.
Secondary prevention aims at preventing the disease from becoming established
and progressing. This includes screening to
detect carious lesions at the earliest possible stage so that appropriate treatment
can be delivered.
Tertiary prevention, for its part, aims to
prevent recurrence of disease as well as the
failure of preventive and restorative care
initially implemented.
The concept of minimal intervention is
based on all the factors that affect the onset
and progression of disease and therefore
integrates concepts of prevention, control
and treatment. The field of minimal intervention dentistry is wide, including the
detection of lesions as early as possible, the
identification of risk factors (risk assessment) and the implementation of preventive/control 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 dental tissue.
Minimal
intervention
Minimally
invasive dentistry
Micro-dentistry
Fig. 2 Diagram illustrating how minimal

intervention dentistry and minimal invasion
(minimally invasive dentistry) are two terms
that are not interchangeable. Minimally
invasive dentistry is actually a phase of
minimal intervention
Minimally invasive dentistry, ultraconservative and micro-dentistry

Minimally invasive dentistry, ultraconservative and micro-dentistry are terms that
embrace operative restorative approaches
that respect both the dental tissues and
patients comfort. The excavation of dentine caries is performed with the objective
of preserving not only sound tooth tissue
but also that tissue which has the potential to remineralise. The use of adhesive
biomaterials is preferred, for example,
resin composite of different viscosities
selected according to the clinical situation
and glass-ionomer cements, particularly
those of high viscosity.15 One should not
confuse minimal intervention dentistry
and minimally invasive dentistry since
the latter is merely a component of the
minimal intervention treatment (care) plan
(Fig.2). In traditional dentistry the preparation and restoration of cavities are the
only and systematic response to the presence of carious lesions. With a minimal
intervention approach, the placement of
restorations is an ancillary phase of the
Figs 3a and b Photographs of multiple

caries lesions and ART prophylactic phase
in the management of the caries process
Fig. 3c Photograph taken after first session

of ART
overall management of patient care where

restorations are indicated only when the
lesion has advanced to frank cavitation
and where remineralisation techniques
have reached their limits. Micro-dentistry
is performed preferably using optical aids
(magnification, microscopes, intra-oral
cameras) and can also make use of more
PRACTICE
Diagnostic
phase
Minimal
intervention
Prophylaxis
phase
R e c a ll
Restorative
phase
Fig. 4 The minimal intervention treatment (care) plan
Risk
predictors
Protective
factors
Pathological
factors
Fig. 5 Diagram of imbalance between protective factors, pathological factors and risk
predictors existing in the case of high caries risk. Concept developed by J.D.B. Featherstone27-29
sophisticated devices other than traditional

rotary instruments mounted on a contraangle handpiece or air-turbine, such as
chemo-mechanical, air-abrasion, sonoabrasion and laser systems.
Atraumatic restorative treatment

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

the case of ART, the restoration and sealant are placed simultaneously using highviscosity glass-ionomer cement. Initially,
this approach was proposed for the management of patients in developing countries because it can be performed using
only manual instruments. The excellent
results from clinical studies suggest that
it also has its applications in industrialised countries especially for patients with
multiple caries lesions during the stabilisation and motivation phase. Figure 3
illustrates the prophylactic phase in the
management of the caries process. This
patient consulted the dental department
of the University Hospital of ClermontFerrand for restoration of his teeth. Many
open lesions can be observed as well as
the presence of abundant plaque. Brushing
was impossible because the many open

dentine caries lesions made it very painful. ART was performed in quadrants. This
not only improved the aesthetics but more
importantly oral hygiene recommendations could then be implemented by the
patient.
DENTISTRY: BUILDING THE
TREATMENT (CARE) PLAN?
Rational clinical practice is based on
fourkey elements:
1. Control of the disease by identifying
and managing the risk factors
2. The detection and remineralisation of
early lesions
3. Minimally invasive surgical
intervention
4. Where possible the repair rather
than replacement of defective
restorations.15,16
Clinically, a cariology-based care plan
comprises threemain phases: the diagnostic phase, the prophylactic phase and the
(recall) monitoring phase (Fig.4).
The diagnostic phase

The diagnostic phase allows one to understand why the disease (caries) has occurred
and is used to evaluate the severity of the
damage caused. It includes the determination of the individual caries risk factors
and detection of carious lesions (presence and activity) for the application
during the next phase, of non-invasive
therapeutic solutions.
The determination of caries risk of individual patients is based on the identification
of the presence of pathological and protective factors that affect the demineralisation
and remineralisation process respectively
but also on the identification of risk predictors.17-19 Within the term risk predictors
are grouped all those factors which, while
being not directly related to the caries process itself, have been shown in longitudinal
studies to be correlated with the appearance
of new lesions. The main risk predictors are
past exposure to caries, the presence of cavitated caries lesions or recent restorations
placed due to caries, as well as demographic
factors relating to the patient in terms of
age, level of education and disabilities
that potentially expose the patient to risk
habitsa teenager with uncontrolled eating habits, the elderly where oral hygiene
443
PRACTICE
is more difficult to maintain due to loss
of motor skills, education associated with
the level of care one takes of oneself and
harmful lifestyles, which expose people to
situations of poor hygiene and failure to
seek care.20-26
Figure 5 illustrates the imbalance
between protective factors, pathological factors and risk predictors that exist
in the case of high caries risk, a concept
developed by Featherstone.27-29 Indeed,
the weight of the caries risk predictors is
important and entails the need to counterbalance them in the implementation of
measures tailored to the pathological factors present for each clinical case.
Prophylactic phase
The second prophylactic phase aims to
readjust the balance between pathological
and protective factors. During this phase,
measures required to curb the phenomena
of demineralisation and to initiate remineralisation are implemented. Emphasis
is placed on recommendations relating to
hygiene and dietary habits, antibacterial
therapy, prescription of appropriate fluoride measures and the placement of preventive sealants. In the case of patients
with cavitated lesions involving the dentine, atraumatic restorative care can complement the arsenal of prophylactic or
partial excavation of caries. ART reduces
the bacterial load, places a glass-ionomer
cement restoration, eliminates the cavity
responsible for retention of the plaque biofilm and protects the dentine allowing the
patient to develop efficient oral hygiene.
Follow-up monitoring
and maintenance
The third phase includes follow-up monitoring and maintenance. It concerns the
reinforcement of patient education, monitoring the effectiveness of all preventive and
control measures implemented for example,
fluoride and preventive sealants, and therapeutic measures for example, the integrity
of therapeutic sealants and restorations.
During follow-up visits, potential failures
can be intercepted and the recall interval
adjusted based on new clinical findings and
the behaviour of the patient.30-32
Restorations
The placement of restorations has long
been regarded, incorrectly, as the primary
444
solution to manage the caries process. The

restorative component is of course not
excluded, when required, from a minimal
intervention care plan, but has no effect on
the aetiologic factors and is not an essential
component unlike the other three described
above. Restorative treatment is therefore
still required when the caries process has
resulted in significant loss of dental tissue,
in order to eliminate the retention of plaque
within cavities and restore physiological
masticatory function and aesthetics. The
restorative phase can fit between control
and surveillance. It must follow a minimally
invasive approach, where caries removal/
cavity preparation is delayed until there are
cavitated dentine lesions and through the
use of adhesive materials, these cavities can
remain minimally invasive.13,15,16,33-37 Such
cavities are, by definition, conservative in
design and there is no so-called extension
for prevention, although sometimes it might
be necessary to remove some sound tissue
for example, reducing a weakened cusp
or making retentive features. In the case
of lesions close to the pulp, the complete
removal of all the carious dentine is now
called into question since glass-ionomer
cements allow ion exchange leading to the
remineralisation of demineralised tissue.38-44
Defective restorations are not systematically
removed and replaced. These radical solutions need to be rethought and nuanced;
polishing reduces the indications for the
complete replacement of the restoration, the
margins of restorations can be sealed and
restorations can be repaired.15,45-48
CONCLUSIONS
High quality modern dentistry based on
minimal intervention focuses on prevention and control of disease with operative
dental interventions that are limited to the
absolute minimum.1 Ideally, care strategies
must meet certain criteria, namely effectiveness, does it work in dental practice?
and efficiency, is the costeffectiveness
adequate? Although there is a growing
scientific evidence-base about the effectiveness of minimal intervention dentistry,
it is nevertheless clear that the problem of
efficiency arises in the context of implementation levels within current healthcare
systems in different countries.
The authors would like to thank Claudie DamourTerrasson, publishing director of the Groupe
Information Dentaire, Paris France, for the
authorisation of translation and publication of the

series in the BDJ, and Christopher Holmgren for his
assistance with the translation of the present article.
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4. Domjean-Orliaguet S, Tubert-Jeannin S. La prise en
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14. Featherstone JD. The science and practice of caries
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18. Stamm JW, Stewart PW, Bohannan HM, Disney
JA, Graves RC, Abernathy JR. Risk assessment for
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23. Azogui-Lvy S, Lombrail P, Riordan PJ etal.
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35. Mount GJ, Ngo H. Minimal intervention: early
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445

part 2. Caries risk assessment
in adults
IN BRIEF
Reviews the importance of caries risk
PRACTICE
assessment in adults.
Demonstrates how risk assessment can

be incorporated in everyday clinical
practice.
Presents a clinical case report of a
patient with a moderate to high risk of
dental caries.
M. Fontana1 and C. Gonzalez-Cabezas2
Risk-based, patient-centred decision-making, supported by best available evidence is an essential component for the correct 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
Risk-based prevention and disease management have been recognised as the
cornerstones of modern caries management1-3 and are essential components of
the minimal (minimum) intervention (MI)
approach. MI stresses a preventive philosophy with individualised risk assessment,
accurate and early detection of lesions
DENTISTRY
3. Paediatric dental care: prevention and
caries lesions
5. Atraumatic restorative treatment (ART)a
minimum intervention and minimally
of dental caries
management: rationale and techniques
This paper is adapted from: Featherstone JDB, Domjean S. Le
concept dIntervention minimale en cariologie. De la dentisterie
restauratrice compulsive aux stratgies thrapeutiques
raisonnes. Ralits Cliniques 2011; 22: 20712.
Associate Professor, Department of Cariology, Restorative Sciences and Endodontics at the University of
Michigan School of Dentistry, Michigan 48109,USA
*Correspondence to: Margherita Fontana
Email: mfontan@umich.edu; Tel: +1 734 647 1225
1*-2

DOI: 10.1038/sj.bdj.2012.1008
and efforts to remineralise non-cavitated

lesions with the prompt provision of preventive care in order to minimise operative
intervention. When operative intervention is required unequivocally, typically
for an active cavitated lesion, the procedure used should be as minimally invasive as possible.4,5 This risk-based clinical
decision-making for caries management in
everyday clinical practice should be based
on the best available evidence whilst taking into account the dentists knowledge
and expertise and focusing on the needs
and desires of the patient.6
Opponents of this strategy maintain
that it is difficult to identify such patients
accurately, and that even if we could, the
evidence for preventive measures on highrisk individuals is still not very strong. All
of this is in part true; however, we contend
that when the wellbeing of the patient is
considered, it is more important to carry
out a risk assessment incorporating the
best available evidence than just doing
nothing due to lack of strong evidence.
Others allege that similar preventive measures should be administered to the whole
population, regardless of the risk. However,
for the current environment of increasing
healthcare costs and resource constraints,
targeted healthcare delivery has become
paramount, depending profoundly on risk
assessment. If a clinician practices in an
environment in which all patients have a
similar risk of caries, then we agree that
doing individual risk assessments would
add no value to the clinician or the patient.

However, dental caries is unequally distributed in most populations around the
world, with a small percentage of individuals carrying the heavier burden of caries
disease.7 For most dentists in private practice, it becomes imperative to be able to
identify a patients risk status in order to
be able to develop the most cost-effective
treatment strategy for that individual. Due
to the multifactorial nature of the caries
process, and the fact that the disease is
dynamic (for example, lesions can progress
and/or regress), studies on risk assessment
tend to be complex, with a multitude of
variables challenging the prediction at
different times during the life of an individual.8 Most studies on risk assessment
have been conducted in children (see
later article in this BDJ series) and there
is very little evidence from adults or the
elderly to help guide practitioners on how
to apply risk assessment models to adult
populations.2,9
Therefore, caries risk assessment should
be useful in the clinical management of
dental caries by helping to:
Determine lesion activity
Estimate the degree of risk so the
intensity of the treatment (for
example, fluoride concentration and
delivery method) and frequency of
appointments can be customised
Identify the main aetiological agents
contributing to the current disease that
might be targeted in the management
447
PRACTICE
of the disease (for example, diet control)
Establish the need for additional
diagnostic procedures (for example,
salivary flow rate/buffering
measurements)
Formulate the best restorative
treatment (care) plan for this patient
(for example, dental material selection)
Enhance the overall prognosis of the
patient
Appraise the efficacy of the caries
management plan established at recall
visits.
This paper reviews the importance of
caries risk assessment in adults as a prerequisite for appropriate caries preventive
and treatment intervention decisions.
RISK INDICATORS
Traditionally, caries disease indicators
have been defined as clinical observations that tell about the past caries history
and activity. They are indicators or clinical signs that there is disease present or
that there has been recent disease.1 These
indicators also include variables that say
nothing about what caused the disease
or how to treat it, but that are related to
disease experience (for example, socioeconomic status, education). Caries experience
is an illustration of an indicator that shows
how the host copes with the biological
activity.10 However, as before, others have
defined risk indicators as factors established only in cross-sectional studies as
being associated with the disease without
any longitudinal validation.11
Caries experience
The strongest risk indicator is past caries
experience and current lesion activity.8,12,13
As a predictor it is simple, inexpensive and
fast, as it requires a dental examination
only. If approximal lesions are included in
the risk analysis, then radiographs, especially radiographic follow-up of existing
lesions, would enhance the diagnosis. Past
caries experience summarises the cumulative effect of all risk factors and protective
factors to which an individual has been
exposed over a lifetime. However, exposure
to risk factors may change over a lifetime,
and this affects the predictive power of this
indicator making it less than 100% accurate. Risk factors that lead to the patients
past caries experience might have changed
448
over their lifetime and sometimes we are

simply seeing the consequences of the disease that occurred years ago. Nevertheless,
as mentioned earlier, epidemiological studies have shown a positive strong correlation between past caries experience and
future caries development, which is why
all available risk tools include this indicator
very prominently. In adults, there is also
a clear association between coronal caries
and the risk of developing root caries 14,15
It is important to assess not only cavitated lesions, but non-cavitated lesions
also. If lesions are present it is imperative
to decide whether they are likely active or
arrested, as this will influence the analysis
of future risk. Presence of current activity would indicate a high likelihood that
if conditions do not change, activity will
continue in the future.
Another important aspect to take into
consideration is the site specificity of the
disease. Caries lesions develop in areas
where dental plaque is stagnant for long
periods of time. For younger individuals,
the occlusal surfaces of posterior teeth are
by far the areas more frequently affected
by the disease, but for older patients,
however, this might not be the case.
Frequently, older adults have very few or
no fissures without restorations in posterior teeth reducing the risk of caries in
those high risk surfaces when restorations
in good condition are present. However,
restorations with significant defects will
accumulate significant amounts of plaque
biofilm, increasing the risk at that specific
site. In these people, newly exposed root
surfaces and defective restorations need to
be carefully examined and have their risk
for caries determined.
Socio-demographic indicators
Although socioeconomic status is a
stronger predictor of caries risk in children than in adults, it is still important in
adults 13,16 However, because dental caries
generally is more prevalent in lower than
higher socioeconomic classes, the dentist
should consider the social environment
of the patient (for example, education,
income, occupation etc) as available to
him/her through the medical history, in
the analysis of caries risk.
Notes
The best indicators of caries risk can
be attained easily from data obtained

at periodic dental examinations and do
not require additional testing routinely.
This is, of course, very encouraging for
every day clinical practice
The fact that previous caries
experience is such a strong predictor
is, from a disease management
perspective, a less than desirable
outcome, considering the fact that the
disease is actually manifest before it
can be accurately predicted, and the
ultimate goal of caries management is
to prevent disease in the first case
The fact that the existence of recent
restorations is one of the greatest
indicators of risk for the development
of new caries lesions only proves that
the act of treating the caries lesion
surgically does little to reduce the risk
of developing the next lesion9,13,17
In a systematic review, Zero etal.
concluded that for caries prediction in
permanent teeth in adults, past caries
experience was the best predictor,
followed by education and marital
status, probably because these factors
influenced attitudes towards oral
health9
It is very important to realise that the
assessment of all risk factors not only
allows a more complete assessment
of future risk of disease, but most
importantly identifies the aetiological
factors responsible for the disease in a
particular patient.2
RISK FACTORS
Traditionally, a risk factor plays an essential role in the aetiology of the disease,
while a risk indicator is indirectly associated with the disease. In other words, caries risk factors are the biologic reasons, or
factors, that have caused or contributed to
the disease, or will contribute to its future
manifestation on the tooth (for example,
bacteria, diet etc).8
Genetics
Although this is the only factor that cannot be measured currently in clinical practice, it is important to highlight that even
when there is still much to learn about
the genetic-environmental relationships
in dental caries aetiology and risk assessment, the amount of evidence relating to
genes and caries experience has increased
PRACTICE
significantly in the last decade. As
reviewed recently by Wright, genes have
been identified linking tooth development,
salivary function and diet/taste to caries
risk or protection.18 This is very important
because as the understanding of genetics associated with caries risk increase, so
does the future possibility of using salivary diagnostics based on genetic scans to
develop either better risk assessment tools
or to better target specific interventions
that would improve the oral and general
health of at-risk populations.
Saliva
It is well established that saliva plays an
important role in the health of soft and
hard tissues in the oral cavity. Dentists
can assess several salivary parameters as
related to caries risk, but the most common
ones include salivary flow rate, buffering
capacity and pH. Chronically low salivary
flow rate (that is, true hypo-salivation)
has been found to be one of the strongest
salivary indicators for an increased risk of
dental caries.19 Apart from this scenario,
the caries prediction of saliva parameters is
modest to low, and thus hard to justify routinely in dental practice for every patient.
Oral complications as a result of salivary gland hypofunction include altered
oral sensations, taste dysfunction, mucosal
dryness resulting in infection and tooth
wear due to abrasion, among other factors.
Pain and diminished quality of life are also
common complaints associated with salivary hypofunction.20 Many dentists tend
to rely on the complaint of dry mouth or
xerostomia to diagnose hyposalivation.
Unfortunately, subjective complaint of
xerostomia often does not correlate with
objective findings of reduced salivary flow
rate. Fox etal.21 recommended that dental care professionals ask their patients
the following questions: does your mouth
feel dry when eating a meal? Do you sip
liquids to aid swallowing dry foods? Do
you have difficulty swallowing any foods?
Does the amount of saliva in your mouth
seem to be too little, too much or do you
not notice it? A positive answer to any of
these questions should prompt consideration as to how long the patient has experienced the problem, whether or not an
increased caries experience has resulted
and lead to an objective measurement of
salivary flow rate. Other questions, such as
is your mouth dry? are not predictive at

all, since most people have dry mouths in
the mornings due to the normal decrease
in salivary flow rate which occurs during
sleep.
Many current medications (for example,
psycho-pharmaceutical products) reduce
the flow rate of saliva in a percentage of
the population using them, and therefore may affect their caries risk. Also,
certain diseases, especially those related
to decreases in salivary flow rate, such
as Sjgrens syndrome and uncontrolled
diabetes, can increase the risk of caries.
captured the greatest interest among

researchers and clinicians. There is
great controversy in the literature
regarding the accuracy of salivary
tests for mutans streptococci and
lactobacilli in predicting future caries
in adults.13 Several tests exist in the
market to measure salivary bacteria
based on culturing. These tests have
disadvantages because they require
incubators, many enumerate bacteria
in saliva only (not in plaque), and in
general they correlate poorly in adults
with future caries risk. However, they
may be useful to motivate and monitor
oral hygiene, assess the effectiveness
of oral antimicrobials and monitor
dietary changes.
Bacteria
Dental caries is a microbial disease in
which the aetiological agents are normal
constituents of the dental plaque biofilm that cause problems only when their
pathogenicity and proportions change in
response to environmental conditions.
It is clear that without any plaque biofilm there would be no caries. However,
most patients do not remove plaque effectively from areas at high risk. The principle
of microbial testing in clinical practice is
the thought that people with high numbers
of cariogenic bacteria are at higher risk
for developing future lesions and, as such,
should be treated, however:
Most plaque indices are ineffective
predictors of future caries because
dental caries typically develops in
fissures and interproximal areas, while
most plaque indices were developed
to evaluate periodontal disease or
gingivitis based on smooth surface
scores
To solely evaluate the effectiveness
of mechanical cleaning is difficult
because tooth brushing usually
involves a dentifrice with fluoride.
However, it is known that any
conditions that compromise the
long-term maintenance of good oral
hygiene, and for which the patient has
not been able to show the ability to
maintain plaque-free, are positively
associated with caries risk
Salivary bacterial tests have existed
for several years and are based on the
premise that saliva levels represent
levels in the oral biofilm. As one
of the primary aetiologic agents of
dental caries, mutans streptococci
and lactobacilli historically have
Newer tests are available that measure

site-specific plaque pH, or measure bacterial load using either monoclonal antibodies, or responses to ATP bioluminescence
and although useful for patient education,
many of these have not been validated
longitudinally yet for risk assessment.
Diet
Sugar exposure is an important aetiological factor in caries development. Due to
the wide use of fluoride and its effect in
lowering the incidence and rate of caries,
it is difficult to show a strong, clear-cut,
positive association between a persons
total sugar consumption and his/her caries development. Thus, for example, selfreported sugar intake seems to have little
value at identifying, by itself, patients at
risk. However, diet is one of the main drivers of caries activity, and recognising the
behaviours that are placing the patient at
risk may be very important for caries prevention and management.22
Other dietary considerations include the
retentiveness of the food, frequency of consumption (this being the most important),
consumption between meals, the presence
of protective factors in foods (for example,
calcium, fluoride) and the type of carbohydrate. Although sugar in liquid form (for
example, soft drinks) is less cariogenic than
sugar in solid form (for example, sweets),
excessive frequent consumption of soft
drinks remains a major risk factor that
may be partly responsible for the high rate
of caries in teenagers and young adults in
many parts of the world. As a reminder,
449
PRACTICE
starches are considered less cariogenic than
the simple sugars sucrose, glucose and fructose, with sucrose possibly being the most
cariogenic due to its unique role in the production of extracellular polysaccharides.
Mental and/or physical disabilities that

affect regular oral hygiene or which
require a more frequent carbohydrateenriched diet also may affect the individuals risk. Additionally, enamel defects, such
as hypoplasia, have also been related to
increase caries risk, especially in children.
periodic professional fluoride exposures.

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

therapeutic factors/measures that can collectively offset the challenge presented by
caries risk factors. The more severe the risk
factors, the higher the protective factors
need to be to keep the patient in balance
or to reverse the caries process.
We recommend that risk assessment in
adults include an analysis of risk indicators, risk factors and protective factors.
To determine the risk status of a patient
we must balance the presence of risk factors that the patient currently has, plus
risk indicators of past and current disease
history and weigh that against the protective factors that the patient is exposed to.1
Although the clinician should analyse all
protective factors the patient is exposed
to, of great importance is the exposure to
fluorides. The widespread use of fluoride
has reduced dramatically the prevalence of
dental caries and the rate of the progression
of carious lesions.23 Its use, which should be
considered one of the most important protective factors when assessing a patients
caries risk, allows more conservative management strategies for the prevention and
treatment of dental caries. The frequency of
fluoride exposure is one of the most important considerations when considering its
use as a management and preventive strategy to control dental caries. This is because
the main mechanism by which fluoride
prevents against caries is by enhancing
remineralisation. When does remineralisation need to happen? Every time there is
demineralisation. The dental care professional should consider all fluoride sources
to which the patient is exposed, for example, fluoridated drinking water, foods/
drinks, home topical fluoride products and
For the patient presented in the following

case report (Figs 1-3) it is not necessary
to complete a complicated and long risk
assessment form or to measure risk factors
using chair-side bacterial or salivary tests
available in the market to determine that
the patient is at elevated risk for dental caries. The presence of clear clinical signs of
disease activity (presence of active caries
lesions) can be used to help predict a higher
risk of future disease progression. But, what
if there had not been any signs of active disease? Does this mean the risk of developing
caries lesions in the next few years is low?
symptoms of salivary dysfunction. None

of the conditions, which could affect the
salivary flow rate, such as Sjgrens syndrome, uncontrolled diabetes or medications, were present in the patient described.
Risk indicators
Bacteria
Caries experience
This patient presented mature, stagnant

plaque around most cervical and interproximal areas, with gingivitis associated
with it. This clinical observation suggests
these are risk areas for caries development
in this patient.
Others
450
Caries experience has been high and there

are numerous lesions present that appear
active; therefore, we should classify this
patient, as explained later on, as moderate
to high risk. Although this information is
helpful, we still do not know the specific
reasons behind the caries experience of
this patient.
Socio-demographic indicators
The patient is female, 63 years old, of lower
middle class, divorced, living independently
for the last sevenyears, but under a lot of
financial stress. Although none of these factors are a strong predictor of her future risk,
they point to an environment which may
be conducive, for example, to difficulty
accessing care as frequently as needed.
Risk factors
Saliva
In the present case, there were no signs or
Figs 1-3 Clinical photographs presenting

patient with a moderate to high risk of
dental caries
Diet
When initially questioned, the patient did
not think she had a high sugar-rich diet.
However, her active lesions suggested
there must be a current dietary factor in
play. Upon closer examination, she admitted to drink very frequently throughout
the day coffee with sugar, usually with a
cookie or two. Although not an unusual
behaviour for some people, the combination of this habit with presence of stagnant
mature plaque and lack of protective factors (discussed next) increases the risk of
the patient.
Protective factors
The patient used to brush twice a day with
a dentifrice with fluoride; however, since
PRACTICE
her divorce sevenyears ago she is brushing
less than once a day. In addition, she has
received no in-office fluoride treatments
over the last two decades. Even though
she may have had an appropriate level of
fluoride exposure at one time, currently
this level is not enough to balance out the
plaque and dietary factors she is being
challenged with.
Re-evaluation
In order to provide frequent counselling
and exposure to inoffice fluoride, the
recall interval was set at fourmonths.
CONCLUSIONS
Considering the current understanding of
the caries disease process, we propose the
following factors, whether appearing singly
or in combination, would yield a moderate
to high risk assessment of caries (as in the
case presented in this paper): the development of new caries lesions, the presence
of active lesions and the placement of restorations due to active disease since the
patients last examination (assuming a one
to two-year lapse between the previous and
current appointment). Finally, of greatest
importance is that for moderate and high
risk individuals; once you have determined
they are at risk and have identified the
reasons why, the dental team then has to
decide what is the simplest and most likely
successful strategy, both from the biological and behavioural perspective, for managing the caries disease in that particular
patient. This includes a decision of both
preventive and restorative approaches.
We also propose that a low caries risk
assessment be based on the following factors: no caries lesion development or progression for a period of one to threeyears;
amount of plaque accumulation; frequency
of the patients sugar intake; presence of
salivary problems; behavioural or physical disability changes; history of fluoride
exposure and pattern of fluoride usage.
A dentists overall subjective impression of the patient has a relatively good
predictive value for caries risk,25 but it is
unclear how this information is incorporated into everyday clinical practice.
Recent concepts in caries management
have not been largely accepted: a recent
survey of clinical practices within a U.S.
practice-based research network suggests
that a significant proportion had yet to
adopt treatments based on assessment of

caries-risk.26 Another practice-based study
showed that in France decision-making in
caries management does not only depend
on pathophysiology.27 Thus, a more objective, easy to implement, and validated risk
assessment instrument is desirable and this
is reflected in the multiple risk assessment
tools that have been developed during the
last few years. Examples for adults include
the American Dental Associations caries
risk tool for adults,28 the caries management by risk assessment (CAMBRA) tool
for adults,29 and the cariogram.3032
Risk assessment is an essential component of clinical practice for caries management. Most of the information needed is
readily available in a properly done health/
dental history and a clinical examination,
with the subjective impression of the clinician having been shown to be very useful. Most of the risk indicators or factors
provide (either by themselves or combined)
only a modest possibility of accurately
predicting adults at future risk. However,
even with these limitations risk assessment can enhance patient care. The most
important factor in predicting future risk
is recent caries experience and current disease activity. However, a careful analysis
of all risk and protective factors will allow
the dental team and patient to understand
the specific reasons for the caries disease
and thus will allow them to tailor the treatment plan and recall interval specifically
to the patients needs.
Information Dentaire, Paris France, for the autorisation of translation and publication of the series in the
BDJ and Dr Sanjay Karunagaran for kindly providing the clinical pictures used in the present article.
31: 129133.
2. Fontana M, Zero D. Assessing patients caries risk.
J Am Dent Assoc 2006; 137: 12311249.
3. Featherstone JD. The science and practice of caries
prevention. J Am Dent Assoc 2000; 131: 887899.
4. Fontana M, Young DA, Wolff MS, Pitts NB,
Longbottom C. Defining dental caries for 2010 and
beyond. Dent Clin North Am 2010; 54: 423440.
5. Reich E, Lussi A, Newbrun E. Caries risk assessment.
Int Dent J 1999; 49: 1526.
6. American Dental Association. Policy of evidence based dentistry. USA: ADA, 2008. Online
article available at http://www.Ada.Org/1754.Aspx
(accessed October 2012).
7. Edelstein BL. The dental caries pandemic and disparities problem. BMC Oral Health 2006; 6(Suppl 1): S2.
8. Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci 2009; 21: 91101.
9. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in
caries management. J Dent Educ 2001;
65: 11261132.
10. Bratthall D, Hnsel Petersson G. Cariogram a multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005;
33: 256264.
11. Burt BA. Definitions of risk. J Dent Educ 2001;
65: 10071008.
12. Powell LV. Caries prediction: A review of the literature. Community Dent Oral Epidemiol 1998;
26: 361371.
13. National Institutes of Health (US). Diagnosis and
management of dental caries throughout life. NIH
Consensus Statement 2001; 18: 123.
14. Ritter AV, Shugars DA, Bader JD. Root caries
risk indicators: a systematic review of risk models.
Community Dent Oral Epidemiol 2010;
38: 383397.
15. Snchez-Garca S, Reyes-Morales H, Jurez-Cedillo
T, Espinel-Bermdez C, Solrzano-Santos F, GarcaPea C. A prediction model for root caries in an
elderly population. Community Dent Oral Epidemiol
2011; 39: 4452.
16. Jamieson LM, Meja GC, Slade GD, RobertsThomson KF. Predictors of untreated dental decay
among 1534year-old Australians. Community
17. Fejerskov O. Changing paradigms in concepts on
dental caries: consequences for oral health care.
Caries Res 2004; 38: 182191.
18. Wright JT. Defining the contribution of genetics
in the etiology of dental caries. J Dent Res 2010;
89: 11731174.
19. Leone CW, Oppenheim FG. Physical and chemical
aspects of saliva as indicators of risk for dental caries in humans. J Dent Educ 2001; 65: 10541062.
20. Navazesh M. Salivary gland hypofunction in elderly
patients. J Calif Dent Assoc 1994; 22: 6268.
21. Fox PC, van der Ven PF, Sonies BC, Weiffenbach
JM, Baum BJ. Xerostomia: evaluation of a symptom with increasing significance. J Am Dent Assoc
1985; 110: 519525.
22. Zero DT. Sugars the arch criminal? Caries Res
2004; 38: 277285.
23. Centers for Disease Control and Prevention.
Recommendations for using fluoride to prevent
and control dental caries in the United States. CDC,
2001. Online article available at http://www.cdc.
gov/mmwr/preview/mmwrhtml/rr5014a1.htm
24. American Dental Association Council on Scientific
Affairs. Professionally applied topical fluoride:
evidence-based clinical recommendations. J Am
Dent Assoc 2006; 137: 11511159.
25. Disney JA, Graves RC, Stamm JW, Bohannan HM,
Abernathy JR, Zack DD. The University of North
Carolina Caries Risk Assessment study: further
developments in caries risk prediction. Community
26. Riley JL 3rd, Gordan VV, Rindal DB etal.
Preferences for caries prevention agents in adult
patients: findings from the dental practicebased
research network. Community Dent Oral Epidemiol
2010; 38: 360370.
27. Domjean-Orliaguet S, Lger S, Auclair C, Gerbaud
L, Tubert-Jeannin S. Caries management decision:
influence of dentist and patient factors in the provision of dental services. J Dent 2009; 37: 827834.
28. American Dental Association. Caries risk form:
(patients over 6years). ADA, 2008. Online form
available at http://www.ada.org/sections/professionalResources/pdfs/topic_caries_over6.pdf
29. Featherstone JD, Domejean-Orliaguet S, Jenson
L, Wolff M, Young DA. Caries risk assessment in
practice for age 6 through adult. J Calif Dent Assoc
2007; 35: 703707, 710713.
30. Fure S, Zickert I. Incidence of tooth loss and
dental caries in 60, 70and 80yearold Swedish
individuals. Community Dent Oral Epidemiol 1997;
25: 137142.
31. Hnsel Petersson G, Fure S, Bratthall D. Evaluation
of a computer-based caries risk assessment
program in an elderly group of individuals. Acta
Odontol Scand 2003; 61: 164171.
32. Ruiz Miravet A, Montiel Company JM, Almerich
Silla JM. Evaluation of caries risk in a young adult
population. Med Oral Patol Oral Cir Bucal. 2007;
12: E412E418.
451

part 3. Paediatric dental care
prevention and management
protocols using caries risk
assessment for infants
and young children
IN BRIEF
Examines the problem of early childhood
PRACTICE
caries and how it can be minimised.
Informs caries is a transmissible,
infectious disease, which can be passed

from mother to child.
Stresses the importance of risk
assessment and preventive dentistry in
paediatric healthcare.
F.J. Ramos-Gomez,1 Y.O. Crystal,2 S. Domejean3 and J.D.B. Featherstone4

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 early 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.
DENTISTRY
caries lesions
5. Atraumatic restorative treatment (ART)
a minimum intervention and minimally
of dental caries
This paper is adapted from: Ramos-Gomez F J, Crystal Y O,
Domjean S, Featherstone J D B. Odontologie pdiatrique.
Prvention et prise en charge de la maladie carieuse bases
sur lvaluation du risque pour les jeunes enfants. Ralits
Cliniques 2011; 22 (3): 221232.
University of California, Los Angeles, USA; 2NewYork University, USA; 3CHU Clermont-Ferrand, Service
dOdontologie, Htel-Dieu, F63,001 Clermont-Ferrand,
France; 4University of California, San Francisco, USA
*Correspondence to: Francisco Ramos-Gomez
Email: frg@dentistry.ucla.edu; Tel: +1 310 825 9460
1*

DOI: 10.1038/sj.bdj.2012.1040
INTRODUCTION
Despite progress made in caries control
worldwide by the protective effects of
fluoride, increased dissemination of oral
hygiene information and widespread
healthy diet education, dental caries still
remains the most common chronic childhood disease. Consequently, it is a major
financial burden on society in many countries throughout the world. In recent years,
reports show that caries in the primary
dentition has been increasing in the USA,
UK, Canada, Australia, the Netherlands
and other countries.1-8
Early childhood caries (ECC) is more
prevalent among young children from
low socioeconomic, ethnic minority populations.9 This uneven distribution occurs
in many developed countries with 25% of
children bearing 75% of the affected surfaces. Dental caries is a preventable and
transmissible infectious disease; it is well
documented that the presence of caries in
the primary dentition is one of the best
indicators for future caries in the permanent dentition.10,11 Thus, the early and
accurate identification of children at risk is

of great importance for cost-effective caries control. Signs of ECC can be detected
soon after the eruption of the first tooth.
If risk indicators are identified early and
oral health preventive practices are implemented at a young age, the disease can
be controlled and its progression slowed.
In the USA, the American Dental
Association (ADA), the American Academy
of Paediatric Dentistry (AAPD), the
American Academy of Paediatrics (AAP),
the American Association of Public Health
Dentistry (AAPHD) and the Academy of
General Dentistry (AGD) all recommend
that a child should see a dentist and establish a dental home by oneyear of age or
when the first tooth erupts.12-16 A dental
home is defined as the ongoing relationship
between the dentist and the patient where
accessible and coordinated oral healthcare
can be delivered comprehensively while
actively involving family participation.17
Despite the widespread advocacy of a
medical and a dental home by age one,
infant oral health visits have not yet been
501
PRACTICE
embraced universally by practicing clinicians. Many paediatricians are unaware of
current oral health evidencebased protocols and recommendations and refer children only when there is clinical evidence
of established dental disease. Since family
physicians and paediatricians often see
children up to six times before age two,
it is crucial to take these appointments
as opportunities to increase awareness of
oral health evaluations and screen young
children for caries risk and refer for dental
care.18 However, general dentists have to
be prepared to accept these young children
for their first dental visits evaluation and
treatment. This article presents an updated,
simple and systematic six-step protocol for
an infant oral examination that will ease
implementation of early visits into dental
practice.19 Due to the infectious and transmissible nature of dental caries, the first
step in preventing the development of ECC
is to provide perinatal oral healthcare to
expectant mothers as soon as possible.
Table 1 CAMBRA for dental providers (05years) assessment tool**

Biological factors
High risk
factors
Mother/primary caregiver has active caries
Yes
Parent/caregiver has low socioeconomic status
Yes
Child has >3 between meal sugar containing snacks

or beverages per day
Yes
Child is put to bed with a bottle containing any sugar
Yes
Child has special health care needs
Yes
Child is a recent immigrant
Yes
Protective
factors
Protective Factors
Child receives optimally fluoridated drinking water or
fluoride supplements
Yes
Child has teeth brushed daily with fluoridated toothpaste
Yes
Child receives topical fluoride from health professional
Yes
Child has dental home/regular dental care
Yes
Primary caregiver uses xylitol chewing gum/lozenges
Yes
Clinical Findings
Child has more than one dmfs
Yes
PERINATAL ORAL HEALTH
Child has active white spot lesions or enamel defects
Yes
Caries is a transmissible, infectious disease.

If this disease keeps progressing, surface
cavitation and destruction of dental tissue worsens over time. The mutans streptococci (MS) group of bacteria (primarily
streptococcus mutans and streptococcus
sobrinus) are key pathogens in the caries
process, due to their ability to adhere to
smooth tooth surfaces and produce acid.20
Generally, colonisation of MS in the oral
cavity of children is the result of transmission of these organisms from the childs
primary caregiver.21 A direct relationship
exists between MS levels in adult caregivers and that of caries prevalence in their
children.22 Factors influencing colonisation include frequent sugar exposure in
the infants and habits that allowed salivary
transfer from mother/caregiver to infants.
Maternal factors, such as high levels of MS,
poor oral hygiene, low socioeconomic status and frequent snacking increase the risk
of bacterial transmission to her infant.23
Infants have been identified with high levels of MS in their mouths even before the
eruption of the first tooth.19 Therefore, it
is critical to consider an infant oral care
programme in the context of a participating pair or mother-and-child dyad, which
includes comprehensive maternal perinatal
oral healthcare, counselling and treatment.
Child has elevated mutans streptococci
Yes
502
Moderate
risk factors
Child has plaque on teeth
Yes
Overall assessment of the childs dental caries risk: High

Moderate
Low
**Modified from Ramos-Gomez etal. CDA Journal 2007; 35: 687702; and ADA caries risk assessment forms available at http://www.ada.org/
sections/professionalResources/pdfs/topic_caries_over6.pdf (accessed October 2012). Copyright 2007/2010 California Dental Association.
Reprinted with permission
Dental professionals are beginning

to recognise the essential role a mother
plays in ensuring her childs oral health.
Improving expectant mothers oral health
by reducing pathogenic bacteria levels in
their own mouths, will delay the acquisition of oral bacteria and the development of ECC in their children.20 Restoring
carious lesions, by itself, is insufficient to
reduce a mothers risk of transmitting cariogenic bacteria to her offspring. An effective perinatal program should institute
practices such as therapeutic interventions
and lifestyle modification counselling both
during pre- and post-partum to reduce
maternal MS and lactobacilli levels.24
Unfortunately, pregnant women often do
not receive oral healthcare and education
in a timely manner. Many women do not
know they should seek dental care during their pregnancy. Of those who do, they
often encounter dentists unwilling to provide care to pregnant mothers. New mothers are also more likely to be receptive to
ideas that would improve their offsprings

oral health,25 making this the best window of opportunity for preventive care.
Therefore, dental, medical and obstetric
providers have the prime opportunity to
educate mothers with positive reinforcement and effective behavioural changes
that could affect significantly their childrens future oral health.
INITIAL INFANT ORAL CARE VISIT

Infants and parents (caregivers) will benefit
from an early infant oral health visit and
the establishment of a dental home. An
infant oral health visit should include caries
risk assessment, individualised preventive
strategies and anticipatory guidance.26,27
Establishing periodicity supervision of care
intervals and age-appropriate care paths
is determined based on the risk of disease
of each individual patient.28 Infants and
toddlers are not expected to be cooperative during an oral examination; crying
and movement are common responses.
PRACTICE
Explaining to the caregivers exactly what
to expect during this visit and engaging
them to participate may allay some of their
fears and concerns.
An infant oral health visit consists of a
six-step protocol:
1. Caries risk assessment
2. Proper positioning of the child
(knee-to-knee exam)
3. Age appropriate tooth brushing
prophylaxis
4. Clinical examination of the childs
oral cavity and dentition
5. Fluoride varnish treatment
6. Assignment of risk, anticipatory
guidance and counselling.
Caries risk assessment

An individualised risk assessment of an
infant or toddler for developing caries
serves as the foundation for healthcare
providers and parents/caregivers to identify and understand the childs ECC risk
factors. A systematic assessment of caries risk serves as a guide for dentists to
design treatment and preventive protocols
for children already with disease and those
deemed at risk. For optimal outcomes,
caries risk assessment should be done as
early as possible, and preferably before
the onset of the disease process. Due to
the fact that caries in the primary dentition is a strong predictor of caries in the
permanent dentition, caries risk assessment and management is crucial, as is the
subsequent follow-up.29,30 The caries balance concept states that the progression or
reversal of dental caries is determined by
the balance between pathological factors
and caries protective factors.31-33 Risk factors are determined from an interview with
the parent and from a clinical assessment
of the child (Table 1).
During the interview with the parent/
caregiver, the assessment should explore
biological and lifestyle risk factors that
contribute to the development or progression of caries. Examples of risk factors
include recently placed dental restorations in the mother, low socioeconomic
status of the family, low health literacy
of caregiver, the childs frequent intake
of fermentable carbohydrates, sleeping with a bottle that contains liquids
other than water and prolonged use of
a sippy cup containing milk, juice or a
sweetened beverage.
Clinical disease indicators from oral

examinations are used to diagnose caries. These include cavitated carious
lesions, white spot lesions/decalcifications
observed visually or by radiographs and
recent restorations. However, these physical manifestations of caries do not tell us
why the disease is present (Fig.1). In the
three clinical cases presented in Figure1,
the clinical signs (carious lesions at different clinical stages) indicate the presence
of active carious processes. The caries risk
assessment and the determination of the
pathological factors, in particular, will
guide the decision-making and the customisation of the therapeutic and the prevention strategies, specific to each patient.
Biological risk factors, also known as
pathological factors, include presence of
plaque, gingival bleeding (an indicator of
dense plaque), low pH and dry mouth. Any
of these recorded indicators can be then
combined with the data from the interview to determine the risk for that patient
(Fig.2). In older children, the presence of
dental or orthodontic appliances increases
plaque retention and the risk for caries.
Protective factors, which are indicators
that may reduce a childs risk for ECC, can
also be assessed during the interview with
the parent. These factors include optimal
exposure to fluoride, access to regular
dental care (for example, the presence of
a dental home), consistent brushing with
fluoride toothpaste, use of fluoridated tap
water and xylitol among other combination therapy.
Fig. 1a Carious lesions at different clinical

stages: child, 18 months old, with advanced
cavitated lesions
Fig. 1b Child, three years old, with

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

white spot lesions (reversible enamel
lesions) localised on the canines and
posterior teeth
Proper positioning
Proper positioning of the child is critical to
conducting an effective and efficient clinical exam in a young child. In general, the
knee-to-knee position should be used with
children aged sixmonths to threeyears, or
up to age five with children who have special healthcare needs. Children older than
threeyears may be able to sit forward on
their caregivers lap or sit alone in a chair.
Examiners and caregivers need to work
together to transition the child smoothly
from the interview to the exam (Fig.3).
The clinician should explain what will
happen (tell, show and do) before starting,
and anticipate that young children may
cry since crying is developmentally appropriate for children of this age. Knee-toknee positioning allows the child to see the
Fig. 2 Biological risk factors. Three-year-old

child, with high caries risk. Presence of visible
dental plaque, gingival bleeding and cervical
white spots lesions on the posterior teeth
Fig. 3 The knee-to-knee position
503
PRACTICE
Table 2 Caries management protocol for 02-year-olds
Diagnostic
Preventive intervention
Risk category
(ages 0 to
2years)
Periodic oral exams
Radiographs
Saliva test
Fluoride
Low
Annual
Posterior bitewings at 1224month

intervals if proximal surfaces cannot
be examined visually or with a probe
Optional baseline
In office: no
Home: brush twice a day w/ smear of F
toothpaste
Xylitol
Not required
Moderate
Every sixmonths

Recommended
In office: F varnish initial visit & recalls

Home: Brush twice a day w/smear of F
toothpaste
Caregiver: OTC sodium fluoride treatment rinses
Child: xylitol wipes

Caregiver: twosticks of gum
or twomints fourtimes a day
Moderate;
non-compliant
Every three to sixmonths

Required

Home: Brush twice a day w/smear of
F toothpaste combined w/smear of
900ppm calciumphosphate paste
leave-on at bedtime Caregiver: OTC
sodium fluoride treatment rinses

High
Every threemonths
Anterior (#2 occlusal film) and

posterior bitewings at 612month
Required


High;
non-compliant
Every one to threemonths

posterior bitewings at 612month
Required


Extreme
Every one to threemonths

posterior bitewings at 612 month
Required
In office: F varnish initial visit and recalls


parent throughout the exam. It also allows

the parent/caregiver to observe clinical findings and hygiene demonstrations
directly, while gently helping to stabilise
the child safely for the clinical examination. If the child can perceive a friendly
and comfortable interaction between the
clinician and caretaker, he or she will be
more likely to cooperate and result in a
smoother examination.
Toothbrush prophylaxis
Toothbrush prophylaxis is efficient in
removing plaque in most young children.
It is non-threatening to young children
and serves to demonstrate the proper
technique of brushing to the caregiver.
The examiner retracts the childs lips and
cheeks and demonstrates brushing along
the gingival margins. The spongy handle
of an age-appropriate sized toothbrush can
be used to prop open the childs mouth.
The handle of a second toothbrush can be
used as a mouth prop. During this tellshow-do encounter, the caregiver should
be encouraged to brush their childs teeth
504
at least twice a day, especially before bedtime. The use of fluoride toothpaste should
be emphasised since fluoride has been
shown to be effective topically to prevent
caries. Parents and caregivers should be
instructed to use a pea-sized amount of
fluoride toothpaste for children age two
to six and a smear for children under
age two.34,35
Clinical examination
The examiner counts the childs teeth
aloud, using the toothbrush handle as a
mouth prop if necessary. Many providers
make a game of this task, singing songs,
engaging the childs attention, and if all
else fails, distracting the child with a
brightly coloured toothbrush or toy. Praise
the child at each step for their cooperation
and/or good behaviour. While counting
the teeth, the examiner also inspects the
soft tissues, hard tissues and occlusion, if
the child is able to cooperate. Data from
the clinical exam results should be combined with data from the caregiver interview to determine the childs overall caries
risk and establish an oral diagnosis and

formulate an individualised care (treatment) plan.
The following information should be
documented:
Visible plaque and its location
White spot lesions
Brown spots that on the occlusal
surfaces may indicate caries
Tooth defects, deep pits/fissures,
tooth anomalies
Missing and decayed teeth
Existing restorations
Defective restorations
Gingivitis or other soft
tissue abnormalities
Occlusion
Indications of trauma.
Fluoride treatment
Fluoride is an important and cost-effective
prevention method to strengthen tooth
enamel and prevent caries. The ADA and
the UK NHS Department of Health recommends that high caries risk children receive
a full-mouth topical fluoride varnish (FV)
PRACTICE
Restoration
Sealants
Antibacterials
Anticipatory guidance/
counselling
Self-management goals
White spot/precavitated
lesions
Existing lesions
No
No
Yes
No
n/a
n/a
Fluoride releasing sealants

recommended on deep pits
and fissures
No
Yes
No
Treat w/ fluoride products

as indicated to promote
remineralisation
n/a

and fissures
Recommend for caregiver
Yes
Yes

remineralisation
n/a

and fissures
Yes
Yes

remineralisation
ITR (interim therapeutic

restorations) or conventional
restorative treatment as
patient cooperation and family
circumstances allow

and fissures
Yes
Yes

remineralisation
ITR or conventional restorative

treatment as patient
cooperation and family
circumstances allow

and fissures
Yes
Yes

remineralisation
ITR or conventional restorative

treatment as patient
cooperation and family
circumstances allow
application and re-application consistently

at three/four-month intervals.36 A minimum
of every sixmonths is recommended for children at moderate caries risk even if the child
lives in a community that already receives
the benefits of water fluoridation. The provider should reiterate the cumulative benefit
of the fluoride varnish, even if it has been
mentioned earlier in the visit. After application, the caregiver should be reminded not
to allow the child to brush their teeth or to
eat crunchy/sticky foods for the rest of the
day to allow fluoride varnish to be effective.
FV is one of the most efficacious and
prevalent methods used by modern dentists to combat early childhood caries.
According to the ADA, extensive research
has shown FV to be safe and effective
for patients of all ages.37 FV is painless,
quick to apply, and therefore can be used
on very young children.38 There is, however, widespread debate on the results in
reference to differing recommendations
for the frequency and periodicity of FV
application. Some sources advocate FV
treatments every six months, citing this
protocol as the most cost-effective method

with the best outcome.39 Others argue that
threeconsecutive varnishes over a weeks
time-period, once annually, are more
effective than semi-annual treatments.40-42
Regardless, all sources agree that FV is
useful as a necessary standard of care
component for the prevention of dental
caries and crucial as a tool in oral health
maintenance for all ages.40-42
Assignment of risk, anticipatory

guidance and counselling
An individualised care plan for each infant/
caregiver is designed based upon the risk
determined from the parent interview
and the clinical examination of the child
(Tables2 and 3). A dual approach is essential
for moderate and high caries risk children
and their parent/caregivers. Strategies need
to be employed to decrease the maternal or
caregiver transmission of cariogenic bacteria to infants through the potential use of
chlorhexidine rinse and xylitol products for
caregivers, and fluoride varnish for both the
caregiver and the child.34 Additionally, the
necessary changes in the childs diet, tooth

brushing and fluoride application can be
identified from the risk analysis.
The science of caries prevention continues to evolve. Table 2 illustrates how to
develop care paths for a practices patients.
There are many alternative approaches to
the prevention and treatment of dental
caries, with more emerging continuously.
Care paths should remain dynamic and
change over time as the effectiveness of
new as well as current protocols is validated by scientific evidence.
Parents should be given additional
information and anticipatory guidance on
oral health prevention that is specific to
the needs of their child. Such information
includes oral hygiene, growth and development issues (that is, teething, digit or
dummy habits), oral habits, diet and nutrition and injury prevention (Tables2 and
3). The anticipatory guidance approach is
designed to take advantage of time-critical opportunities to implement preventive
health practices and reduce the childs risk
of preventable oral disease.43-45
505
PRACTICE
An important component of the visit is
to counsel the parents to change specific
factors which may contribute to active caries or to an increased caries risk in their
child. Traditionally, generic recommendations, such as brush your teeth twice a day
and dont eat sweets, have been offered to
parents with limited success. Using family-centred, customised recommendations
have been shown to be more promising as
parents are more engaged in changing specific practices. Motivational interviewing
is a counselling technique that relies on
two-way communication between the clinician and the patient or parent46 (Fig.4).
This includes establishing a therapeutic
alliance (that builds rapport and trust), by
asking questions to help parents identify
the problem and listening to what they say,
encouraging self-motivational statements,
preparing for change (discussing the hurdles that interfere with action), responding
to resistance and scheduling follow-up, as
well as preparing the parent for the inevitable bumps in the road.47
Following the brief motivational interviewing (counselling), the parent/caregiver
is asked to select two self-management
goals or recommendations as their assignments before the next re-evaluation dental visit. The parent/caregiver is asked to
commit to the two goals selected and is
informed that the oral healthcare providers
will follow-up on those goals with them
at the next appointment (see Tables 2
and 3 for self-management goals for
parent/caregiver).
RECALL VISITS
AND RECALL PERIODICITY
The clinician must consider each childs
individual needs to determine the appropriate interval and frequency for oral
examination;48 some infants and toddlers with high caries risk should be reevaluated on a monthly basis (Tables 2
and 3). Most children at high risk need
to be seen on a three-month interval for
re-evaluation. Those children in the moderate risk category need to be placed on
a six-month interval and the low risk
child at a 6-12 month range interval
(Tables2 and 3).
After the parent has been following the
recommendations for three to sixmonths,
have them and their child come back for
reassessment. Parents need encouragement
506
Fig. 4 The motivational interviewing (counselling)
early on when new behavioural change is

required and time to ask questions regarding any difficulties with following the recommendations. They should be aware that
changing home practices does not happen
overnight. At these infant oral care visits,
it is essential to reassess the risk status
and monitor improvement on the previously set self-management goals. During
these reassessment appointments, changes
can be made and prevention protocols
reinforced.
CONCLUSIONS
Paediatric dentists and general dentists
have the most influential role in preventing and reducing the severity of early
childhood caries in young children. By
embracing the concepts of the dental
home, perinatal and infant oral health,
providers can implement preventive and
treatment protocols. These care paths are
based on individually determined caries
risk and utilize an appropriate age-specific
caries risk assessment. For example, care
for very young children should include
preventive interventions such as fluoride
varnish applications, sealants and use
of xylitol products. When restoration is
required but cant be performed readily for
a variety of reasons, practitioners should
consider interim therapeutic restorations
(ITR), employing the use of hand or slow
speed rotary instruments for partial caries removal followed by the application
of adhesive, fluoride releasing restoratives
such as auto-curing resin-modified glass
ionomer cement.49 Motivational interviewing, anticipatory guidance and setting
self-management goals increases the probability for better oral health outcomes and
behaviour, not just for the child, but for
the whole family. Partnerships with other
healthcare professionals with the aim of

providing preventive care for our high risk
populations is crucial to achieving better
oral health outcomes in the future. The
overall aim is to lower the risk level over
time and eliminate the need for further restorations by controlling the caries process.
Information Dentaire, Paris France, for the authorisation of translation and publication of the series
in the BDJ; Dr Norman Tinanoff, Dr Manwai Ng
for contributing their support and knowledge to this
project; Ms Debra Tom for her editorial assistance;
and the HRSA Oral Health Disparities Collaborative
for the implementation of the CAMBRA instrument
and the development of the self-management goal
instrument through High Plains Health Center.
Finally, they wish to acknowledge the AAPD and
AAP for their support and leadership on Caries
Risk Assessment development.
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PRACTICE
Table 3 Caries management protocol for 36-year-olds

Risk category
Ages 3 to 6
Diagnostic
Periodic oral
exams
Radiographs
Saliva test
Fluoride
Low
Annual
Posterior bitewings at
1224month intervals
if proximal surfaces
cannot be examined
visually or with a
probe
Optional
Baseline
In office: no
Home: Brush twice a day
w/ pea size of F toothpaste
Moderate
Every
6months
Posterior bitewings
at 612month
intervals if proximal
surfaces cannot be
examined visually or
with a probe
Recommended
In office: F varnish initial

visit and recalls
Home: Brush twice
a day w/pea- size of
F toothpaste
Caregiver: OTC Sodium
Fluoride treatment rinses
Moderate;
non-Compliant
Every
36months
Posterior bitewings
at 612month
intervals if proximal
surfaces cannot be
examined visually
or with a probe
Required

visit and recalls
Home: Brush twice
a day w/pea- size of
F toothpaste combined
w/pea-size of 900ppm
calciumphosphate paste
leave-on
at bedtime
Caregiver: OTC sodium
fluoride treatment rinses
High
Every
3months
Anterior (#2 occlusal

film) and posterior
bitewings at
612month intervals
cannot be examined
visually or with
a probe
Required

visit and recalls
Home: Brush twice a day
w/pea-size of F toothpaste
combined w/pea-size
of 900ppm calciumphosphate paste leave-on
at bedtime
High;
non-Compliant
Every
13months

film) and posterior
bitewings at
612month intervals
cannot be examined
visually or with
a probe
Required

visit and recalls
Home: Brush twice
a day w/pea-size of
leave-on
at bedtime
Extreme
Every
13months

film) and posterior
bitewings at
612month intervals
cannot be examined
visually or with
a probe
Required

visit & recalls
Home: Brush twice
a day w/pea-size of
leave-on
at bedtime
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46. Weinstein P, Harrison R, Benton T. Motivating parents
to prevent caries in their young children: one-year
findings. J Am Dent Assoc 2004; 135: 731738.
47. Weinstein P. Provider versus patient-centered
approaches to health promotion with parents of
young children: what works/does not work and
why. Pediatr Dent 2006; 28: 172176.
48. Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL,
Featherstone JD. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif
Dent Assoc 2007; 35: 687702.
49. American Academy on Pediatric Dentistry
Clinical Affairs Committee- Restorative Dentistry
Subcommittee, American Academy on Pediatric
Dentistry. Council on Clinical Affairs Guideline on
pediatric restorative dentistry. Pediatr Dent 20082009; 30: 163169.
Erratum
Practice article (BDJ 2012; 213: 447451)
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 ladulte. Ralits Cliniques 2011; 22: 213219.
We apologise for any confusion caused by this error.
508


part 4. Detection and diagnosis
of initial caries lesions
IN BRIEF
Discusses the methods recommended for

approach to caries diagnosis and
treatment.
Presents a clinical case to consolidate
diagnostic methods.
A. Guerrieri,1 C. Gaucher,2 E. Bonte3 and J.J. Lasfargues4

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
The initial caries lesion can be defined as
a primary lesion which has not reached
the stage of an established lesion with
cavitation. It is therefore amenable to
DENTISTRY
caries lesions
of dental caries
This paper is adapted from: Guerrieri A, Gaucher C, Bonte E,
Lasfargues J J. Dtection et diagnostic des lsions carieuses
initiales. Ralits Cliniques 2011; 22: 233244
Facult de Chirurgie Dentaire, Universit PARIS

DESCARTES(1 rue Maurice Arnoux, 92120 Montrouge)
et Service dOdontologie, Hpital Bretonneau, APHP
(2 rue Carpeaux, 75018 Paris), France.
*Correspondence to: Professor Jean-Jacques Lasfargues
Email: jean-jacques.lasfargues@brt.aphp.fr;
Tel: +33 1 53 11 14 30
1-4
Accepted 21 June
DOI: 10.1038/sj.bdj.2012.1087
being treated by non-invasive procedures

including ultra-conservative or minimal
intervention dentistry.
The detection of carious lesions at an
early stage is necessary in order to implement preventive and interceptive treatment
strategies. In daily practice, the diagnosis
of initial lesions is not always simple; it
is often subjective and based on the clinicians clinical sense. For this reason, the
search is on for more specific and sensitive
tools, using new technologies, to help the
practitioner diagnose initial caries lesions
as precisely as possible. The purpose of
this paper is to review the recommended
clinical methods for diagnosing initial caries lesions and to examine recent tools for
early detection of these lesions.
BACKGROUND
The initial enamel lesion results from an
imbalance between the processes of demineralisation and remineralisation. The
first changes in enamel appear at those
sites where there is plaque biofilm retention and stagnation. The demineralisation
alters the enamel surface, which becomes
micro-porous, and with an opaque and
matt appearance, characteristic of a white
spot lesion. Acid penetration along the
sheath of the enamel prism leads to the
dissolution of crystalline spaces adjacent to the lesion and progressing to the
enamel-dentine junction (EDJ) and, in the

absence of treatment, cavitation occurs.1-3
High evidence-level studies are in
agreement that the ideal tool for detection
of the initial lesion, the gold standard,
has not yet been identified. Such a tool
should have both a high level of sensitivity (the ability to detect disease when it
exists) and a high level of specificity (the
ability to confirm the absence of disease).
The conventional and validated tools for
detecting early carious lesions include visual and tactile examination and radiography (bitewings). These methods have good
specificity but only moderate sensitivity
and are relatively operator-dependent.4-6
The combination of clinical examination
and bitewing radiographs nevertheless
allows diagnoses with improved sensitivity and specificity. Some new technologies are appearing and it is of interest to
link them with standard clinical practices,
with a view to improving caries detection
and diagnosis.3
THE STANDARD
CLINICAL APPROACH
Systematised caries diagnostic procedures
consist of threestages: the detection of a
lesion, evaluation of its severity (depth)
and its level of activity.7,8 Before an examination, the practitioner will have noted
the general context of caries activity. The
BRITISH DENTAL JOURNAL VOLUME 213 NO. 11 DEC 8 2012
551
PRACTICE
clinical diagnosis of initial carious lesions.
Stresses the importance of a systematic
PRACTICE
principle general risk factors should be
noted: age group, health state and use of
medications, lifestyle, oral hygiene, nutrition and use of fluorides (Figs 1 and 2).
Evaluation of individual caries risk cannot
be separated from the actual diagnosis of
carious lesions. It is essential to categorise
a patient as being at low or high risk of
caries for the correct choice of preventive,
interceptive, or therapeutic care.
General context of caries

activity (diet, life-style
and habits)
Initial clinical examination
Obvious lesions
EXTENSIVE CLINICAL
OBSERVATION
Observation is used to classify each
lesion according to its site and its stage
of advancement, with a view to therapy.3
Pre-cleaning is fundamental to the quality of diagnosis, both for the direct visual
examination and for the use of complementary diagnostic aids such as fluorescence-based techniques.9 Undertaken with
a rotating brush and prophylactic paste,
or by air-polishing, the aim is elimination
of the surface biofilm and deposits. Once
cleaned, the suspect sites are dried and
inspected individually. The use of visual
aids (magnifying loupes, minimum2.5)
greatly improves the detection rate of initial carious lesions.10 The signs to look for
552
Suspect sites
Probe collects plaque

= active site
INITIAL CLINICAL EXAMINATION

The purpose of the examination is to
detect visually changes of colour, translucency and structure of the enamel. An
initial inspection, tooth by tooth, on wet
surfaces can spot cavities and brown or
white stains. Periodontal status and restorations may also be checked initially. At this
stage, caries activity must be evaluated by
checking the build-up of plaque biofilm and
the gingival pathology at suspect sites. A
blunt/rounded probe (a periodontal probe is
appropriate) may be used, with gentle force
(Fig.3). Clinical parameters that indicate
and quantify the activity state of a single
carious lesion are, according to Ekstrand:8
The appearance of the lesion, correlated
with its severity (extension, depth)
The position of the lesion (in an area
in favouring plaque build-up or not)
Tactile perceptions on probing (used to
assess the presence of surface deposits
and the roughness of the enamel)
The status of the gingival margin
in relation to the areas of interest
(assessed by the absence or presence of
bleeding caused by a careful probing).
Initial interview
Gingival bleeding on probing

= active site
Cleaning and drying

of tooth surfaces
In-depth clinical examination
Complimentary tools
(Diagnodent, LED camera)
Optical aids
Visual criteria
(ICDAS II)
Radiographic examination
(bitewings)
SiSta Classification
Caries risk
Low to moderate
High
Treatment decision
Fig. 1 Flow-chart of the practical approach to assessment of initial carious lesions (from
Lasfargues and Colon, 2010)3
are changes in colour and translucency

that indicate the state of demineralisation
of surfaces and sub-surface zones compared with adjacent healthy areas. These
visible signs indicating caries have been
rationalised in a classification system,
the International Caries Detection and
Assessment System (ICDAS).11 The classification includes sixcodes. Initial lesions
are mainly covered by codes 1and 2.
ICDAS II Code 0: the tooth is healthy
ICDAS II Code 1: the tooth has a lesion
visible only after drying and histology
reveals that the lesion is limited to the
external half of enamel
ICDAS II Code 2: the lesion penetrates
the full thickness of enamel. Clinically,
an opacity or discoloration distinctly
visible without air-drying is apparent
but without cavitation (Fig.4).
A statistically significant correlation
exists between the anatomical and histological stages of lesions and the major
Fig. 2a Young patient presenting with a high

caries risk, as evidenced by the presence of
multiple white-spot demineralisations and
severe gingivitis
Fig. 2b Close-up of area of plaque retention,

indicating high disease activity
visual signs.12 Carious lesions thus identified are classified on the ICDAS system
according to the site: occlusal (site 1),
PRACTICE
Table 1 Criteria for visual detection of carious lesions (ICDAS) and SiSta classification; from
Lasfargues and Colon, 20103
Fig. 3a Detection of a proximal carious

lesion. Identification of a suspected site of
carious activity distal to 36
ICDAS Criteria for visual

Code lesion detection
0
Sound surface
Degree of severity
of lesion
1
2
Earliest optical change,

visible on drying enamel
Clear enamel change; white
or brown blemishes, visible
without drying
Demineralisation in outer
third of enamel
Demineralisation reaching
the inner third of enamel,
possibly the ADJ
Localised break in enamel
Dentine not visible
Enamel opaque or greyish,

suggestive of an underlying
dentine lesion, with or
without enamel cavitation
Dentine cavity
Demineralisation of outer
third of dentine
Demineralisation of
middle third of dentine,
no weakening of dental
crown structure
Demineralisation of middle
third of dentine, weakening
of dental crown structure
Fig. 3b Carious activity confirmed by the

presence of bleeding on probing with the
periodontal probe, allowing the severity of
the lesion to be evaluated
Fig. 3c Bitewing showing SiSta classification

Stage 2
proximal (site 2), and cervical (site 3), then

according to their stage (Table 1).
VISUAL EXAMINATION ASSISTED

BY PROBING
Tactile sensation has long been the principal diagnostic tool in cariology, involving the use of a sharp dental explorer. It
has been demonstrated that probing does
Therapeutic options
Not necessary
Demineralisation of inner
third of dentine,
undermining of cusp
structure and support
Minimal intervention;
non-invasive care,
remineralisation or sealant
1 and 2
Minimal intervention;
adhesive ultra conservative
restoration
3 and 4
Operative dental care;

functional crown
restoration with or
without cusp coverage
SiSta = Site and Stage
not improve the diagnostic sensitivity of

visual examination, especially in detecting lesions in pits and occlusal fissures.
Indeed, the result of this subjective method
depends on the size of the probe tip, the
resistance of the enamel and the force
exerted by the probe. Furthermore, probing can cause iatrogenic damage to enamel
(and loss of the possibility of remineralisation) so favouring lesion progression.13
Probing with a sharp dental explorer cannot be considered a reliable technique for
detection of carious lesions.
RADIOGRAPHIC EVALUATION
Fig. 4 Multiple ICDAS II score initial lesions

(breach of any thickness of cervical enamel).
Note the white areas, clearly visible without
drying
SiSta*
stage
Bitewing radiographs are the method

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

None of the new caries detection techniques developed in recent years is 100%
reliable when used alone. They complement the systematic approach already
described, with, for the most validated,
an increase in detection sensitivity
when combined with conventional techniques.14,15 Their development is based
on the need for increased detection sensitivity to allow lesions to be identified
as early as possible (particularly before
invasive restoration becomes necessary).
Today the treatment of initial lesions is
well understood,16 as is the need for early
caries lesion detection and diagnosis.
The new diagnostic tools are classified
on the basis of the physical principles that
underpin them.17 The most prominent include
transillumination (Diagno.cam, Kavo), and
fluorescence systems (DIAGNOdent, Kavo;
CS 1600 Kodak; VistaCam iX, DrrDental;
SoproLife, Acteon).
OPTICAL TECHNIQUES
Optical aids
The visual examination requires optical
magnification to be properly conducted.
This is not a matter of a microscope for
clinical use for the detection of early carious lesions. The use of Galilean loupes
(magnification 25) is satisfactory for
daily practice. The practitioner may choose
the most ergonomically appropriate type
553
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
and motivation purposes but their quality
is not always satisfactory for diagnosis.17
Fig. 5d An air-polisher, here the Air Max by

Satelec. It uses a 250m grain powder in a wet
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 fluorescence is attributed to the proteins that
make up the enamel and dentine matrices.
It may also occur when bacterial metabolites from the carious process, plaque,
composite resins or prophylactic paste
residue absorb high energy light. Before
using devices based on fluorescence, it is
important to undertake meticulous cleaning, rinsing and drying of the surfaces to
be studied so as to eliminate as much as
possible matter which could cause confusion (Fig.5).
e
b
Fig. 5 Use of modern caries diagnosis

tools: (a) diagnostic systems such as the
SoproLife camera (Acteon) and the
DIAGNODENT pen (Kavo) should be used
with (b) an air-polishing system to preclean surfaces
f
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
the late 1990s. The red light and the subsequent fluorescence emissions are carried via optical fibres. The return signal
is filtered and modulated to indicate the
degree of mineralisation of the examined
surface on a scale from 1 to 99, displayed
on a screen. Some authors agree that this
system has better sensitivity than visual
or radiographic examination.18-21 Its specificity is acceptable but its reproducibility remains controversial.22-24 Using the
DIAGNOdent pen is easier than its predecessor because the hand piece is no longer
connected to a monitor by an optical cord.
On the other hand, its use requires some
precautions: the tips must be aligned correctly on the test surfaces, thorough cleaning and drying without dehydration and
careful scanning of the entire surface with
the repeating beep pulses indicating good
signal reception.
554
Fig. 5c Clinical examination reveals stained

fissures, often considered as affected and
treated as carious lesions
Quantitative light fluorescence

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

DIAGNOdent does not indicate the presence
of a lesion nor does (f) the fluorescence
camera used in diagnostic mode with (g) white
light or (h) polarised light (SoproLife, Acteon)
with visual examination results in significantly increased detection sensitivity of

initial lesions. The extended time required
for acquisition of the images makes the
use of this technology impractical in daily
practice.14,17,25,26
PRACTICE
Fig. 6a Using the SoproLife camera

(Acteon) for the diagnosis and treatment of
SiSta 1.1 lesions. After cleaning and drying
the tooth surfaces, visualisation of the lesion
in diagnostic mode with fluorescence
Fig. 7a Facial view of the patient, Mrs A,

who attended for a dental assessment before
orthodontic treatment
Fig. 7b Frontal view of the anterior dentition
Figs 7e and f Checking the accumulation

of plaque and gingival conditions at the
2526and 1516embrasures
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
LED cameras
The newest detection system for carious
lesions is the use of intraoral cameras with
LED technology. These systems illuminate
the tooth, record the fluorescence of the
dental tissue and enhance the image using
dedicated software. Clinical studies are
underway to confirm their usefulness. The
Vista Proof camera is used with DBSWIN
software (Drr Dental AG) which can also
analyse digital radiographs. As with QLF
systems, the healthy enamel appears green.
Fig. 7d Occlusal view of the mandibular arch
Fig. 7g Clinical details of Quadrant 1
Demineralised enamel appears blue and dentine is yellow to red, depending on the severity of the demineralisation.27 This device was
recently improved (VistaCam iX).
The fluoLED camera Sopro-Life offers
fluorescence images in twomodes: a diagnostic mode and processing mode. Healthy
tissues appear green (blue in areas with very
thick enamel) and carious tissue is light
to very dark red. In diagnostic mode, the
distribution of colours is limited to those
observed on the tooth while, in processing
mode, the range of red is amplified to guide

the practitioner in his elimination of carious
tissue (Fig.6).28 Finally, there is a day light
mode that allows intraoral photographs and
videos to be made.
Research and development of these
new technologies should lead to further
improvements in their sensitivity, specificity and reproducibility to facilitate the reliable and objective quantitative diagnosis
of carious lesions. Beyond the pre- and
during-operative diagnostic stages, the
555
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 specificity of caries lesion detection.
Fig. 7k Bitewings of right premolar area
CLINICAL CASE
Fig. 7h Clinical details of Quadrant 2
Fig. 7i Clinical details of Quadrant 3
Mrs A, aged 30 years, consulted for an

oral check before commencing orthodontic
treatment (angle Class II associated with
21labially positioned teeth). The patient
was cooperative but not easily available
for dental appointments (Fig.7).
During the initial consultation, inspection revealed absence of pain and a healthy
lifestyle. A food diary conducted the week
following the consultation indicated a high
sugar intake. At the preliminary oral examination, oral hygiene appeared less than perfect (moderate quantities of plaque) despite
brushing twice daily. The presence of defective amalgam restorations and noticeable
superficial gingivitis was noted.
After air-polishing to eliminate surface
discolouration and the biofilm (Fig. 5), a
more detailed observation using optical aids
was undertaken of suspect sites, particularly
in the premolar and molar areas. Gingival
condition and the accumulation of plaque
were audited at the embrasures with the
aid of a periodontal probe. Gingival bleeding on probing was noticed in the region
of teeth 2526 (Fig.7e) and 1516 (Fig.7f),
raising suspicions of the presence of proximal lesions due to plaque retention in these
confined areas. Changed colour in the mesial
marginal ridge of 47 (Fig.7j) indicated a dentinal lesion with undermined enamel (ICDAS
code 4). At this stage, bitewing radiographs
in these tworegions was deemed necessary
to confirm the presence or absence of lesions
and, if present, their extent. The radiographs
indicated initial caries in the right sector:
SiSta 2.0on 15D and 14D as well as 44D
and 45D, and SiSta 2.2on 47M and, in the
left sector: SiSta 2.0on 24M, 25D, 26M
and SiSta 2.0 on 36D and 37M.
Ultraconservative minimal
intervention dentistry
Fig. 7j Clinical details of Quadrant 4; note
the lesion on mesial surface of 47
556
Analysis of all risk factors and predictors

revealed by the dietary diary and the clinical examination, indicated a high caries
Fig. 7l Bitewing of right molar area
Fig. 7m Bitewing of left premolar area
Fig. 7n Bitewings of left molar area
risk requiring management and follow-up

every threemonths (Table 2). The following treatment objectives were proposed for
this patient:
Control caries disease by lowering
caries risk (plaque control and
dietary advice)
Treatment of non-cavitated lesions
using non-operative methods
(remineralisation or resin impregnation)
Treatment of cavitated lesions with
adhesive restorations (composite)
Replacement of defective amalgam
restorations by long-lasting
provisional adhesive restorations
Prevention of recurrent caries during
PRACTICE
Table 2 Evaluation of caries risk of Mrs A

Risk factors and predictors
Present
Absent
New carious lesions

New active lesions in the past 3years
9lesions
Restorations placed in the past 3years
Oral factors (hygiene, plaque, saliva)

Twice daily toothbrushing
Topical fluoride (toothpaste, mouth rinse)
Dental plaque accumulation
Gingival bleeding (on probing, spontaneous)
Salivary pH and stimulated salivary flow
Increased counts, Lactobacillus and S.mutans
Not done
General factors (age, nutrition, health)

Risk age group (child, adolescent, senior (reduced autonomy)
Sugar consumption, snacking, frequent sugary drinks
X
X
Boulimia, obesity, diabetes
Pregnancy
Dry mouth due to medication; addiction
Sjgrens syndrome
Chemotherapy, radiotherapy of head and neck region
Behavioural factors
Risk occupation; injurious cultural habits
Low socio-economic status, unemployed
Caries risk
High
Frequency of caries check-up
3months
orthodontic treatment by active

maintenance.
CONCLUSIONS
In recent years, methods of detection of
early carious lesions have evolved considerably, moving firstly towards the identification of the earliest mineral changes and then
to controlling the demineralisation process
using non-operative procedures. Previously
an indiscriminate routine task, caries diagnosis has become a fully-fledged, codified
discipline which demands of the practitioner
precise knowledge, rigor and time. In addition to the identification of risk factors and
the early detection of lesions, it is essential
to evaluate the extent of each lesion (noncavitated vs cavitated) and its status (active
or arrested) so as to establish a monitoring procedure and predict the outcome, as
for any other disease. Such a systematic
approach should lead to a care plan for
caries, based on prophylactic measures with
minimal use of restorative measures, leading
to better patient oral health.
None of the new tools designed to
enhance and facilitate caries diagnosis
is yet proven, so there is still no absolute substitute for the traditional clinical
examination and radiographic bitewing
examination. The technologies, particularly those based on fluorescence, may
nevertheless assist in raising the awareness
and motivation of patients; they are also
interesting for their monitoring potential
and controlling the process of regression/
progression over periodic intervals.
The authors would like to thank Claudie
DamourTerrasson, President and publishing
director of the Groupe ID Espace LInformation
Dentaire, Paris France, for the authorisation of
translation and publication of the series in the BDJ.
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26. Khnisch J, Bcher K, Henschel V, Hickel R.
Reproducibility of DIAGNOdent 2095and DIAGNOdent
Pen measurements: results from an invitro study on
occlusal sites. Eur J Oral Sci 2007; 115: 206211.
27. Eberhart J, Frentzen M, Thoms M etal. New optical
techniques for caries detection. Fluorescence-based
systems to identify non-cavitated lesions. Paris:
Drr Dental Publication, 2007.
28. Terrer E, Koubi S, Dionne A, Weisrock G, Sarraquigne
C, Mazuir A, Tassery H. A new concept in restorative
dentistry: light-induced fluorescence evaluator
for diagnosis and treatment. Part 1: diagnosis and
treatment of initial occlusal caries. J Contemp Dent
Pract 2009; 10: E086E094.
557
IN BRIEF
Describes the clinical aspects of the
atraumatic restorative treatment (ART)

approach.
Stresses the importance of following the
treatment protocol to ensure reliable
results and reviews the evidence base
supporting its use.
Suggests ART should be considered as a
therapeutic option especially in children,
anxious patients and those with special
needs.
PRACTICE

part 5. Atraumatic restorative
treatment (ART)a minimum
intervention and minimally
invasive approach for the
management of dental caries
C. J. Holmgren,1 D. Roux2 and S. Domjean3
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 twodecades, the atraumatic
restorative treatment (ART) approach has become a worldwide phenomenon; used not only in some of the poorest developing 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 simultaneously using high viscosity glass-ionomer inserted under finger pressure. Reliable results can only be obtained if the treatment 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.
DENTISTRY
caries lesions
of dental caries
This paper is adapted from: Holmgren CJ, Roux D, Domjean
S. Traitement restaurateur atraumatique (ART). Une approche
a minima de la prise en charge des lsions carieuses. Ralits
Cliniques 2011; 22: 245256.
Aide Odontologique Internationale, Paris, France;

Senior lecturer, Hospital consultant, CHU ClermontFerrand, Service dOdontologie, Htel-Dieu, F63001
Clermont-Ferrand, France and Univ Clermont 1,
UFR dOdontologie, F63000 Clermont-Ferrand,
France; 3Professor, Hospital consultant, Centre de
Recherche en Odontologie Clinique, EA4847;
CHU Clermont-Ferrand, Service dOdontologie, HtelDieu, F63001 Clermont-Ferrand, France and Univ
Clermont1, UFR dOdontologie, F63000 ClermontFerrand, France
*Correspondence to: Dr Christopher Jonathan Holmgren
Email: oralhealth@chrisholmgren.org;
Tel:+33 254 371951
1*
2

DOI: 10.1038/sj.bdj.2012.1175
INTRODUCTION
Atraumatic restorative treatment (ART)
was developed in the 1980s but embodies
all the principles of an alternative philosophy of dental care that was ultimately to
become known as minimal (or minimum)
intervention dentistry.1,2 Minimal intervention management of caries attaches
importance to the diagnosis and evaluation of caries risk and includes prevention,
stabilisation and healing (remineralisation)
of early lesions and minimally invasive
restorative treatment for cavitated dentine lesions with selective excavation of
destroyed tissue combined with maximal
preservation of healthy tissues. While
developed originally in response to a
need to provide effective restorative and
preventive treatment in underserved communities, over the past two decades the
ART approach has become a worldwide
phenomenon. ART can be considered to
be a cornerstone of minimal intervention
caries management in combining prevention and minimal invasion.
The objectives of this paper are to:
1. Describe the philosophy of the ART
approach within the overall concept
of minimal intervention and minimal
invasion for the management of
dental caries
2. Describe the clinical aspects of ART

3. Review the evidence base for
supporting the use of ART
4. Describe the indications for ART.
WHAT ARE ART SEALANTS

AND RESTORATIONS?
Over the past 20years some confusion has
arisen as to what constitutes the atraumatic restorative treatment (ART) approach
since a number of authors use the term to
describe procedures that are not considered
to be ART. To avoid confusion a recent definition by Frencken and van Amerongen
should be adopted as follows: ART is a
minimally invasive approach to both prevent dental caries and to stop its further
progression. It consists of twocomponents:
sealing caries prone pits and fissures and
restoring cavitated dentin lesions with sealant-restorations. The placement of an ART
sealant involves the application of a highviscosity glass-ionomer that is pushed into
the pits and fissures under finger pressure.
An ART restoration involves the removal
of soft, completely demineralised carious
tooth tissue with hand instruments. This is
followed by restoration of the cavity with
an adhesive dental material that simultaneously seals any remaining pits and fissures
that remain at risk.3
BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013
11
PRACTICE
This definition implies that if any other
method is used to prepare the cavity, for
example, use of rotating instruments to
open a cavity or the use of non-adhesive
restorative material this cannot be considered as ART nor should the term modified ART be used since this may lead
to confusion.4
The philosophy and science

behind the ART approach
The sealing of fissures with sealants has
been shown to be an effective approach
both for the prevention of fissure caries
lesions de novo and for the prevention
of the progression of early lesions in this
site.5-8 As such, sealants, including ART
sealants that use a high-viscosity glassionomer cement (GIC), play an essential
role in a minimal intervention and noninvasive approach.9
The principle by which preventive and
therapeutic sealants function is by providing a physical barrier that excludes
bacteria and their nutrients from pits and
fissures that cannot be cleaned and that
have minimal access to saliva and fluoride. There is no reason why this principle
shouldnt be extrapolated to situations
where the caries process has extended
into the dentine resulting in frank cavitation but without pulpal involvement.
Here, the major constraint of a cavitated
caries lesion is that in order to achieve a
seal to the cavity and to render the external surface cleansable, there is a need to
place a restoration, preferably with an
adhesive material.10,11
If a restoration is required for caries
control in cavitated lesions then the next
question is how best to restore the cavity.
Ideally the objectives should be to retain
a maximum amount of sound tooth tissue
for strength, make the restoration as small
as possible so it is long lasting and to seal
the adjacent pits and fissures that are of
high caries risk (placement of a sealant restoration). Adhesive restorative materials,
namely composites and GIC, have revolutionised cavity restoration since the need
to destroy sound tooth tissue to achieve
mechanical retention, as was the case
for amalgam, has been greatly reduced.
Furthermore, a better understanding of
the histopathology of the dentine caries
lesion means that a minimally invasive
cavity preparation can safely be used. The
12
term cavity preparation is better named

cavity cleaning since it emphasises the
more biological approach that ART and
other minimal invasive approaches adopt
over purely mechanistic approaches.
Over 50 years ago, Fusayama and
Massler independently showed that the
dentine caries lesion could be divided
into two layers.1214 The layer closest to
the opening into the cavity defined as
outer carious dentine or infected dentine is a soft, infected biomass that has no
sensation and is largely incapable of being
remineralised. As such it is of no further
structural use to the tooth and therefore
should be removed (Fig.1). The deeper part
of the dentine caries lesion, that which is
more distant from the opening of the cavity, is harder since the mineral content is
higher. This is called inner carious dentine
or preferably affected dentine. This often
darker and stained layer is vital, minimally
affected with bacteria and has the potential
to remineralise. It is therefore logical to
retain this layer. If rotary instrumentation
is used to clean (prepare) the cavity, tactile feedback that enables the distinction
between the softer infected dentine and the
harder affective dentine is compromised.
This often leads to excessive cavity preparation and unnecessary removal of sound
tooth tissue or that which has the potential to remineralise.15,16 While a number
of alternatives to rotary instrumentation
for cavity cleaning exist, the best compromise between effectiveness of caries
removal and efficiency has been shown
to be the use of hand-excavators.15,16 These
are used for cavity cleaning in the ART
approach since they are readily available
and, as they do not rely on electricity or
running water, can be used both in the
traditional dental clinic environment and
for outreach situations where dental facilities do not exist.
It is important to emphasise that the
ART approach to manage cavitated caries lesions does not intentionally leave
soft, infected dentine behind in the cavity.
The sole exception might be in deep caries lesions where there is a risk of pulpal
exposure. As is now becoming common
practice, in such cases soft dentine is
retained deliberately and the cavity filled
and sealed with a sealant restoration. The
deliberate leaving of soft dentine caries in a cavity is contrary to traditional
Inner affected dentine

few bacteria
remineralisable
vital
sensitive
useful
Outer infected dentine

bacterial invasion
unmineralisable
dead
without sensation
not useful
Fig. 1 Layers of a dentine caries lesion. The

outer carious dentine or infected dentine is
soft and infected and should be removed. The
inner carious dentine or affected dentine
can remineralise and should be retained
Fig. 2 A small enamel hatchet used to open

access to underlying softened dentine
Fig. 3 Twospoon-shaped excavators,

onesmall with a spoon approximately 1mm
across, another slightly larger are used to
excavate soft dentine
Fig. 4 A small flat plastic instrument is used

for applying the GIC and for shaping the
restoration. An Ash 6 special is shown here
PRACTICE
Fig. 5 An Enamel Access Cutter (EAC) can

be used to access the cavity when the enamel
hatchet is too large
real dangers of complete removal of all

soft infected dentine in deep lesions, which
have been shown to lead to an increased
number of pulpal exposures.19,28 It is therefore not only logical but also good practice
to retain some soft caries on the pulpal
floor of deep caries lesions when there is a
likelihood of causing a pulpal exposure in
a vital and otherwise symptomless tooth,
irrespective of the restoration method used.
PRACTICAL CONSIDERATIONS
WHEN USING ART
Instruments required
Fig. 6 The instruments are laid out in the

sequence that they are going to be used
Fig. 7 The tooth surface is cleaned by

rubbing with a damp cotton wool pellet and
then dried with a dry pellet or a triple syringe
dictum but there is little evidence that

infected dentine must be removed before
sealing the tooth with a restoration.1719
Conversely, there is now a substantial evidence base from long-term studies that
caries lesions that are sealed in place do
not progress and might even regress.11,2022
This is consistent with the principles of
therapeutic sealing since if cariogenic
bacteria are isolated from their source of
nutrition they either die or remain dormant and therefore cannot result in caries
lesion progression.2327
While the notion of intentionally leaving a limited amount of soft, infected
dentine behind in a cavity to be restored
might be totally contrary to what has been
taught in dental schools over the years,
the unsubstantiated dangers of such an
approach must be balanced against the
Under normal situations no special instruments are needed to perform ART since
most can be found in a normal dental clinic. The instruments required are
as follows:
Mirror, probe and tweezers
A small enamel hatchet to open access
to underlying softened dentine (Fig.2)
Twospoon-shaped excavators,
onesmall with a spoon approximately
1mm across, another slightly larger
(Fig.3). These are used for the removal
of soft dentine. The larger excavator
can also be used for packing filling
material under enamel and for the
removal of excess filling material
A small flat plastic instrument for
applying the GIC and for removing
excess filling material and for shaping
the restoration. An Ash 6 special is
ideally suited to this purpose (Fig.4).
In addition to this basic set of instruments, a special instrument might be necessary. The Enamel Access Cutter (EAC)
has been developed to access smaller cavities where the blade of the enamel hatchet
might be too large (Fig.5). To reduce hand
fatigue it is recommended that the instruments have a wide handle.
Materials required
In addition to the normal consumable
materials that are found in a dental practice, for example, cotton wool rolls, petroleum jelly (Vaseline) etc, the only other
requirement is a high-viscosity, highstrength GIC. Encapsulated GIC generally produce a more consistent mix but
are usually more expensive than handmixed GIC. Furthermore, if an encapsulated GIC is to be used then a separate
dentine conditioner will be required. Fuji

IX (GC International), Ketac Molar (3M
ESPE) and Chemflex (Dentsply) have
been validated for use for ART. Other GIC
that purport to be suitable for ART should
only be used if there is evidence that they
are effective.
ART RESTORATIONS STEP-BY-STEP

For experienced dentists the ART approach
might at first appear simple and straightforward. However, reliable outcomes can
only be achieved if the following steps are
rigorously adhered to.
Step 1. Preparation of the ART

instruments and materials
before the clinical procedure
Before starting the clinical procedure
ensure that all the instruments and consumable materials are laid out in a logical and ordered manner. They should be
arranged in the sequence that they are
going to be used (Fig. 6). Since cotton
wool pellets are used for many steps in the
ART approach, it saves time to separate an
adequate number of these into individual
pellets of suitable size beforehand.
Step 2. Isolation of the

operating site
As for all restorations, isolation is important since contamination of the operating
site with saliva or blood will affect bonding of the GIC to the tooth surface. For
ART, a rubber dam is not necessary since
isolation with cotton rolls is adequate.
These must be changed as soon as they
are saturated with saliva.
Step 3. Examining the

cavitated tooth
Once the operating site has been correctly
isolated, the tooth and the extent of caries lesion can be examined more easily.
To assist in this task, carefully remove
any plaque or food debris from the pits
and fissures with a dental explorer, taking care not to create additional cavitation. The tooth surface is then cleaned
by rubbing with a damp cotton wool
pellet, followed by drying the surface
with a dry pellet or gently with a triple
syringe (Fig. 7). Discoloured or translucent enamel usually indicates demineralisation where the enamel might be weak
and where the caries process might have
13
PRACTICE
spread laterally along the enamel-dentine
junction (EDJ).
Note: unlike for conventional restorations, a local anaesthetic is very rarely
required since only necrotic tooth tissue
is being removed during cavity cleaning.
However, an anaesthetic can be given at
the request of the patient.
Step 4. Gaining adequate

access to the caries lesion
In small caries lesions, where the opening
into the cavity is small, it is often necessary to widen the access. A dental hatchet
is used ensuring that the instrument is
correctly stabilised using an appropriate
finger rest. The corner of the hatchet is
placed in the entrance of the cavity, usually in the deepest part of the pit or fissure
for the occlusal surface, and the instrument tip rotated backwards and forwards
while maintaining slight pressure (Fig.8).
This fractures off the weak demineralised
enamel surrounding the cavity entrance,
permitting adequate access to the dentine
caries for the smallest excavator. As mentioned above, an EAC can also be used
to improve access to a caries lesion. This
instrument is placed in the cavity opening
and rotated in a similar way as the hatchet
to fracture off weak demineralised enamel.
The EAC has twopyramidal shaped working tips, one large and one small. The
largest tip can be used when the cavity
opening is relatively wide, but needs to be
opened further; the smaller tip being used
in small openings where there might be
difficulty in using the hatchet.
Note: the EAC should not be used for
creating cavities where they do not exist.
If in doubt about the presence of a possible lesion it is better to place a therapeutic sealant without any mechanical
preparation.
Step 5. Cavity cleaning

Hand excavators are used to remove soft,
infected dentine. Cavity cleaning starts
with the removal of soft dentine from
the EDJ. Here the smallest excavator is
used making circular scooping movements under the enamel (Fig.9). This so
called unsupported enamel only needs to
be removed if it is thin and weak or if
additional access is required to complete
removal of soft dentine at the EDJ. Here,
some of the enamel can be gently fractured
14
off with the blade of the hatchet along the

line of the enamel prisms (Fig.10).
Note: there is no danger in leaving
sound, unsupported enamel since it effectively becomes supported when the cavity
is restored with GIC.
Soft dentine from the rest of the cavity
is now removed with the larger excavator as access permits. Care must be taken
in deep cavities where there is danger of
exposing the pulp. It is advisable not to
exert excessive pressure on the pulpal floor
with a small excavator since this increases
the likelihood of exposure. For deep cavities close to the pulp it is better to leave
some soft dentine on the pulpal floor than
risk exposing the pulp. The resultant cavity
is then washed and gently dried. In outreach situations a wet cotton wool pellet
is used and the cavity dried with a dry
pellet. Note, that since a local anaesthetic
is not routinely used, luke-warm water for
rinsing is preferable to reduce tooth sensitivity during this stage. The use of a triple
syringe is not recommended. The cavity
is then examined carefully and additional
cavity cleaning is undertaken if necessary.
It is important that stained or discoloured
dentine that is hard should be retained.
There is normally no indication to use
a lining material for an ART restoration
except in the deepest of cavities. Here a
setting calcium hydroxide liner can be
used but only at the spot closest to the
pulp. Excessive use of lining material will
reduce the surface area available for bonding of the GIC.
Fig. 8 The corner of the hatchet is placed in

the entrance of cavity, usually in the deepest
part of the pit or fissure for the occlusal
surface and the instrument tip rotated
backwards and forwards while maintaining
slight pressure
Fig. 9 The smallest excavator is used to

remove soft dentine from the enamel
dentine junction by making circular scooping
movements under the enamel
Step 6. Conditioning the cavity

and adjacent pits and fissures
Fig. 10 Where more access is required, some

of the enamel can be gently fractured off
with the blade of the hatchet along the line
of the enamel prisms
The use of hand instruments on the dentine

surface results in a smear layer. In order
to improve the chemical and mechanical
bonding of the GIC to the tooth tissues
this smear layer must be removed by the
use of a dentine conditioner. When using
encapsulated GIC it will be necessary to
use a separate dentine conditioner specially developed for this purpose. This
differs from the liquid used for acidetching for composites since a dentine
conditioner usually contains a solution
of between 1040% polyacrylic, tartaric
and/or maleic acid. Because of the difference in dentine conditioners available, it
is important to carefully follow the manufacturers instructions. If a hand-mixed
powder-liquid GIC is used the liquid component of the GIC can be used as the conditioner. The concentration is often too
high and needs to be reduced. This can be
achieved easily by dipping a cotton wool
pellet in water, removing excess on a paper
towel and then dipping this moist cotton
wool pellet in a drop of the liquid component of the hand-mixed GIC.
Note: the liquid component of GIC can
only be used for conditioning if it contains
the acid component of the GIC. There are
some brands of GIC where the liquid component consists of demineralised water only,
the acid being in the powder in a freezedried form. Under such circumstances a
PRACTICE
Fig. 11 The GIC is inserted into the cavity in

small increments using the rounded end of the
applier/carver instrument. Where possible, pack
the GIC under any overhanging enamel first,
before filling the central portion of the cavity
Fig. 14 The excess GIC is displaced to the

outer margins of the occlusal surface and will
need to be removed as soon as possible with
the carver or large excavator taking care not
to dislodge the restoration
Fig. 12 Slightly overfill the cavity and then

place additional GIC in any pits and fissures
adjoining the cavity
Fig. 15 The finished restoration is then

covered with petroleum jelly or varnish and
the patient advised not to eat for at least
onehour
a negative effect on the bonding of the GIC

to dentine and enamel. Therefore, if the
conditioned tooth surface becomes contaminated it is essential to wash and dry it,
recondition, wash and dry it again.
Step 7. Mixing GIC
Fig. 13 The tip of the index finger is

then placed onto the central part of the
restorations to enable the GIC to be pressed
firmly into the cavity, pit and fissures
separate dentine conditioner must be used.

The conditioner is applied to the cavity
and pits and fissures using a cotton wool
pellet for 1520seconds or for the period
of time specified by the manufacturer.
Bond strength is affected if insufficient or
too long a time is allowed for conditioning.
Wash the cavity and pits and fissures with
pellets dipped in clean, luke-warm water
and then dry carefully. If a triple-syringe is
used, take care not to over-dry the cavity
since this will tend to reduce the chemical
bonding of the GIC to the dentine.
Note: At this stage proper isolation is
essential. Contamination of the conditioned
tooth surface with saliva or blood will have
A consistent and correct mix of GIC is essential for reliable results. Always follow the
manufacturers instructions. This involves
following recommendations for mixing
time and finishing the restoration within
the specified working time. For hand-mix
GIC, the correct powder to liquid ratio must
be maintained since too much powder or too
much liquid can result in a weaker restoration.29 If a hand-mix GIC is used, those for
ART have a high powder-to-liquid ratio and
are usually more difficult to mix than other
GICs, thus special care needs to be taken.
The consistency of the final mix does, however, vary between different manufacturers.
Step 8. Restoring the cavity

and filling the pits and fissures
The mixed GIC must be used promptly
since any delay will compromise bonding
to the tooth surface. The GIC is inserted
into the cavity in small increments using
the rounded end of the applier/carver
instrument. Where possible, pack the GIC

around the margins of the cavity, particularly under any overhanging enamel,
before filling the central portion of the
cavity (Fig.11). This helps to prevent air
bubbles from being incorporated into the
restoration. Overfill the cavity slightly and
then place additional GIC in any pits and
fissures adjoining the cavity (Fig.12).
Rub a small amount of petroleum jelly
on the gloved index finger. Spread the
petroleum jelly thinly over the tip of the
gloved index finger with the thumb. Then,
place the index finger on the occlusal
surface and press the GIC firmly into the
cavity, pit and fissures (Fig.13). Roll the
ball of the finger slightly bucco-lingually
and then mesio-distally so that material
is spread over the whole occlusal surface.
This is called the press-finger technique.
After at least tenseconds, slide the finger
sideways to prevent the restorative material from lifting out of the cavity or pits
and fissures. The press-finger technique
results in excess GIC being displaced to
the outer margins of the occlusal surface.
Remove this excess as soon as possible
with either the carver instrument or the
large excavator, taking care not to dislodge
the restoration (Fig. 14). Ensure that the
proximal areas are clear of excess GIC.
Note: in the event that insufficient GIC
has been mixed to ensure the cavity and
fissures are completely filled, pack this first
mix into the cavity with the applier but DO
NOT use the press-finger technique at this
stage. While maintaining good moisture
control, a second batch of GIC is mixed
that can then be used to completely fill the
cavity and pits and fissures.
Step 9. Finishing the

ART restoration
Before the GIC becomes too hard, the
occlusion is checked with articulating
paper. Any parts of the restoration that
are too high can be adjusted using the
carver instrument or the large excavator.
The finished restoration is then covered
with petroleum jelly or varnish (Fig.15).
Ask the patient to avoid eating for at least
an hour.
Note: the dentist can adapt the clinical
procedures according to the equipment
available and his normal working practice.
For example, a local anaesthetic can be
used, a rubber dam can be placed, and a
15
PRACTICE
rotary instrument instead of a hatchet can
be used to gain minimal access to the body
of the lesion. The use of rotary instruments
is, however, specifically not part of the classic ART approach. Since the ART approach,
as has been described above, provides satisfactory clinical results (see our section
on the evidence base), there is no need to
overload the clinical procedures with methods or equipment that may raise anxiety in
patients (eg rotary instruments are often not
accepted by children and dental phobics).
ART SEALANTS STEP-BY-STEP

The only difference between placing an
ART restoration and an ART sealant is that
with the latter there is no cavity to clean
and restore. Otherwise all the other steps
and materials remain identical.
The same high-viscosity GIC is used but
cavity preparation is not undertaken. Thus,
techniques of isolation, cleaning, conditioning and filling of the pits and fissures
remain identical. The steps are therefore
summarised as:
Step 1. Preparation of the ART
instruments and materials before the
clinical procedure
Step 2. Isolation of the operating site
Step 3. Cleaning the pits and fissures
and examination of the tooth
Step 4. Conditioning the pits and fissures
Step 5. Mixing the GIC
Step 6. Filling the pits and fissure
Step 7. Press-Finger
Step 8. Finishing the ART sealant
(Fig.16).
THE EFFECTIVENESS OF ART

WHAT IS THE EVIDENCE BASE?
Ideally all dental care decisions and treatments should be based on a sound research
evidence base, this being the basis of evidence-based dentistry. This helps to ensure
that dental care is both safe and effective.
Unfortunately, the evidence base to support the effectiveness of many of the commonly performed treatments in dentistry
is limited both in quantity and quality.30,31
Gradually, properly conducted systemic
reviews of dental treatment approaches
are appearing in the literature and there
are attempts by a number of organisations
to sensitise and educate the dental profession (Cochrane, NICE, American Dental
Association, etc). Despite initiatives by
organisations such as the Centre Franais
16
dEvidence Based Dentistry, which has

started to make some Cochrane reviews
available in French, there remains a dearth
of information in the French language.
Since its early development, ART has
constantly been subject to research evaluation and remains one of the most researched
minimal intervention approaches with
currently over 200 publications on the
subject. With respect to the effectiveness
of the approach a number of systematic
reviews and meta-analyses have been
undertaken. The first meta-analysis of the
effectiveness of single-surface ART restorations in the permanent dentition was
published by Frencken etal. in 2004.32 This
study, based on an analysis of fivestudies
reported no difference in survival results
over three years between single-surface
ART restorations and amalgam restorations. It also indicated that results were
better from the then more recent studies
as the ART approach evolved and better
restorative materials became available.
The interest in the ART approach led
to a substantial number of research publications on the subject during this time
that permitted a second more comprehensive meta-analysis to be undertaken
in 2006.33 Here, 28studies were included
in the analysis. The high mean survival
rates for single-surface ART restorations
using high-viscosity GIC in permanent
dentitions found in the previous metaanalysis was confirmed and a survival
rate of 72% over a period of six years
was reported.32 Similarly, in primary teeth
single-surface ART restorations using
high-viscosity GIC had a high mean survival rate of 95% after oneyear and 86%
after three years. The survival rates of
multiple-surface ART restorations in the
primary dentition were low with a mean
annual failure rate of 17%.
The most recent meta-analysis of ART
survival based on 29publications reported
that for single-surface ART restorations in
permanent teeth over the first three and
fiveyears the mean survival rates were 85%
and 80% respectively and 86% for multiple-surface ART restorations in permanent
teeth over oneyear.34 The survival rates of
single and multiple-surface ART restorations in primary teeth over twoyears were
93% and 62% respectively. A systematic
review comparing the longevity of ART
and amalgam restorations concluded that,
Fig. 16 A completed ART sealant
in the permanent dentition, the survival of

ART restorations is equal to or greater than
that of equivalent amalgam restorations
for up to 6.3years and is site-dependent.35
In primary teeth no difference in survival
outcomes between the twotypes of restoration was observed.
ART has also been used in institutionalised elderly populations for treating root
surface caries where short-term results
suggest that ART restorations compare
favourably with traditional approaches
to treat such lesions.36 In this context, an
earlier study where ART restorations were
provided for housebound Finnish elderly
also showed high success rates.37
With respect to the evidence base for
ART sealants, the meta-analysis of vant
Hoff etal. in 2006 found that the number
of studies reporting on the retention and
caries preventive effect of ART sealants was
low but based on available evidence the
mean survival rate for partially and fully
retained ART sealants in permanent dentitions using a high-viscosity GIC was of the
order of 72% after threeyears.33 In terms of
effectiveness in preventing caries over this
time period, 97% of sealed teeth remained
sound. The more recent meta-analysis by
de Amorim etal.34 showed that the caries
prevention effect of ART sealants was high.
A summary of the evidence base for ART
is that:
Single-surface ART restorations using
high-viscosity GIC in both primary and
permanent teeth show high survival
rates and can therefore be safely used
The survival rate for multiple surface
ART restorations in primary teeth is
rather low
ART restorations have the ability to
PRACTICE
outperform amalgam restorations in
terms of survival
ART sealants have a high caries
preventive effect.
INDICATIONS FOR
THE ART APPROACH
As with all preventive and restorative
approaches ART must not be considered a
panacea and therefore careful case selection is essential. The indications for ART
are based on the strengths of the approach
for certain situations combined with the
evidence base for its effectiveness. Thus,
the indications can largely be divided into
twolevels, the patient and the tooth.
Indications at the patient level

At the patient level, one of the major
strengths of the ART approach is that it is
well accepted by patients. The high acceptance is because, unlike most traditional
restorative treatment of vital teeth, ART
rarely requires a local anaesthetic. This is
largely because of the minimally invasive
nature of the approach where only necrotic
tissue is removed and where remaining
sound tissue is retained. Moreover, since
rotary instrumentation is not used with ART,
the threatening sound from this and the
necessary high-volume suction is absent. In
this respect, a recent review on dental anxiety and pain relating to the ART approach
concluded that the ART approach has been
shown to cause less discomfort than other
conventional approaches and is, therefore,
considered a very promising atraumatic
management approach for use in carious
lesions in children, anxious adults and possibly dental-phobic patients.38
The other major strength of the ART
approach is that it can be used equally well
in a dental practice setting as in an outreach environment such as in schools or in
old peoples homes. The concept of delivering care outside the dental practice setting
is largely alien to the dental profession. In
France, as in many developed countries,
little dental care is delivered outside the
traditional dental clinic environment. This
does, however, limit the coverage of dental
care to those persons who can easily access
a dental clinic or are adequately motivated
to do so. As an example, in France for
children at age six, two thirds of dental
cavities in primary teeth are not treated.
Similarly, in 12-years olds, only half the
decayed teeth are restored.39 The reasons

for this lack of care is obviously multifactorial but demands the question whether
other models of delivery of oral care using
approaches such as ART could be explored
in France, for instance providing prevention and caries management within the
schools as is done in other countries.40
Likewise, non-mobile elderly or physically and mentally handicapped people might not easily be able to access
the dental clinic. Although oral health
data for the elderly in France is limited,
a report by the Haute Autorit de Sant
(HAS) showed that elderly people have little access to dental care and that between
30-60% require restorative treatment.41,42
Here some extractions and restorative care
using the ART approach could be delivered
in their homes without resort to expensive
portable dental equipment.36,37
Indications at the tooth level

The indications at the tooth level are based
on the best evidence from clinical studies.
There is now evidence to show that ART
single-surface restorations using highviscosity GIC have a high survival rate in
both primary and permanent teeth that is
comparable to, if not better than, traditional
amalgam restorations.34,35 Taken that ART
restorations are both minimally invasive
and caries protective when compared to
other traditional restorative methods, ART
restorations might therefore be considered
a treatment of choice for single-surface caries lesions. The evidence suggests that ART
restorations can be used for multiple surface
caries lesions in primary teeth but that, as
for other multiple-surface restorations in
primary teeth, the survival rates are lower
than those for single-surface restorations.
There are limited data on the use of ART
restorations for multiple-surface lesions in
permanent teeth and therefore additional
research is required on this aspect.
With respect to the use of sealants
generally, their use should be targeted to
individuals and teeth that are at high risk
of developing caries and to teeth that are
already exhibiting early caries lesions.
This means that instead of adopting an
invasive approach for initial or incipient caries lesions, the placement of sealant can effectively halt the progression
of these lesions. Such an approach can
potentially preserve tooth structure and
lower the likelihood of future complex

restorations.8,43 ART sealants made using
a high-strength high-viscosity GIC have
the advantage over resin-based sealants
in that they can be used where moisture
control is less than optimal, for instance,
in erupting teeth in high caries risk individuals or in younger children.
Irrespective of the type of sealant used,
be it ART or resin-based, its placement is
non-invasive. Therapeutic sealants can
effectively halt the progression of initial or
incipient caries lesions. Conversely, even if
a minimal invasive approach is used to treat
such a lesion, the tooth is condemned for
life to the repeat restoration cycle.43 Thus,
therapeutic sealants using resins or ART
can preserve tooth structure and lower the
likelihood of future complex restorations.8
REPAIR OF ART RESTORATIONS

An important element of the minimal intervention approach is the repair of defective
restorations rather than their total replacement.9 Replacement of defective restorations is accompanied by a risk of increasing
the size of the cavity thereby weakening the
tooth if the defective restoration is removed
in its entirety. Tyas etal.9 discuss at length
the decision-making process as to whether
to leave, repair or replace what is deemed
to be a defective restoration. Alternative
treatments to replacement of both defective
amalgam and resin-based composite restorations using refinishing, sealing of defective margins or repair, show the viability
of this approach in the long term.44,45 These
principles can also be applied to ART restorations and sealants made with GIC. Indeed
Christensen positively encourages the use of
GIC for the repair of defective restorations.46
CONCLUSIONS
Over the past twodecades ART, as a minimal intervention and minimal invasion
approach for the management of dental caries, has proven to be a success in
both developed and developing countries.
There is now a strong evidence base to
show that ART is a quality approach to
control caries that is reliable and effective. As with many developments in oral
health, but especially minimal intervention and minimal invasion approaches, the
dental profession and the dental education
system has been very slow to take these
on board even though there is a strong
17
PRACTICE
evidence base for these approaches. Thus
the concepts that are described in this article might be alien and hard to accept by
many dental practitioners who have had a
traditional, rhetorical-based dental education. This is consistent with what is known
as the research-application gap. In France,
it appears that very few practicing dentists
or dental academics are aware of the ART
approach or other minimal intervention
and minimal invasion approaches and the
opportunities they can afford. Failure of
the dental profession and the dental education system to embrace these approaches
results in the oral health of our patients
being placed at a disadvantage.
ADDITIONAL NOTE
The indications for ART at the patient level
mentioned in this article relate to the situation in France with country-specific examples given. For example, while in France for
children at age six, two-thirds of primary
teeth with cavities are not restored, this figure is even worse in the United Kingdom
where, according to the 2003 survey of childrens dental health in the United Kingdom,
for children age five, only one eighth of
decayed teeth are restored on average. This
does not imply that the authors advocate
that all decayed primary teeth be restored.47,48
With respect to 12-year-old children the situation appears better in the United Kingdom
than in France since over half the decayed
permanent teeth are filled.47,48 In common
with France, access to oral dental care in the
United Kingdom is difficult for the elderly or
handicapped.49 For example, in onesurvey of
nursing home residents in Avon, 63% were
found to have root caries.50 The commonality of untreated dental caries in both France
and the United Kingdom points to the need
to explore new approaches to the delivery of
oral care. Atraumatic restorative treatment
might be one of a number of approaches that
could lead to an improvement of oral health
in our populations.
The authors would like to thank Dr Jo Frencken for
reviewing the manuscript and for kindly providing
Figures 6 to 15 and Claudie Damour-Terrasson,
publishing director of the Groupe Information
Dentaire, Paris, France, for authorising the translation and publication of the series in the BDJ.
1. Dawson AS, Makinson OF. Dental treatment and
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2. Dawson AS, Makinson OF. Dental treatment and
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and some new treatment modalities in operative
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3. Frencken JE, van Amerongen WE. The Atraumatic
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clinical management. 2nd ed. pp 427442. Oxford:
Blackwell Munksgaard, 2008.
4. Frencken JE, Leal SC. The correct use of the ART
approach. J Appl Oral Sci 2010; 18: 14.
5. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mkel
M, Worthington HV. Pit and fissure sealants for
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6. Beauchamp J, Caufield PW, Crall JJ etal. Evidencebased clinical recommendations for the use of
pitandfissure sealants: a report of the American
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7. Gooch BF, Griffin SO, Gray SK etal. Preventing
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8. Griffin SO, Oong E, Kohn W etal. The effectiveness
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Oliveira E, Maltz M. Qualitative and quantitative
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Pathol Oral Radiol Endod 2010; 109: 135141.
12. Fusayama T, Okuse K, Hosoda H. Relationship between
hardness, discoloration, and microbial invasion in
carious dentin. J Dent Res 1966; 45: 10331046.
13. Massler M. Pulpal reactions to dental caries. Int
Dent J 1967; 17: 441460.
14. Fusayama T, Terachima S. Differentiation of two
layers of carious dentin by staining. J Dent Res
1972; 51: 866.
15. Banerjee A, Kidd EA, Watson TF. Invitro evaluation
of five alternative methods of carious dentine
excavation. Caries Res 2000; 34: 144150.
16. Celiberti P, Francescut P, Lussi A. Performance of
four dentine excavation methods in deciduous
teeth. Caries Res 2006; 40: 117123.
17. Kidd EA. How clean must a cavity be before
restoration? Caries Res 2004; 38: 305313.
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19. Thompson V, Craig RG, Curro FA, Green WS, Ship
JA. Treatment of deep carious lesions by complete
excavation or partial removal: a critical review. J Am
Dent Assoc 2008; 139: 705712.
20. Handelman SL, Leverett DH, Espeland MA, Curzon
JA. Clinical radiographic evaluation of sealed
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1986; 113: 751754.
21. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW,
Rueggeberg FA, Adair SM. Ultraconservative and
cariostatic sealed restorations: results at year 10.
J Am Dent Assoc 1998; 129: 5566.
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restorative treatment: clinical, ultrastructural and
chemical analysis. Caries Res 2002; 36: 430436.
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J Dent Child 1975; 42: 275280.
24. Jensen OE, Handelman SL. Effect of an autopolymerizing sealant on viability of microflora in occlusal
dental caries. Scand J Dent Res 1980; 88: 382388.
25. Wambier DS, dos Santos FA, Guedes-Pinto AC,
Jaeger RG, Simionato MR. Ultrastructural and
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by caries lesions in primary molars treated by minimal intervention. Pediatr Dent 2007; 29: 228234.
26. Oong EM, Griffin SO, Kohn WG, Gooch BF,
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29. Dowling AH, Fleming GJ. Is encapsulation of
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Holmgren CJ. Effectiveness of single-surface ART
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39. Hescot P, Rolland E. La sante dentaire en France.
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B, Steele JG. The dentinal caries experience of children in the United Kingdom, 2003. Br Dent J 2006;
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49. Simons D. Who will provide dental care for housebound people with oral problems? Br Dent J 2003;
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IN BRIEF
Suggests the inhibition of caries
progression by resin infiltration should

now be considered an alternative to
invasive restorations.
Describes the principle and protocol of
resin infiltration of carious lesions.
PRACTICE

part 6. Caries inhibition
by resin infiltration
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-cavitated 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
In recent decades, the management of
carious lesions has shifted the paradigm
of drilling and filling into the paradigm
of prevention, control and minimally
DENTISTRY
caries lesions
of dental caries
This paper is adapted from: Lasfargues JJ, Bonte E, Guerrieri A,
Fezzani L. Inhibition carieuse par infiltration rsineuse. Ralits
Cliniques 2011; 22: 257267.
Facult de Chirurgie Dentaire, Universit Paris

Descartes, 1rue Maurice Arnoux, 92120 Montrouge,
France; 2Service dOdontologie Hpital Bretonneau
APHP, 23 rue Joseph de Maistre, 75018 Paris, France
*Correspondence to: Professor Jean-Jacques Lasfargues
Email: jean-jacques.lasfargues@brt.aphp.fr;
Telephone: +33 1 53 11 14 30

DOI: 10.1038/sj.bdj.2013.54
British Dental Journal 2013; 214: 5359
invasive restoration.1 In this context a

new technique to stop the progression of
initial caries without the use of drilling
has been proposed: the inhibition of caries
by resin infiltration, that is, stopping the
active carious process at its site without
any invasive procedure.2
Remineralisation of enamel demineralised by acids from the cariogenic biofilm can be achieved principally through
the application of topical fluorides and
remineralising agents3,4 by the use of fissure sealants or by repair of the lesion
using bioactive materials.5 In all cases
the goal is to stop lesion progression.
Remineralisation by topical application
of fluoride requires multiple treatment
sessions and strict long-term follow-up,
which implies strong cooperation from the
patient and is often difficult to obtain. In
addition, monitoring systems for assessing
the status of the lesions over time are still
being studied and are difficult to apply
in every-day clinical practice.6 Sealing
techniques using resin or glass-ionomer
cements are primarily intended for initial
carious lesions in the pits and fissures on
occlusal surfaces of erupting posterior
teeth. They have been proven to prevent
tooth decay7 but their effectiveness in the
sealing of carious lesions in site 1 (occlusal
surfaces) to prevent the need for a restoration of stages 0 and 1 (SiSta classification)8
remains controversial. Thus, hitherto there
has been a lack of effective procedures

for stopping initial lesions in one session. This applies particularly to proximal
carious lesions and the buccal and lingual
smooth surfaces.
Resin infiltration of carious lesions represents an approach to the treatment of
non-cavitated lesions on proximal and
smooth surfaces of primary and permanent teeth. The principal feature of this
technique is that it is non-invasive, preserves tooth structure and can be completed in a single visit. The concept was
first developed in Germany, at the Charit
University Hospital in Berlin, from invitro
studies on the penetration of resin into
caries9-11 and marketed under the brand
name of Icon (DMG America Company,
Englewood, NJ).
PRINCIPLE OF RESIN INFILTRATION

OF CARIOUS LESIONS
The principle of resin infiltration is to perfuse porous enamel with resin by capillary
action, thereby stopping the process of
demineralisation and stabilising the carious
lesion. The principle can be compared with
the saturation of a sugar cube or sponge
with a liquid (Fig.1). The infiltration takes
place within the enamel, in contrast to pit
and fissure sealants, which forms a superficial mechanical barrier on the outer surface
of the initial lesion, depriving the bacteria
that colonise the surface of the lesion of
53
PRACTICE
Fig. 1 Illustration of the concept of

infiltration by a low viscosity resin:
coffee plays the role of infiltrating the
sugar cube, analogous to porous enamel
(a); Clinical application of the concept:
the infiltration by resin is achieved
by depositing the liquid resin on the
demineralised enamel using a specially
developed method (b) and then the resin in
the saturated area (c) is light-cured
Fig. 2 Sealing and infiltration of initial

caries lesions at Site 1and Site 2 (a) are
two different therapeutic concepts; (b) at
Site 1, the sealant forms a physical surface
barrier which deprives bacteria of nutrients.
At Site 2, infiltrating the enamel with resin
traps the bacteria that have penetrated the
body of the lesion and the outcome is a
hybrid resin enamel
54
Fig. 3 Microscopic appearance of resin infiltration illustrated using lesions coloured by a direct
staining technique (a-d) and an indirect technique (e-h), observed by confocal microscopy
(CLSM) in dual fluorescence (DF) and combined transparent fluorescence (CTF) modes, and
by transversal microradiographs (TMR) and scanning electron microscopy (SEM). With the
direct technique, areas infiltrated by the resin are not all identified by red fluorescence. With
the indirect technique, the images obtained by CLSM infiltration DF are a good fit with the
different reference methods. (Figure reproduced courtesy of the Journal of Microscopy Research
and Technique, John Wiley Publishing)18
nutrients from the biofilm (Fig.2). Bacteria

that have penetrated the demineralised
enamel are trapped in the infiltrating resin
once it has been cured.
It has been shown that bacteria can
physically cross the outer, macroscopically intact or slightly damaged enamel
of non-cavitated lesions.12 The presence
of these trapped bacteria does not prevent the resin infiltrating and does not
warrant operative treatment by surgical
tissue removal and restoration.13 To penetrate the entire thickness of the enamel,
to seal its pores, to block the diffusion of
nutrients and to stop caries progression
it is essential that the infiltrating agent
has a high penetrative ability. Despite the
novelty of this technique several research
studies both invitro and invivo14-18 have
tested the:
Erosive potential of different etching
agents, including hydrochloric acid, on
the compact layer and the pseudointact enamel surface to permit resin
impregnation of the enamel
Ability of different adhesive systems
and low viscosity resin fluids to
penetrate the enamel subsurface
and their capacity to obstruct

caries progression.
The results indicate that the inhibition
of caries progression is achieved by the
sequential effects of 15% hydrochloric acid
gel applied for twominutes, followed by
the application of a low viscosity resin of
type TEGDMA (tri-ethylene glycol dimethacrylate) with a sufficiently high (>200cm/
sec) penetration coefficient. Studies by
confocal laser microscopy19 have produced
images demonstrating the penetration of
the resin, thus allowing the depth of the
lesion and its non-progression after resin
infiltration to be checked (Fig.3).
INDICATIONS FOR RESIN INFILTRATION OF CARIOUS LESIONS

The erosion/infiltration technique has been
proposed for hiding white spots associated
with non-carious conditions such as fluorosis20,21 and it appears to give satisfactory
aesthetic results in patients (Fig.4). This
use of the technique will not be discussed
further in this article.
Infiltration of carious lesions may be
indicated in all age groups- children, adolescents and adults, for all initial lesions
PRACTICE
Prevention
(No invasive care)
EI
Restoration
(Invasive care)
EII
DI
Fig. 4a Preoperative situation showing

non-carious white spot on 11and 21, in an
18-year-old patient
Fluoridation
Infiltration
Infiltration?
Resin infiltration
(Micro-invasive care)
Fig. 4b Situation during the procedure:

application of infiltrating resin after etching
with hydrochloric acid
Fig. 4c Result threemonths after treatment;

the aesthetic result obtained after the
infiltration procedure is maintained and
continues to satisfy the patient
where the depth does not exceed the outer

third of dentine, that is, SiSta stages 0 and
1 (Fig.5). The technique is aimed primarily
at initial proximal lesions. Below a threshold depth estimated at 800 microns2 the
tissue lost by demineralisation is replaced
by infiltrated resin, creating an internal
barrier to the diffusion of sugars and
organic acids which would otherwise colonise the proximal embrasure. This barrier
stabilises and freezes the lesion without
affecting the anatomical shape of the tooth
since the surface is not directly concerned.
Thus, the interproximal physiology is not
disturbed, provided that the excess resin is
carefully removed in accordance with the
application procedure (see protocol).
The second indication for the technique
is for carious lesions on non-proximal
smooth surfaces, such as opaque white
lesions around orthodontic devices used
Fig. 5 Schematic representation of comparative indications for remineralisation by fluoride, by

resin infiltration and minimal intervention dentistry. These treatment options are offered for
guidance, given the difficulty of creating a categorical decision based on the radiographs alone
Key:- E 1: demineralisation in the outer half of enamel; E 2 demineralisation of the entire
width of the enamel; D 1: demineralisation of the outer third of dentine without cavitation
(corresponding with the SiSta classification: E1 and E2 = Stage 1; D1 = stage 2).
Fig. 6 White spot demineralisation after

orthodontic care, before treatment:
(a) processing by resin infiltration; (b)
condition after etching with hydrochloric
acid, dried with ethanol; (c) result after
sixmonths
in a high caries risk oral environment, provided that they are not cavitated and are
surrounded by intact enamel. In addition
to stabilising the lesion, the appearance
of the tooth is generally improved by the
technique (Fig.6).
OPERATING PROTOCOL
All the necessary elements are included
in the proximal treatment kit, including
syringes with special tips for delivering
insitu the acid gel and infiltration resin
(Fig7). The nozzle itself consists of a double film of superfine transparent plastic,
perforated on oneside for the delivery of
the agents and simultaneously protecting
the neighbouring surface from them. These
tips can be rotated 360, which facilitates
application from all angles. Two screw
syringes are used to control extrusion of
acid gel and the infiltration resin respectively. Interdental wedges can be used to
separate the surface to be treated and the
contiguous surface.
55
PRACTICE
Fig. 8f Drying with air syringe

Fig. 8a Operative Protocol. Initial clinical
view of the segment 1416
Fig. 8g Dehydration with 99% ethanol (Icon

Dry)
Fig. 7 Icon treatment kit for smooth

and proximal surfaces: (a) equipment for
proximal surface treatment; (b) threescrew
syringes (set up for use) for etching, drying
and infiltration
The operative steps (Fig.8) will be illustrated by the treatment of a proximal

lesion of a maxillary premolar (distal surface of tooth 15), using as an example the
following clinical case.
Mrs A., 30 years old, attends for a dental
consultation before commencing orthodontic care. The patient has difficulty coming for appointments at the dental office
because of her immediate professional
commitments. She presents as a high caries risk patient with numerous proximal
lesions and corroded amalgams with marginal overhangs. Given the anticipated
orthodontic care and the patients poor
immediate availability, initial care is limited to initial interventions to lower caries
risk (plaque control and dietary advice),
treatment of non-cavitated lesions by
resin infiltration, treatment of cavitated
lesions with direct composite restoration
and replacement of amalgam restorations
by adhesive long-term temporary restorations. Follow-up should confirm the
absence of recurrent caries and decisions
about prosthetic restorations should be
deferred pending decisions about orthodontic treatment:
Indications for resin impregnation
treatment should be based on
bitewing radiographs, showing an
enamel stage 0 initial lesion and on
the clinical situation
56
Fig. 8b Pre-operative bitewing showing

amalgam with marginal excess at 15and
several proximal initial lesions, including 14
(D) and 15 (D)
Fig. 8h Application of the infiltration resin
using the proximal nozzle
Fig. 8c Isolation by rubber dam and

interdental wedges (amalgam in 15removed)
Fig. 8i Light polymerisation of the
infiltration resin from all angles for 40s,
after withdrawing the nozzle and removing
excess resin with dental floss
Fig. 8d Etching (Icon Etch) the

demineralised area for twominutes (15D)
Fig. 8e Rinsing (30s)
Fig. 8j No immediate but short time recall

radiographic examination; postoperative
radiograph shows that the two lesions on
15and 14 treated by resin infiltration have
not progressed. Replacement of the amalgam
with marginal excess by a composite restoration
allows the patient to manage plaque control.
Other Stage 0 lesions are treated identically.
See: Figs 1b-c
PRACTICE
Before treatment, the teeth must be
cleaned and then isolated by rubber
dam, rinsed and dried
A plastic inter-dental wedge should be
inserted into the inter-dental space
The transparent proximal application
nozzle should be screwed onto
the syringe, pre-filled with 15%
hydrochloric acid, and then set
up correctly positioned in the
interdental space
The etching gel (Etch Icon) should
be extruded towards the affected
proximal surface and left in place for
twominutes to make the outer layer of
enamel porous
The transparent application nozzle
should be withdrawn occlusally
and the site thoroughly rinsed for
30seconds and again dried
The surface should be dehydrated with
99% ethanol, delivered by a metal
tipped syringe (Icon dry) to facilitate
the drying process, because the
TEGDMA is hydrophobic
The proximal application nozzle of
the resin can then be screwed onto the
syringe pre-filled with transparent low
viscosity resin and positioned to access
the affected surface
A slight excess of infiltration
resin should be applied, directly in
contact with the previously etched
demineralised zone. It must be
well spread over the interproximal
contact area and be left in place
for threeminutes so that the resin
penetrates the pores of the lesion by
capillary attraction
The transparent application nozzle is
then removed, and the excess resin
is removed with dental floss. The
resin is then photo-polymerised from
threeangles (buccal, lingual, occlusal)
for 40seconds
A new proximal application nozzle
is mounted on the preloaded syringe
and infiltration resin is applied a
second time. This second layer of resin
infiltration is applied for oneminute
only and light cured as before for
40seconds
After removing all the equipment the
interproximal space is evaluated with
dental floss and the cervical excess is
removed using, for example, a probe
or a curved mini-CK6
A clinical and radiographic follow-up

should be initiated to confirm that the
lesions do not progress and that there
is no recurrence. The same protocol
is recommended for the treatment of
white spot carious lesions on buccal
and palatal surfaces, using the Icon
Smooth Surfaces kit, in which the
proximal nozzles are replaced by
nozzles with pads suitable for buccal
or lingual surfaces (Fig.9).
DISCUSSION
A systematic review of the literature
comparing techniques for sealing and
infiltration in the treatment of initial
caries lesion, concludes, with a good
level of evidence, that the sealants act
by forming a superficial barrier against
the penetration of bacteria and their byproducts, while infiltration techniques
create an internal barrier in the lesion by
replacing lost minerals with low viscosity light-cured resin.22 Occlusion of pores
by penetration of the resin into the body
of the lesion is probably responsible for
the retention of the material, allowing an
expectation of a stable result over time.
The durability of the result is dependent
on the lesions environment. Caries inhibition is being maintained in a weakly
demineralising environment, but it is
likely that in a patient at uncontrolled
risk of caries demineralisation will continue or recur at the periphery of the resin
infiltrated area. The technique does not
make proper management of caries risk
and patient monitoring redundant.
Resin infiltration seems suited particularly for proximal lesions where, when
invasive treatment is chosen, the ratio of
normal tissue to carious tissue leads to a
not insignificant loss of healthy tissue in
order to gain access to the lesion, even
when applying micro-invasive methods of
preparation such as sono-abrasion.23
It is extremely difficult for the practitioner to locate the border between
the absence or presence of cavitation
clinically and radiographically in the
interproximal spaces between adjacent
posterior teeth. Initial lesions evaluated
as non-cavitated may nevertheless appear
with broken-down surface layers.12 In a
recent invitro study assessing the degree
of penetration of the resin according
to ICDAS codes it has been shown that
Fig. 9 Resin infiltration treatment of a

demineralisation spot on the buccal surface
of a molar after the use of orthodontic
bands
57
PRACTICE
cavitated lesions (code 5) showed significantly less resin infiltration than non-cavitated lesions (codes 2and 3) and the resin
was unable to fill the cavities (Fig.10).24
The technique is therefore not recommended for the management of cavitated
lesions and it should be borne in mind
that, if a proximal cavity has not previously been detected, infiltration may be
faulty and caries inhibition may fail. Here
again, the technique does not dispense
with the requirement for early detection, thorough diagnosis and rigorous
caries monitoring.
The risk-benefit ratio of this non-invasive and aesthetic technique is favourable but clinical experience is limited,
and questions arise about the aging of the
resin, even though the risk of hydrolysis
appears limited due to the hydrophobic
nature of the resin. There is little information on the wear resistance of the impregnated zone and on the colour stability and
aesthetics after infiltration. Finally, this
technique is described as without drilling
and without anaesthesia, deceptively simple and fast. The duration of full treatment
of a lesion is 1520minutes (rubber dam
included) for a practitioner who masters
the technique. Undertaking the treatment
is relatively difficult. It requires the teeth
to be perfectly cleaned and dried and isolated by the rubber dam. Passing the clear
plastic nozzle between the proximal contacts is not always easy, despite the aids.
Measuring the amount of infiltration resin
to be placed is imprecise (Fig.11) despite
the needle screw and excess cured resin
may persist in the recess, which must be
carefully verified otherwise there is a risk
of promoting papillary inflammation. The
application of resin should always be done
in two stages to fill cracks and voids in
the first layer, observed by microscopy,
and to obtain a better surface quality. The
state of the final surface is slightly rough
and imperfect and does not appear to be
improved by available finishing systems,
such as interproximal abrasive strips.25
The removal of the equipment (nozzle,
wedge, rubber dam) frequently leads to
haemorrhage due to the inevitable compression of the papilla for the duration of
treatment. The absence of radio-opacity,
inherent with unfilled resin, does not
allow the result to be seen on radiograph.
The alleged efficacy of the treatment
58
patients, in particular for children and

their parents. The benefits depend on the
overall management of caries risk and
adequate follow-up. Experience is hitherto limited. High evidence level clinical
trials are needed to assess the long-term
results and development is needed to
simplify the system for use in ordinary
dental practice.
The authors would like to thank Claudie DamourTerrasson, President and publishing director of the
Groupe ID Espace- LInformation Dentaire, Paris France,
for the authorisation of translation and publication of
the series in the BDJ.
Fig. 10 The resin did not fill the small

carious defect, dissuading the method for
the cavitated lesions. Initial situation (a)
and after resin infiltration (b)
Fig. 11 Excess resin expressed from the

syringe and collected in the bottom of
the dam
cannot be evaluated since progression

of the lesion cannot be visualised at
subsequent visits.
CONCLUSIONS
Infiltrating resins have opened up an
innovative pathway in the management
of initial carious lesions, corresponding with the goals of the physician to
heal without causing harm. The inhibition of caries progression by infiltration
should be considered an alternative to
more invasive therapies and warrants a
place in the range of minimally invasive dentistry techniques. Compared
with remineralisation techniques that
may require several follow-up visits, this
therapy can be undertaken in onetreatment session, which is important for
1. Lasfargues years Evolution des concepts en odontologie conservatrice. Du modle chirurgical invasif
au modle mdical prventif. J Dent du Qubec
1999; XXXVI: 6577.
2. Kugel G, Arsenault P, Papas A. Treatment modalities
for caries management, including a new resin infiltration system. Compend Contin Educ Dent 2009;
3: 110.
3. Carvalho JC, Van Nieuwenhuysen JP, Maltz M.
Traitement non opratoire de la carie dentaire.
Ralits Cliniques 2004; 15: 235248.
4. Miller C, Ten Cate J, Lasfargues JJ. La reminralisation des lsions carieuses (1) Le rle essentiel des
fluorures. Ralits Cliniques 2004; 15: 249260.
5. Lasfargues JJ, Ten Cate J, Miller C. La reminralisation des lsions carieuses (2) Synergies
thrapeutiques. Ralits Cliniques 2004;
15: 261276.
6. Guerrieri A, Gaucher C, Bonte E, Lasfargues JJ.
Dtection et diagnostic des lsions carieuses
initiales. Ralits Cliniques 2011; 22: 233244.
7. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mkel
M, Worthington HV. Pit and fissure sealants for
preventing dental decay in the permanent teeth of
children and adolescents Cochrane Database Syst
Rev 2008; 4: CD001830.
8. Lasfargues JJ, Kaleka R, Louis JJ. A new therapeutic
classification of cavities. Quintessence Int 2001;
32: 97.
9. Meyer-Lueckel H, Mueller J, Paris S, Hummel M,
Kielbassa AM. The penetration of various adhesives into early enamel lesions invitro. Schweiz
Monatsschr Zahnmed 2005; 115: 316323.
10. Mueller J, Meyer-Lueckel H, Paris S, Hopfenmuller
W, Kielbassa AM. Inhibition of lesion progression
by the penetration of resins invitro: influence
of the application procedure. Oper Dent 2006;
31: 338345.
11. Paris S, Meyer-Lueckel H, Mueller J, Hummel M,
Kielbassa AM. Progression of sealed initial bovine
enamel lesions under demineralizing conditions
invitro. Caries Res 2006; 40: 124129.
12. Kielbassa AM, Paris S, Lussi A, Meyer-Lueckel H.
Evaluation of cavitations in proximal caries lesions
at various magnification levels invitro. J Dent 2006;
34: 817822.
13. Parolo CC, Maltz M. Microbial contamination
of noncavitated caries lesions: A scanning
electron microscopic study. Caries Res 2006;
40: 536541.
14. Meyer-Lueckel H, Paris S, Kielbassa AM. Surface
layer erosion of natural caries lesions with
phosphoric and hydrochloric acid gels in preparation for resin infiltration. Caries Res 2007;
41: 223230.
15. Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural caries lesions. J Dent Res 2007;
86: 662666.
16. Meyer-Lueckel H, Paris S. Improved resin infiltration
of natural caries lesions. J Dent Res 2008;
87: 11121126.
17. Paris S, Drfer CE, Meyer-Lueckel H. Surface
conditioning of natural enamel caries lesions in
deciduous teeth in preparation for resin infiltration.
PRACTICE
J Dent 2010; 38: 6571.
18. Meyer-Lueckel H, Paris S. Infiltration of natural
caries lesions with experimental resins differing
in penetration coefficients and ethanol addition.
Caries Res 2010; 44: 408414.
19. Paris S, Bitter K, Renz H, Hopfenmuller W, MeyerLueckel H. Validation of two dual fluorescence
techniques for confocal microscopic visualization
of resin penetration into enamel caries lesions.
Microsc Res Tech 2009; 72: 489494.
20. Paris S, Meyer-Lueckel H. Masking of labial enamel
white spot lesions by resin infiltration a clinical

report. Quintessence Int 2009; 40: 713718.
21. Tirlet G, Attal JP. Lrosion/infiltration: une nouvelle
thrapeutique pour masquer les taches blanches.
Inf Dent 2011; 4: 1216.
22. Kantovitz KR, Pascon FM, NobredosSantos M,
Puppin-Rontani RM. Review of the effects of infiltrants and sealers on non-cavitated enamel lesions.
Oral Health Prev Dent 2010; 8: 295305.
23. Decup F, Tison B, Lasfargues JJ. Intervention
restauratrice minimale: mini-cavits et
mini-obturations. EMC Odontologie 2006;

[23144A-10].
24. Paris S, Bitter K, Naumann M, Drfer CE, MeyerLueckel H. Resin infiltration of proximal caries
lesions differing in ICDAS codes. Eur J Oral Sci 2011;
119: 182186.
25. Mueller J, Yang F, Neumann K, Kielbassa AM.
Surface tridimensional topography analysis of
materials and finishing procedures after resinous
infiltration of subsurface bovine enamel lesions.
Quintessence Int 2011; 42: 135147.
59
IN BRIEF
Describes minimally invasive operative

caries management techniques.
PRACTICE

part 7. Minimally invasive
operative caries management:
rationale and techniques
Highlights the degree to which dental

caries should be excavated.
Suggests removal of grossly softened
caries-infected dentine is recommended

in most situations along with the
placement of a sealed restoration.
A. Banerjee1
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 patients 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 interface clinically to aid the cooperative, motivated patient in biofilm removal is an essential pre-requisite to prevent further
secondary caries.
INTRODUCTION
The term MI dentistry or MID has been
used for many years with several meanings
DENTISTRY
caries lesions
of dental caries
This paper is adapted from: Banerjee A. Stratgies invasives a
minima de lxrse des tissus caris. Ralits Cliniques 2011;
22: 141156. The authors would like to thank Claudie DamourTerrasson, publishing director of the Groupe Information
Dentaire, Paris, France, for the authorisation of translation and
publication of this MI series in the BDJ.
Professor of Cariology & Operative Dentistry/Hon

Consultant, Restorative Dentistry, Conservative
Dentistry, Floor 26, Tower Wing, Kings College London
Dental Institute, Guys Dental Hospital, London Bridge,
London, SE1 9RT
Correspondence to: Professor Avijit Banerjee
Email: avijit.banerjee@kcl.ac.uk;
Tel/fax: +44 207 188 1577/7486

DOI: 10.1038/sj.bdj.2013.106
in the dental literature. Minimum(al) intervention dentistry is the holistic patient care
philosophy that encompasses the complete
patient-dentist team-care approach to
managing dental disease by identification
and diagnosis (including caries risk assessment), prevention and control, restoration
and recall, so educating and empowering the patient to take responsibility for
their personal oral health.1,2 Minimally
Invasive Dentistry describes contemporary
ultraconservative operative management
of cavitated lesions requiring surgical
intervention. It does not mean unduly
early operative intervention of incipient
lesions, which in most cases is unnecessary
as more effective and appropriate noninvasive preventive approaches exist. It is
the latter definition that will be discussed
further in this paper.
Golden triangle of MID

A thorough understanding and appreciation of the interplay between threecritical factors is required to achieve success
clinically when using a minimally invasive operative caries management strategy
(MI OCMS):
1. The histology of the dental substrate
being treated
2. The chemistry/handling of the adhesive

materials used to restore the cavity
3. Consideration of the practical
operative techniques available to
excavate caries minimally.
Appreciation of these factors will enable the dental practitioner to embrace the
contemporary oral physicians biological
approach to operative caries management
as opposed to the surgeons mechanistic
efforts of preparing cavities of a pre-determined shape, governed primarily by the
properties of the chosen restorative material as opposed to the actual histopathology of the disease process and retention of
tooth substance.3,4
LESION HISTOLOGY
Enamel caries
Long-term, repeated episodes of bacterial acid demineralisation instigated at a
susceptible tooth surface by the residing
plaque biofilm results in the growth of
subsurface structural porosities, eventually enlarging, if not controlled at the
earliest stages by remineralisation/oral
hygiene procedures, coalescing and ultimately causing cavitation. Carious enamel
BRITISH DENTAL JOURNAL VOLUME 214 NO. 3 FEB 9 2013
107
PRACTICE
with its unsupported prismatic structure
is weak under stress from compressive/
shear occlusal loads or from tensile shrinkage forces from photo-cured resin-based
adhesive materials.5 If carious enamel is
retained at the margin of the cavity and
subsequently restored, deficiencies may
allow the ingress of plaque biofilm bacteria
through micropores within the defective
enamel structure - cohesive microleakage.
Further complications are associated with
the potential of secondary caries developing along defective marginal interfaces
where plaque biofilm stagnates, further
compromising tooth structure.3
Dentine caries
Carious dentine can be subdivided into
twohistopathological zones:
1. The peripheral caries-infected
zone (close to the enamel-dentine
junction [EDJ]), irreversibly damaged,
necrotic and softened by long
standing bacterial contamination and
proteolytic denaturation of collagen
and acid demineralization of the
inorganic component
2. The deeper caries-affected zone,
reversibly damaged by virtue of
carious process, which has the
potential to repair under the correct
conditions as the collagen is not
denatured.5-7
The soft, wet, necrotic nature of caries-infected dentine means it is an inferior chemical and physical substrate for
adhesion and seal formation, whereas the
potentially repairable caries-affected dentine has been shown to exhibit adequate
adhesive bonding potential, especially
when surrounded by a periphery of sound
dentine and enamel.8
It is important to appreciate that using
the principles of minimally invasive (MI)
dentistry may often lead to less carious
dentine excavation overall than past caries
excavation rationales based on a mechanistic approach to maximise the retention and
physical properties of the restorative material
within the cavity.9 MI cavities will exhibit cut
surfaces with different qualities of enamel
and dentine histology along the same cavity
surface and these tissues will require handling in different ways in order to optimise
adhesive bonding. Indeed, clinically delineating between the layers of caries-infected and
108
affected dentine within a lesion is a rather

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

should be excavated?
The answer to the above question is specific to the individual tooth/lesion, oral
cavity, patient and dentist as there are
numerous inter-relating co-variables that
have to be considered.
Pulp status
The vitality (sensibility) of the pulp must
be assessed from the clinical signs and
symptoms and suitable investigations (a
combination of electrical, thermal and
radiographic). Signs of an acute, reversible pulpitis can resolve if the carious process is arrested using a sealed restoration
along with effective patient control measures, tipping the histopathological balance
from the bacteria in favour of the healing dentine-pulp complex and its acute
inflammatory mediators.5,11.
Lesion depth
Lesion-pulp proximity affects the level
of protection afforded to the vital pulp.
Indirect pulp protection (capping) conserves caries-affected dentine close to the
pulp, minimising the risk of unnecessary
pulp exposure, and a suitable material
(for example, glass ionomer cement) with
anti-bacterial properties as well as bonding
and sealing chemically to the remaining
dentine affords a potential seal, so permitting rejuvenation of the dentine-pulp
complex.5,12,13
Extent of viable tooth structure

The functional and aesthetic restorability
of the tooth must be assessed. A minimally
invasive approach removing only cariesinfected dentine will conserve more tooth
structure that can help retain and support
the definitive sealed restoration. The optimal restorative material is natural tooth
substance and smaller cavities are easier
to manage for both the dentist and the
patient. A reduced surface area of restoration with its margins in cleansable,
accessible areas will increase the patients
ability to regularly agitate and remove the
plaque biofilm, thus reducing the risk of
further onset of caries.
Patients caries risk assessment

The MI operative caries management strategy (OCMS) relies on close collaboration
with successful prevention/control regimes
instigated by the patient and the dental
team. These can often be linked to the
overall risk assessment of the individual
patient as a motivated patient has the
greater potential to be converted to low
caries risk. If these are in place MI restorations have a good chance of medium to
long-term success.14,15 If, however, the caries risk is high in less motivated patients
then adhesive restorations may show a
reduced long-term survival rate.16
Clinical factors
Practical considerations in restoration
placement must play a part in deciding
whether MI is a feasible option for particular individuals. These may include:
Suitable access for instrumentation
Ability to control moisture levels
(ideally with rubber dam isolation)
Appreciation of the final position of
the cavity-restoration margin (supraor subgingival)
Appropriate handling of adhesive
restorative materials by the dental team
(for example, ensuring that dentine
bonding agent bottle lids are replaced
promptly after dispensing to ensure
minimal evaporation of any solvent
carrier; appropriate ratios of powder:
liquid mixed when required etc).
Prospective long-term randomised controlled clinical trials have assessed the
validity and efficacy of minimally invasive caries removal with or without indirect pulp capping in terms of restoration
longevity and pulp status.13-15 Systematic
analysis of the results has concluded that
PRACTICE
Table 1 Tooth-cutting/caries removal technologies, the substrates acted upon and their
mechanism of action
Mechanism
Dental substrate affected
Tooth-cutting technology
Mechanical, rotary
Sound or carious enamel

and dentine
SS, CS, diamond, TC and plastic burs*
Mechanical,
non-rotary

and dentine
Hand instruments (excavators, chisels), air-abrasion,

air-polishing**, ultrasonics, sono-abrasion
Chemomechanical
Carious dentine
Caridex, Carisolv gel (amino acid-based), Papacarie

gel (papain-based), pepsin-based solutions/gels
Photo-ablation

and dentine
Lasers
Others
bacteria
Photo-active disinfection (PAD), ozone
Key: SS=stainless steel; CS=carbon steel; TC=tungsten carbide; *=works only on carious dentine; **=used for stain-removal3
as long as there is a suitable patient-dentist

team-care approach to maintaining oral
health, adhesive sealed restorations placed
in ultra-conservative cavity preparations
can last well in the functioning oral cavity.9,12,17 The issue of pulp capping using
a separate lining or base material has
been reviewed in the literature. In modern
day MI OCMS, using adhesive restorative
materials, the clinical need of a separate
layer of pulp protection has been shown
to be unnecessary (apart from the scenario
where the pulp may be protected with a
thin layer of glass ionomer cement beneath
a large amalgam restoration with close
pulp proximity).18
MATERIALS SCIENCE
A thorough understanding of the clinical relevance of contemporary adhesive
dental materials science is required to
implement successfully the MI OCMS. The
physico-chemical interaction of the relevant dental substrate retained at the cavity
surface with the adhesive material must
be enhanced by the operator to achieve
medium to long-term successful outcomes. The restoration seal is reliant upon
the integrity and morphology of mineral
(calcium ions, micromechanical undercuts,
supported prismatic structure in enamel)
and of the collagen nano-matrix/tubular
structure in dentine (hybrid zone). The
clinical relevance of the individual steps
in adhesive bonding (acid etch, primer
and bond) have been discussed in an
alternative publication.4 Issues regarding
chemical or micro/nano-mechanical bond
mechanisms revolve around the longevity of the seal achieved, which is affected
adversely by physico-chemical hydrolysis
and potential enzymatic degradation by
indigenous, acid-activated dentine matrix
metallo-proteinases (MMPs).4,19-21 Latest invitro research indicates the potential use of

anti-MMPs in dental adhesives to block the
activity of the indigenous MMPs, hence
resisting collagen degradation in the carious dentine.21,22
Fig. 1 Cavitated occlusal lesion 17 with

demineralised, unsupported peripheral enamel
and visible caries-infected dentine. Symptoms
were those of an early reversible pulpitis and
the pulp was vital to electric pulp testing and
ethyl chloride
MINIMALLY INVASIVE
OPERATIVE TECHNIQUES
As can be seen from Table 1, there are
several clinical technologies available for
cutting teeth and removing caries. Most
are not self-selective for caries-infected
dentine and involve active discriminatory
action from the operator when considering
MI OCMS.23,24 Dentists are highly trained
at using dental burs in slow speed or air
turbine handpieces as well as hand excavators, and although not self discriminatory in favour of caries-infected dentine, a
good operator can still practice MI OCMS
effectively using these instruments as
illustrated in Figures16.
Ultrasonic and sonic instrumentation
use the principle of probe tip oscillation and micro-cavitation to chip away
hard dental tissues. Lasers transfer high
energy into the tooth through water causing photo-ablation of hard tissues. Great
control is required by the operator in order
to harness this energy effectively and the
effects on the remaining enamel, dentine
and pulp continue to be investigated in
terms of residual strength and bonding
capabilities. A recent systematic review
concluded that laser caries removal is
not yet a viable general dental practice
option for effective caries excavation.25
Enzymatic (including hypochlorite-, pepsin- and papain-based) solutions have
and are being investigated to help further
breakdown of collagen in already softened
carious dentine in the hope of developing
Fig. 2 Radiograph of 17 showing

demineralisation extending into the inner third
of dentine towards the pulp. The pulp chamber
is clearly visible with a potential bridge of
dentine between it and the advancing lesion.
There is no proximal cavitation
Fig. 3 The peripheral unsupported enamel has

been removed using a long tapered diamond
bur in a high speed air turbine handpiece and
the sound margins lightly bevelled
a more self-limiting technique of removing caries-infected dentine alone.23 Other

chemical methods include photo-activated disinfection (PAD) where tolonium
109
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 operative technique used for the removal of
enamel and dentine during cavity preparation.27,28 Air abrasion units are capable of
minimally invasive tooth preparation using
27m aluminium oxide (-alumina).24,29,30
However, dentists are used to the parameters of tactile feedback and an appreciation of finite cutting depth when using
rotary tooth-cutting techniques, both of
which the end-cutting alumina air abrasive
jet lacks. This makes the use of alumina
air abrasion highly operator-sensitive and
requires careful education of clinicians to
realise its potential for minimally invasive
preparation and the prevention of cavity
over-preparation.31 Studies have been
published that characterise the efficacy
of alumina air-abrasion and its cutting
characteristics on both sound and carious
enamel and dentine and collectively these
show the technique to be efficient if specific operating parameters (for example,
air pressure, powder flow rate and reservoir volume, nozzle diameter and working distance) are regulated judiciously
by the operator.3235 Clinical studies have
indicated good patient acceptance of the
technology in terms of the lack of vibration, no heat generation and the reduced
need for local analgesia.36,37
An important clinical use of air-abrasion
is obtaining suitable enamel access in minimally invasive preventive resin restorations. Meticulous cleaning of the occlusal
surface before visual examination using a
rotary brush or air-polishing is essential
for caries detection,38 followed by the use
of a small head dental bur or alumina airabrasion for the removal of the carious,
demineralised enamel. The microscopically
roughened enamel surface created by alumina air-abrasion is devoid of weakened
prisms and is therefore better adapted
for adhesive bonding. However, lack of
substrate selectivity and no self-limiting
110
Fig. 7 Cavitated occlusal caries with soft

infected dentine evident
Fig. 4 The dentine at the periphery has been
initially excavated to a depth of cariesaffected dentine but flakes of very soft
infected dentine remain over the pulpal
aspect of the cavity
Fig. 8 Initially clear, slightly viscous Carisolv

gel introduced into the cavity using the
mace-tip hand instrument and left for
40seconds before excavation
Fig. 5 The dentine adjacent to the enameldentine junction is both scratchy and slightly
sticky to a dental probe, indicating it is
affected histologically. The peripheral enamel
margin is sound histologically
Fig. 9 This process is continued until the gel

has a muddy consistency when it is washed
out of the cavity and the relative hardness
of the remaining cavity walls tested using a
sharp dental explorer
Fig. 6 The final resin composite restoration

has been placed and finished to reduce plaque
biofilm adherence in the oral cavity
operator feedback when using these operative technologies can result in cavity
over-preparation. Innovation in abrasive
powder development has resulted in the
production of a commercially available
bio-active glass powder capable of removing extrinsic dental stain, desensitising
Fig. 10 MI prepared cavity with affected

dentine retained over the pulpal aspect
of the cavity. The peripheral margins in
the case have purposely been excavated
to histologically sound dentine to aid the
restorative peripheral seal
PRACTICE
exposed dentine and exhibiting an intrinsic selectivity towards carious, demineralised enamel and resin composite
restorations.3941 Research is ongoing into
development of a self-selective air-abrasive powder for caries-infected dentine.
Chemo-mechanical caries removal

After the development and subsequent
demise of the Caridex system in the
1970s, chemo-mechanical caries removal
techniques were resurgent with the commercialisation of Carisolv gel in the late
1990s. This hypochlorite/amino acidbased gel system assists the MI OCMS
with special non-cutting hand instruments offering greater tactile sensitivity
to the operator, thus permitting selective
infected and affected dentine removal.23,24
Studies indicated good patient acceptance
of this technique.37 An example of MI caries excavation using Carisolv gel is given
in Figures710. Developments in chemomechanical technology include the laboratory development of pepsin-based gels
using specially designed nylon brushes
and plastic disposable hand instruments
to abrade the softened infected dentine as
well as papain-based systems (see Table1).
CONCLUSIONS
The evidence for the minimally invasive operative caries removal strategy in appropriately selected patients
exists. The removal of grossly softened
caries-infected dentine is recommended
in most situations (except perhaps in a
deep lesion overlying the pulp where
its vitality assessment leans towards an
acute inflammatory response and an
adequate clinical seal can be achieved at
the periphery of the cavity). Peripheral
caries removal should extend to sound
dentine where inadequate quantity and
quality of enamel remains. It is at this
tooth-restoration interface that the
peripheral seal is critical to prevent further histopathological progress of the
disease. The seal can be achieved using
adhesive dental biomaterials that penetrate micro/nano-mechanically to the
mineral and collagenous components of
enamel and dentine respectively. With
judicious use of contemporary adhesives

with their bacteriocidal/static properties,
there is little need clinically for a separate
lining/base layer to protect the pulp. A
thorough understanding of the chemistry
of the materials and how they relate to
the histology of the tissues is necessary
to ensure the best prognosis of a sealed,
adhesive restoration.
19.
20.
21.
Figures16 have been reproduced with publishers

permission from Banerjee A. A large carious lesion.
In Odell EW (ed) Clinical problem solving in
dentistry. 3rd ed. pp 4348. Edinburgh: Churchill
Livingstone, 2010.
22.
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Minimal intervention dentistry:

part 1. From compulsive

Explains the differences between minimal

J.D.B. Featherstone1 and S. Domjean2

Office of the Dean, Box 0430, 513 Parnassus Ave,

Accepted 21 June 2012

of its pathogenesis, its transmission, the

Fig. 1 The limitations of traditional dental

of restorations results in the restoration

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

intervention dentistry, minimally invasive

WHAT ARE THE DIFFERENCES