New technologies

dealing with dental

caries

Supervisor
Professor Dr. May yousry

By
Ahmed Mohamed fayed
Montaser fadl
List of content
Introduction
1

Biological model

Caries risk assessment (CRA)

New technology in diagnostic tools for early caries detection

Categories and Classification of dental caries correlated with biological model

Reduction of cariogenic bacteria to decrease the risk of further demineralization and cavitation.

Remineralization and monitoring of non-cavitated arrested lesions.

Placement of restorations in teeth with cavitated lesions, using minimal cavity designs

Caries Management by Risk Assessment (CAMBRA)

Nanotechnology
conclusion

Introduction
(Wolff et al., 2007)
o

Human beings have advanced their lives with technology. Man has built huge dams, bridges and
jet aircrafts as well as microscopically small things, like the computer chips, which are affecting
nearly every aspect of our lives, and the genetically modified bacteria that create new drugs for us.

In the 21st century, we are plunging forward into a new era of technological power, one that offers
enormous promise for the future and enormous dangers as well.

History of dental caries management:

In the United States, dentistry originated in the 17th century when several ''barber-dentists'' were
sent from England.
o The practice of these dentists consisted mainly of tooth extraction because dental caries at that
time was considered a ''gangrene-like'' disease.
o Later it became known that treatment of the defective part of a tooth (the cavity) could occur by
removal of the cavity and replacement of the missing tooth structure by ''filling'' the cavity with
some type of material.
o Dentists began to be educated in the basic sciences as well as clinical dentistry, resulting in
practitioners who possessed and demonstrated intellectual and scientific curiosity.
o

G.V. Black's concepts in dealing with dental caries

For many years even until now, the black tooth preparation, with few modifications, formed the basis for
:most operative preparation procedures. These objectives are
Remove all defects and provide necessary protection to the pulp {biological objective}

(1

Extend the restoration as conservatively as possible {mechanical objective}

(2

Form the tooth preparation so that under the force of mastication the or the restoration or both will
not fracture and the restoration will not be displaced{mechanical objective}

(3

.Allow for the esthetic and functional placement of a restorative material. {Esthetic objective}

:Extension for prevention"; Self cleansable and non self cleansable areas"
Black, a dentist of considerable experience and observational skills, noted:

The development of caries on virgin inter-proximal surfaces because of the stagnation of food in
these uncleansable areas.
Caries development around occlusal restorations that failed to include susceptible pits and fissures.
As well as, its development in areas below the greatest diameter of the tooth which provide a shelter
for food debris.
And those site are considered according to Black, caries susceptible areas (Non self cleansable areas).
Black necessitated the extension of the prepared cavity to include those vulnerable caries susceptible
areas and to terminated the prepared cavity to self cleansable or caries immune areas thus to prevent
caries recurrence.
According to Black observation, self cleansable or caries immune areas are:
1. Tips of the cusps.
3

(4

2. Crest of the marginal and crossing ridges.

3. All inclined planes of cusps and ridges.
4. Occlusal, incisal, facial, and lingual embrasures.
5. Facial or lingual surfaces incisal or occlusal to the height of contour with the exception of pits if
present.
6. Axial angles of teeth.
Thus, arise the famous term "Extension for prevention".
:"The G.V.Black concept "Surgical model of treatment
When Black defined the parameters for his classification, the cavity designs were controlled by
a number of factors which are:
1. The lack of understanding of the caries process, in particular the potential for
remineralization.
2. Radiographs were not in general use so, on average, a cavity was not diagnosed until it was large
enough to be identified with a sharp probe or seen by the naked eye.
3. The limitations in the available instruments for cavity preparation as well as the selection of
restorative materials.
Black suggested that it was necessary to
Remove additional tooth structure to gain access and visibility.
Remove all trace of demineralized enamel and dentine from the floor, walls and margins of the
cavity.
Make room for the insertion of the restorative material in sufficient bulk to provide strength.
Provide mechanical interlocking retentive designs
Extend the cavity to self-cleansing areas to avoid recurrent caries.
Consequences of Black's concept:
Gross weakening of the remaining tooth structure
Increased potential to pulpal irritation
Increased gingival and periodontal irritation
Due to these consequences, G.V. Black concept had to be revised and reviewed.
Black published a series of papers and texts on dental materials and preparations and restorative
techniques between 1869 and 1915. Black wrote a series of papers that addressed the problems of caries at
the margins of restorations, amalgam and composition, and tooth restorations. These papers represented
the earliest workbooks on the quality of operative of that era, and these papers were based on the best
knowledge available. Black described the placement of the outer margins in ''self-cleansing'' areas so that
they terminated in regions less susceptible to recurrent caries. Black wrote:

Although many current authors have credited or blamed these tenets for overly aggressive preparations and
restorations in modern dentistry, the present authors contend that Black was the first dentist to propose
treating dental caries using minimal intervention based on the knowledge and materials available at that
time.
The breakthroughs which led to changes in G.V. Black concept:
1.
2.
3.

The increased knowledge of the nature of dental caries and healing factors operating in the mouth.
Improvement of laboratory and clinical tools.
Proper understanding of the material properties

This led to a sever shift in the treatment of dental caries from surgical approach to the
medical, biologic or therapeutic model or approach (minimally invasive dentistry, or
minimal intervention dentistry)

Biological model
Definition:
Respecting the health, function and aesthetics of oral tissue by preventing disease from occurring or
intercepting its progress with minimal tissue loss.

Objectives
5

1.
2.
3.
4.
5.
6.
7.
8.
9.

Assessment of individual caries risk.

Early caries diagnosis.
Classification of caries depth and progression.
Reduction of cariogenic bacteria to decrease the risk of further demineralization and cavitation.
Arresting of active lesions.
Remineralization and monitoring of non-cavitated arrested lesions.
Placement of restorations in teeth with cavitated lesions, using minimal cavity designs.
Repair rather than the replacement of defective restorations.
Assessing disease management outcomes at pre-established intervals.

1. Caries risk assessment (CRA): (Margherita and Dominck, 2006)

Definition:
It is defined as determining the probability of caries incidence, which is the number of new cavities or
incipient lesions, and/or change in size or activity of existing lesion in the mouth.
Importance:
1.Assessment of the individual etiological factors of existing carious lesions and of the caries risk
situation.
2.Repeated determination of the caries-risk allows an evaluation of the success of, or the need for,
modification of preventive measures.
3.Indication of an increased caries-risk in specific children in community preventive programmes will
allow selection of an individual preventive programme in order to minimize the development of
caries lesions.
4. Diagnosis of the disease process utilizing cost-efficient materials and technique.
5.

Identification of all risk factors including etiological and non-etiological factors.

6. Treatment planning that goes beyond caries removal and tooth restoration to include risk factor
modification or elimination, arresting or reversing non-cavitated carious lesions and preventing
future caries.
Risk Factors for the development of caries:
Caries is not the consequence of a singular event (as is a classical infectious disease for example) but it
is rather a sequel of a series of processes happening over a longer period of time.
In the scientific studies various so-called 'predictors' for the risk of caries have been investigated. These
could be clinical signs of caries or risk indicators, such as factors associated with the development of
caries. Their effects on the development of caries can be either causative or modifying.
Causative relationships are often identified as risk factors. An individual with an increased risk of caries,
therefore, be a person with a higher than average exposure to the causative risk factors mentioned below.
Caries:Epidemiological studies have shown a positive correlation between past caries experience and future
caries development. The sensitivity of that parameter is almost 60 percent. Initial caries lesions are

supposed to give a better predictability than the number of filled (FS) or carious surfaces (DS). Conversely,
the inclusion of initial lesions in DMFS or DS-values doesn't increase the accuracy.
In adults, existing DMF-values are less sensitive for predicting future coronal caries than in children.
However, there is a close connection between existing caries and the risk of developing root caries. Caries
prevalence in primary teeth can correctly predict future caries in the permanent teeth. The sensitivity of
prediction was increased by including primary teeth and first permanent molars into the assessment.
Fluoride:There are various concepts as to the mechanisms of action of fluorides especially regarding the extent of
the pre-eruptive versus post-eruptive effects. The local action of fluoride on the tooth surface appears to be
at least as important as the incorporation of fluoride into the dental hard tissues during tooth formation.
The post-eruptive effect of fluoride depends on the concentrations in the mouth; therefore, regular
fluoride exposure is of a decisive importance in reducing caries. The salivary fluoride content has some
association with caries susceptibility but its diagnostic or predictive value is questionable.
Oral hygiene:A further prerequisite for caries development is the existence of bacterial plaque on the teeth. Caries can
be reduced by mechanical removal of plaque from the tooth surfaces; however, most patients don't remove
it effectively.
Frequent (biweekly) para-professional tooth cleaning with a fluoride-containing paste substantially
prevents caries and reduces gingivitis but the practicability and cost of such programmes is questionable.
The effectiveness of mechanical cleaning alone is hard to evaluate, since tooth brushing is usually done
using fluoridated toothpaste. Furthermore most plaque indices are based on smooth tooth surface scores
whereas most caries occurs in fissures and interproximally.
Bacteria:Shortly after birth an oral ecosystem is established consisting of the different kind of bacteria.
The colonisation of the mouth by odontopathic bacteria is by human transmission, mostly from mothers,
fathers or caregivers to infants, depends upon the quantity of these bacteria the parents harbour.
Toddlers who carry a large amount of mutans streptococci already at 2 and 3 years of age show
a noticeably higher risk of developing caries on primary teeth.
A correlation between the number of carious lesions and numbers of mutans streptococci has been
established in the saliva of children and adults. The accuracy of salivary tests for mutans streptococci in
predicting caries in the whole population is less than 50 percent.
Microbiological tests show close associations between odontopathogens and caries in subjects with high
caries experience and conversely, low numbers of odontopathogens in low or non-caries subjects.
Even though lactobacilli are not primarily responsible for caries development, they are found in
increased numbers when large amounts of carbohydrates are eaten.
7

Saliva:
Saliva has a buffering effect on acids which are produced by plaque micro-organisms and can also clear
food particles from the mouth.
The production of saliva and salivary clearance is stimulated by chewing. The salivary flow rate
increases in small children up to the age of approximately 10 years and continues to increase slightly
thereafter to adulthood.
The number of patients who show a reduced salivary flow rate is increasing especially in seniors.
This is not so much due to age per se, but rather the side effects of certain medications that reduce salivary
flow. In individuals with markedly reduced salivary function, caries activity is significantly increased.
Other salivary factors such as concentration of proteins, different ions or enzyme activities are of slight
value for prognosis of caries-risk.
Eating habits:
The role of diet in the caries process is primarily local rather than systemic. The cariogenicity of food
depends on its components and is influenced by various factors.
Carbohydrates are metabolised by plaque bacteria into acids at different rates. Combination of starch
and sucrose as found in cakes are highly cariogenic in studies, which is attributed to their slow clearance
rate. The root surface is extremely susceptible to demineralization by starchy foods.
In addition to the intrinsic cariogenicity of a food, the manner of its consumption is of great importance
as demonstrated in the Vipeholm-study and other investigators. It is known that the amount of
carbohydrate, particularly sugars alone is not the only factor, but the frequency of the intake is important.
Patient's statements about their eating habits have to be critically evaluated; therefore, self-reporting of
diet has low predictability. The amount of sugar intake has a noticeable effect on fissure caries.
Today, per capita sugar disappearance (utilisation) in industrial nations with low caries incidence, has
only a slight effect on caries prevalence. Thus, little caries increase was found in young children with good
oral hygiene irrespective of dietary habits. At the same time high sugar intake showed an increased caries
prevalence only when the oral hygiene was poor.
Modifying factors(CRA indicators):
Age:
Epidemiological surveys of caries show an increase in caries prevalence with age. Newly erupted teeth
are more susceptible to caries, particularly at the pits and fissure sites. The susceptibility seems to be
increased also by the difficulty of cleaning the teeth until they have reached the occlusal plane and
opposing teeth are occluding. As the enamel matures it is less likely to decay. Accordingly children are at
a greatest caries risk at those ages when teeth have just erupted.
Gender:

During childhood and adulthood women show higher DMF-values than men. But in general their oral
hygiene is better and they have fewer missing teeth than men. It is unlikely that women have higher caries
susceptibility; rather they seek more dental care, which is reflected in a higher F-component of the DMFindex.
Behaviour:
The patient's attitude towards his or her health has a distinct effect on the resulting caries susceptibility.
A health-conscious behaviour, which is reflected in sensible eating habits and regular oral hygiene using
a fluoridated dentifrice, reduces caries incidence. Behavioural patterns, especially eating habits, influence
'caries susceptibility' and 'caries risk'.
Social, genetic and occupational factors:
Socio-economic status is highly relevant to caries prevalence. Caries is more prevalent in lower than in
higher social classes. This is not due to more expensive treatment, but to a greater health interest in upper
social classes.
Studies of identical twins who have been raised separately, have shown that other etiological factors are
more important than genetic factors such as tooth morphology, position, and occlusion.
Workers in industries such as bakeries, candy and chocolate factories and sugar cane cutters, have higher
caries prevalence than workers in other industries.
General medical factors:
General medical factors, like long-term use of sugar liquid medications by children, increase caries
prevalence. Many other medications, especially psycho-pharmaceutical products, reduce the flow of saliva
and thus increase caries risk.
Dental therapy:
The type of treatment delivered by dentists depends in part on the costs to the patient. On the other hand
the dentist's academic education, continuing education, knowledge of preventive measures, and the use of
modern techniques are additional factors influencing treatment.

Health systems:
The therapy proposed by the dentist is influenced by that society's health system.
Based on current knowledge about the aetiology of caries, this disease cannot be cured by restorative
measures, but only by preventive and biological models.
Examples of caries risk assessment models

Cariogram
9

The cariogram is a computer program that serves as a risk assessment model. This program assesses and
graphically illustrates the caries risk of the patient, expressed as the chance to avoid new caries in coming
years. The cariogram also demonstrates how and what extent the various caries-causing factors may affect
the patient's risk.
The cariogram is a five sectors pie-circle diagram. The sectors have the following colors: green, dark blue,
red, light blue and yellow indicating the different groups of factors related to dental caries. The aims of the
cariogram are to:
o
o
o
o

Illustrate the chance to avoid caries.

Illustrate the interaction of caries related factors.
Express caries risk graphically.
Provide an educational program.

Traffic light matrix model (TL-M) (Ngo and Gaffany 2005)

The traffic light is the first element of this system and it builds on the existing risk assessment models
as well as including an assessment of patient motivation and lifestyle activities. It doesn't attempt to predict
caries incidence but rather it acts as an early warning system that alerts the clinicians to the presence of
risk factors that are capable of changing the oral environment. It is designed to the clinician to select
appropriate clinical pathways for individual patients based on their current personal risk profiles.
The TL-M model allocates a threshold value for each risk category. If the information elicited from
questioning or by clinical testing yields results which exceed the predetermined threshold values the model
alerts the clinician to a possible problem. The threshold values used have validity for individual risk factors
but the model doesn't attempt to make any assumptions about either the relative importance of individual
risk factors or their relationship to each other.
The model investigates sixteen risk factors and scores a red light, a yellow light, or a green light for
each risk factor predetermined criteria.

10

2. New technology in diagnostic tools for early caries detection (Pretty, 2006)
With the greater understanding of the caries disease, comes an opportunity to promote 'preventive'
therapies that encourage the remineralization of non-cavitated lesions and the preservation of tooth
structure, function and esthetics. Central to this vision is the ability to detect caries lesions at an early stage
and correctly quantify the degree of mineral loss, ensuring that the correct intervention is instigated.
The failure to detect early caries, leaving those detectable only at the deep enamel, or cavitated stage has
resulted in poor results and outcomes for remineralization therapies.

11

A range of new detection systems have been developed and are either currently available to
practitioners or will shortly be made so.

Magnification technology
Loupes:
o

Extension of eye glasses with magnification power 2x-5x

Microscopes:
o
o

Magnification power is 10x-25x

Either fixed or mobile

Radiographic technology
Digital Radiography
Direct digital images may be acquired by two methods; the charge-coupled device (CCD) or the storage
phosphor system (SP). In the CCD system, the sensor plate is connected to a computer with the resultant
image being directly displayed on the computer monitor. In the SP system the image plate is similar to an
x-ray film. The imaging plate is placed in a laser scanner and a latent image is created. The images can be
enhanced using special software. The use of digital radiography overcomes two of the primary
disadvantages of dental films, including image manipulation and reduction in the radiation required to
obtain a radiographic image. Digital image enhancement and subtraction were made available by this
technique, through which caries progression or regression can be assessed through storage of different
radiographs at different intervals.

Tuned aperture computed tomography TACT

TACT is a recently introduced diagnostic method. Based on digital radiography, this method constructs
radiograph slices and cross sections through teeth. Then the slices can be viewed for the presence of
radiolucencies. In addition, the slices can be reconstructed in to a three dimensional computer model called
a pseudo-hologram, which can be generated by sequentially displaying two-dimensional image frames
from different angles. This simulates varying projection geometries and provides some perception of three
dimensions to the viewer.
This new imaging modality allows interactive sampling of three-dimensional data. The radiation dose is
equivalent to one conventional x-ray film. Multiple views or slices through a tooth are obtained in
a limited exposure time. The patient can move between exposures without affecting the image. These
images can provide up to ten times greater contrast resolution than conventional tomography.

Optical coherence tomography (OCT)

12

Is an emergent technology for biomedical applications. OCT is an attractive method since it non-invasively
investigates biological samples with high resolution. It utilizes beam splitter technology followed by image
capture with electronic detector in order to provide image analysis.

Light technology
Digital image fiber-optic transillumination (DiFOTI):
A high-intensity safe white light is passed through the tooth and the transilluminated
image of the tooth is captured on a chargecoupled device (CCD), then analyzed by
computer software and displayed on
a computer screen for diagnosis.
It is based on the fact that carious enamel has a lower caries index of light
transmission than sound enamel. It allows the capture and view of real-time digital
images on the computer monitor.
Its mouthpieces enable dentist to view:
a. Decay on occlusal surfaces, around restorations, & facial and lingual surfaces.
b. It detects incipient caries & fractures.

ToothSpy:

It is very popular punctual transillumination device which opens up new diagnostic

possibilities. It allows you to see deeply into teeth and gums and immediately detect
flaws, fissures, early caries, existing Implants and Root fillings and is an absolutely
valuable diagnostic tool. It is battery powered and comes with 20 autoclavable
silicon tips.

Advantages:
1. Fast, safe diagnosis without x-ray.

2. Detection of existing implants and root fillings.

3. It can be used with your intra oral camera (for the patient).
4. Easy-Touch and integrated automatic switch off (it lights up when you touch it and
goes out shortly after you put it down which prevents the battery going flat by
mistake).

Laser Technology:
Laser-based device (DIAGNOdent):

The device works on the fluorescing nature of bacterial (mutans streptococci)

metabolic by-products. This fluorescence is detected into numerical figure that can
be used in the diagnostic protocol. It thus allows measuring the level of cariogenic
bacterial activity. In other words, it detects caries-induced changes in the tooth.
It is supplied with two fiber optic tips; a tapered one for the fissure caries and a flat
one for smooth surface caries.
The instructions suggested that, in general numeric data between 5 and 25 indicate
initial lesions in the enamel while values greater than that indicates dentinal caries.

Advantages:

The quantitative nature of its readings gives a basic guideline that could be followed
up longitudinally to monitor the decay extent.

Disadvantages:
13

1. The device showed higher diagnostic accuracy in the detection of dentinal

caries than enamel caries.
2.
The diagnodent values were dependent on the volume of caries more than
depth of caries.
3. It is very sensitive to the presence of stains, deposit and calculus which may
lead to false reading.

Laser/Light induced fluorescence:

Laser light is composed of electromagnetic waves with equal wavelengths and equal
phases. Some materials possess the characteristic of fluorescence when illuminated
with laser light.
Fluorescence is a phenomenon by which the wavelength of the emitted (original)
light is changed into a larger wavelength upon reflectance.
Dental enamel and dentin possess the characteristic of fluorescence and this natural
fluorescent is called auto-fluorescence. Caries lesions, plaque and microorganisms
also contain fluorescent substances.
The difference between the fluorescence of sound tooth tissues and that of a caries
lesion can be made visible by the quantitative laser or light induced fluorescence
(QLF) method and yields a quantitative caries diagnosis.

Electrical Technology:
Electrical caries monitor (ECM):

It's based on the electrical conductivity differences between sound dental tissues
and carious dental tissues in absence of liquid (saliva). High measurements indicate
well-mineralized tissue while low values indicate demineralized tissue.
It has the ability to:
a)

Detect demineralization even when the surface remains macroscopically

intact.

b)

Monitor lesion progression, in remineralization.

Vanguard electronic caries detector:

It works as ECM, but the measured conductance is represented on a scale from 0-9
to represent the degree of demineralization.

Ultra-sonic Technology:
Ultrasonic caries detection:
In dentistry, ultrasound has been used to image the tooth and to find carious lesions on smooth surfaces. It
was concluded from this initial study that, although small lesion could be detected, the method was
inappropriate to apply in patients. Moreover, it was not possible to detect shallow caries lesions. Ten years
later, results showed great promise for ultrasound caries detection for proximal surfaces.

Dyes Technology:
Caries detection dyes:
Caries detection dyes are a reliable diagnostic tool for occlusal carious lesions. 75% of occlusal carious
lesions missed by probing were found using CDD. The dye fills the voids in enamel and dentin that are
created by acid attack, or fills the voids present in hypomineralized enamel.
14

New diagnostic Technologies:

- These new methods are still under research & not yet applied clinically.
-There are several methods which have been proposed in the last few years for
caries detection as:

Multi-Photon Imaging
Infra-red Thermography
Infra-red Fluorescence
Optical coherence tomography (OCT)
Terahertz Imaging

Multi-Photon imaging:

A longer wavelength of light for imaging reduces the scattering, allowing the light to
penetrate more deeply within the tooth. This may make any image of the tooth
clearer. For multi-photon imaging of teeth, infrared light (= 850 nm) has been used.

Infra-red Thermography:

The method uses indium/antimony thermal sensors, which can detect temperature
changes in the order of 0.025C. With a constant flow of air over the surface of the
tooth, the change in temperature of the lesion is compared with that of the
surrounding sound tooth structure.

Infra-red Fluorescence:

This technique is able to discriminate between sound and carious enamel and
dentin. Further work is required to determine if the fluorescence signal from
exposure to infrared irradiation is greater than that from other wavelengths.

Terahertz Imaging:

This method of imaging uses waves with terahertz frequency (= 1012 Hz or a

wavelength of approximately 30 m). This wave-form is short enough to provide
reasonable resolution but long enough to prevent serious loss of signal due to
scattering.

3. Categories and Classification of dental caries correlated with biological model:

A. Site/Stage classification:
With modern understanding of caries dynamics accompanied by a far better improvement in caries
detection, diagnosis, and treatment, other far more effective methods of dealing with a carious lesion are
now available. It is suggested that it is time for a reassessment of the traditional caries classification as set
out by G. V. Black over one hundred years ago.
Mount and Hume 1998 designed a classification to simplify the identification of lesions and to define
their complexity as they enlarge (Table 1). This classification determines the carious lesions according to
their site and size.
Site/Stage Cavity Classification.
15

Site

Pit/fissu
re 1
Contact
area 2
Cervical
3

Size
Mi
ni
m
al
1
1.
1
2.
1
3.
1

Mo
der
ate
2
1.2
2.2
3.2

En
lar
ge
d
3
1.
3
2.
3
3.
3

Ext
en
siv
e
4
1.4
2.4
3.4

The three sites of carious lesions:

Carious lesions occur in three sites on the crown or root of a tooth, which are actually the areas where
bacterial plaque tends to accumulate. These are:
Site 1: Pits, fissures and enamel defects on occlusal, buccal, and lingual surfaces of posterior teeth or on
other smooth surfaces except the proximal surfaces of the crown, such as cingulum pits on anterior teeth.
Site 2: Carious lesions initiated on the proximal surfaces of all teeth immediately below areas of contact
with adjacent teeth.
Site 3: Carious lesions initiated on the cervical one-third of the crown or, following gingival recession, the
exposed root surfaces.
It is logical to classify lesions by these sites and then to grade them by size according to the extent of
progress. With the four stages of carious lesions, taking into account the progress of the carious lesion, it is
possible to consider restoration in four sizes regardless of the site of origin of the lesion:
Size 1: Minimal involvement of dentin just beyond treatment by re-mineralization alone.
Caries/tooth ratio (C/T r) = 1/4
Size 2: Moderate involvement of dentine. Lesion with localized cavitations in dentin without weakening
of cusps.
(C/T r) = 2/4
Size 3: The lesion is enlarged beyond moderate. The remaining tooth structure is weakened with the
cavitations in dentin causes weakening of cusps to the extent that cusps or incisal edges are split.
(C/T r) = 3/4
Size 4: Extensive caries with bulk loss of tooth structure has already occurred, in which one or more cusps
are destroyed.

16

(C/T r) = 4/4
In 2000 Lasfargues modified this classification by including another stage which is stage (0).
He defined it as an active lesion without cavitation requiring no surgical intervention. Further,
remineralization treatment or sealants with subsequent progression monitoring is indicated.
'Zero' means no restoration necessary, (C/T r) = 0/5.
B. ERK Classification:
In 1995, Ekstrand et al developed a visual ranked scoring system called it (ERK). The system claimed to
relate the visual appearance of the lesion to its underlying histological features.
The histological classifications in conjunction with the macroscopically observations made it possible to
demonstrate a clear relationship between the external degree of caries progression and the internal enamel
and dentine reactions. The macroscopic examination was performed under direct, strong illumination
without the use of a probe.
In 1997, Ekstrand et al modified their classification because they found that the eight separate visual
criteria might be impractical for routine clinical use. Their modified version was as follows:
Criteria used for visual examination of carious lesions.
Score
0
1
2
3
4

Criteria

No or slight changes in enamel translucency after prolonged air

drying more than 5 seconds
Opacity or discoloration hardly visible in the wet surface but
distinctly visible after air drying
Opacity or discoloration distinctly visible without air drying
Localized breakdown in opaque or discolored enamel/ or grayish
dentin discoloration
Enamel cavitation with exposed dentin

Criteria of histological examination of carious lesions.

Score
0
1
2
3
4

Criteria

No enamel de-mineralization or a narrow surface zone of opacity

(edge phenomenon).
Demineralization of the enamel outer half
Demineralization extending between enamel and external one
third of the dentin
Demineralization involving the middle 1/3 of the dentin
Demineralization involving the inner 1/3 of the dentin

17

C. World Health Organization( WHO) classification:

The WHO classified dental caries into five scores labeled as D scoring. These 'D' labels for lesion
severity have been used for many years (Pitts, 2004). This system allows data to be produced at a variety
of diagnostic thresholds. 'Diagnostic threshold' is a term that describes the cut-off level used in an
arbitrary decision of what to classify as diseased and what to classify as 'sound'.
WHO classification of carious lesions.
Co
de
0

D
1

D
2

D
3
D
4

Category

Criteria

Surface Sound

Initia
l
Carie
s

No evidence of treated or untreated clinical caries.

For
pits
and
fissure
s
For
smooth
surface
s

Enamel Caries

Caries of Dentin
Pulp Involvement

There may be
significant
staining, discoloration, or
rough spots in the enamel that
do not catch the explorer

No
clinically
detectable loss of
tooth substance.

There may be white, opaque

areas with loss of luster.
Demonstrable loss of tooth substance of pits, fissures, or
on smooth surfaces, but no softened floor or wall or
undermined enamel.
The texture of the material within the cavity may be
chalky or crumbly, but there is no evidence that
cavitation has penetrated the dentin
Detectably softened floor, undermined enamel, or a
softened wall, or the tooth has a temporary filling.
Deep cavity with probable pulp involvement

Pitts (2004) represented this system for caries scoring as an iceberg and called it iceberg of dental
caries. The peak of the iceberg represents gross or frank dentin caries (the so-called D4 and more limited
D3 caries lesions) which rests on increasingly larger volumes of less extensive decay at the D2 (enamel
cavity) and more limited D1 (white- or brown-spot caries lesions) levels of severity. Pitts, described the
base of the iceberg as carious lesions that are sub-clinical initial lesions in a dynamic state of progression
and regression. Diagnostic threshold for these lesions can be achieved by recent and sensitive diagnostic
tools.

18

D. International Caries Diagnosis and Assessment System (ICDAS): (Banting et al. 2005)
The ICDAS detection codes for coronal caries range from 0 to 6 depending on the severity of the
lesion. There are minor variations between the visual signs associated with each code depending on
a number of factors including the surface characteristics (pits and fissures versus free smooth surfaces),
whether there are adjacent teeth present (mesial and distal surfaces) and whether or not the caries is
associated with a restoration or sealant. Therefore, a detailed description of each of the codes is given
under the following headings to assist in the training of examiners in the use of ICDAS: Pits and fissures;
smooth surface (mesial or distal); free smooth surfaces and caries associated with restorations and sealants
(CARS). However, the basis of the codes is essentially the same throughout:
Code
Description
0:
Sound
1:
First Visual Change in Enamel (seen only after prolonged air drying or restricted
to within the confines of a pit or fissure)
2:
Distinct Visual Change in Enamel
3:
Localized Enamel Breakdown (without clinical visual signs of dentinal involvement)
4:
Underlying Dark Shadow from Dentin
5:
Distinct Cavity with Visible Dentin
6:
Extensive Distinct Cavity with Visible Dentin
E.The universal visual scoring system (UniViSS)(Kuhnisch et al. 2009)
Given the limitations of adjunct caries detection and diagnostic tool, as well as the difficulties in
controlling all possible confounding factors, the need for an objective visual caries detection and
diagnostic system has become evident. It aimed at systematizing caries lesions for occlusal and smooth
surface lesions

19

4. Reduction of cariogenic bacteria to decrease the risk of further demineralization

and cavitation.
a)Diet and habits modification:
If it was found that the main cause of the demineralization is the faulty diet or habits, so they must be
modified as they are crucial to the success of preventing caries and erosive lesions. For some patients,
20

a habit (eg, frequent consumption of chocolate or sugar-containing lozenges or snaking at night) may
explain their caries activity and may be easily corrected. For others, very complex eating patterns may be
found. Therefore the patient must be informed about the relationship between diet and dental health.

b) Salivary flow and buffering capacity adjustment:

If the cause of demineralization is deficient salivary flow, we can use either artificial saliva (contain
electrolytes normally found in saliva) or sialogogues (drugs stimulating flow rate, chewing gum sugar-free
or Biotene products containing antibacterial enzymes).
If the cause is decreased buffering capacity of saliva, use of buffering agents, such as carbonic anhydrase,
urea, is always sufficient to treat the case.

c) Mechanical preventive measures:

These measures are used to fit into a dental office preventive program and they include several items:
1-

Plaque control:
Plaque control is the removal of microbial plaques and prevention of its accumulation on the teeth and
adjacent gingival surfaces. Its success depends on the level of personal oral hygiene practiced by the
patient. Thus mechanical plaque control could be carried out professionally or by self-care.
Self-care program
It can be achieved by;

1)
Tooth brushing: manual or bowered.
2) Interdental cleaning aids: Dental floss, interdental brushes and wooden tips.
3)
Oral irrigation devices using disclosing agents to remove plaque.
Professional program
It can be achieved by;
1) Plaque disclosing pellets.
2) Means of professional tooth cleansing: Ulttrasound devices, power-jet-device and/or hand
instruments.
3) A fluoride containing prophylaxis paste and rubber cup.

2- Pit and fissure sealants:

These sealants are in the form of low viscosity resinous materials or glass-ionomers and their
modifications. They obliterate pits and fissures that represent good habitats and niches and allow trapping
of food and microorganisms.
3- Enameloplasty:
This refers to the ultraconservative surgical procedure of eliminating developmental fault in the pit and
fissure area. It is indicated when a sound pit or groove (fissured or not) penetrate to 1/4-1/3 enamel
21

thickness. If this shallow feature is removed and convolution of enamel is saucered by round diamond
point, the area becomes non-retentive, cleansable and smooth.

d) Antimicrobial agent:
It is used to fit into home-care preventive program.
The antimicrobial agents could be classified into the following:
a-

b-

c-

d-

Cationic agents: This group is generally more potent antimicrobials because they bind to
the negatively charged bacterial surfaces. They include the following:
o Bisbiguanide detergents: Chlohexidene and alexidine.
o Quaternary ammonium compounds: Cetylpyridinium chloride.
o Surfactants: Delmopinol.
o Heavy metal salts: Copper, tin and zinc.
o Pyrimidines: Hexetidine.
o Herbal extracts: Sanguinarine.
Anionic agents:
o Fluoride.
o Sodium lauryl sulphate.
Non-ionic agents:
o Triclosan (non-charged agent).
o Listerine (combination of the phenol-related essential oils thymol and eucalyptol).
Combination agents:
Plaque is a complex aggregation of various bacterial species. Therefore combining two or more agents
with complementary inhibiting modes of action may enhance the efficacy. Examples are heavy metal ions
(Zn) plus chlorhexedine or sodium lauryl sulfate, Triclosan plus copolymer or zinc citrate and stannous
fluoride.

e-

Enzymes:
Their action is to control the proliferation of bacteria by augmenting the presence of hypothiocyanite at
neutral pH or hypothiocyanous acid at low pH. Hypothiocyanite is believed to enhance the lytic action of
lysozymes.

f-

Sugar alcohols:
Xylitol is a sugar substitute that cannot be metabolized by microorganisms and its consumption has
minimal effect on plaque pH.

g-

Natural materials extracts:

Examples are tea, cacao, shiitake and miswak.

h-

Ozone therapy:
It is a powerful antimicrobial agent. Studies have shown that exposure of carious dentin to ozone for
10-20 seconds has caused a substantial reduction in the level of cariogenic organisms. It can penetrate the
bacteria and kill them in their protected niches. It can alter the bacterial metabolic activities that inhibit the
process of remineralization and thus allow clinical reversal of the lesions.

22

Ozone is supplied through a medical device known as Healzone. It reaches the lesion via a hand piece
covered by a cup that is placed on the lesion for a period of 10 seconds. This followed by rinse and suction
to eliminate any ozone remnants and a neutralizing agent is applied. Then the remineralization process will
start within 25 seconds. The patient is sent with "all house care kit" consists of dentifrice and mouth rinse.
i- Zeolite:
Zeolites are crystalline aluminosilicates with fully crosslinked open framework structures, made up of
corner-sharing SiO4 and ALO4 tetrahedra. Zeolites act as a molecular sieve, as they have selective
adsorption properties capable of separating components of a mixture on the basis of a difference in
molecular size and shape. The primary building unit of a molecular sieve is the individual tetrahedral unit.
Therefore, Zeolites are selective, high capacity adsorbents, because of their high intracrystalline surface
area and strong interactions with adsorbate. These special characteristics suggest that, treatment of caries
lesion with Zeolites before bioactive glass or mineralizing solution may play an important role in the
reminerslization process.in addition, It could be used as antimicrobial agent, e.g. Zeomic, an inorganic
antimicrobial agent that can be used in a powder form, by incorporating silver ions with antimicrobial
power into the three-dimensional alumino-silicate mineral structure of zeolite.

5) Remineralization and monitoring of non-cavitated arrested lesions.

(Walsh, 2009)

(A) Fluoride-cotaining agents

Fluoride mouth rinses
In an attempt to find simple, time-saving and effective methods for fluoride applications, the mouth
rinses were developed in the 1950's. The system, often based on mouth rinses every week or every 2 week
with 0.2% sodium fluoride solution. The FDA approved fluoride mouth rinses as prescription anti-caries
agents in 1974. In 1980, a lower concentration (0.05% sodium fluoride or 230 ppm) fluoride mouth rinse
was approved for. A higher concentration formulation (0.2% sodium fluoride or 900 ppm) remains
available by prescription and is recommended for use weekly or biweekly for adults at high risk for dental
caries. A recent Cochrane Library systematic review concluded that regular supervised use of fluoride
mouth rinses reduced tooth decay in school-age children, particularly in those who already experienced
caries.

Fluoride varnish
It is recommended that fluoride varnish should be applied at intervals of 3-6 months, predominantly in
patients at high risk of caries.
Fluoride Gels
The most common fluoride gels contain 0.2% or 1% F. The gel treatment is sometimes used for patients
with high caries risk. In some cases, for example, when trying to reduce high counts of mutans
23

Streptococci, it has been combined with chlorhexidine. It should be observed that the patient often
swallows parts of the gel, even when caution is used. Fluoride gels with the concentrations mentioned
should not be used in children and the 1% gel only in adults under supervision. Individually-made mouthtrays are preferred to minimize the amount of fluoride gel that may be swallowed.
Fluoridated Chewing-gums
They are sometimes recommended to patients with high caries risk (for example due to oral dryness
and high counts of mutans streptococci) as they stimulate saliva secretion.
Saliva substitutes containing fluoride
A saliva substitute may be helpful and sometimes necessary in patients with practically no saliva
production as in cases of patients receiving radiation towards the head and neck region, medication,
diseases in salivary glands or other reasons that may result in long-lasting oral dryness. Some of these
products are fluoridated and prescribed when caries risk is high.
Fluoride slow release devices
Slow release delivery systems offer much potential for contributing to sustained release fluoride delivery
and may be useful for individuals who are at high risk of dental carious lesions but who may not
cooperate to allow fluoride to be applied in other ways. There is extra safety in that, the fluoride is not
swallowed in one dose which may be important in very young children to avoid fluorosis of development
teeth.

(B) Other remineralizing agents and systems

Biotene products: (mouthwashes, toothpastes, gel, gum)
Oral balance gel and toothpastes products contain the enzymes lactoferrin, glucose oxidase, and
lactoperoxidase. When these enzymes combine with potassium thiocyanate, which is present in saliva,
they form the hypothiocyanate ion, which mildly inhibits the growth of acid-producing micro-organisms.
Biotene mouthwash contains lysozyme, glucose oxidase, and lactoferrin.
Novamine:
NovaMin is an amorphous, calcium sodium-phospho-silicate that was developed as a fine particulate to
physically occlude dentinal tubules and reduce dentin sensitivity. Although it has been shown that
Novamine can form apatite-like calcium phosphate, and it is therefore very likely that this product will
enhance remineralization, but there is no published clinical evidence till now.
Carifree system:
Is an early caries detection and treatment approach based on the infectious disease nature of dental caries.
The system consists of a screening caries susceptibility test, a rapid bacterial test, a caries assessment
form, and a unique antimicrobial home care product line to reduce the caries risk.
Prospec MI paste:
24

Is a water-based FDA-approved for sensitivity that uses Recaldent (CPP-ACP) technology to deliver
calcium and phosphate ions to enamel surfaces. Recaldent is derived from the milk protein, casein. Casein
benefits teeth by bringing calcium phosphates to demineralised enamel. Casein phospho-peptide (CPP)
creates a stable delivery vehicle for amorphous calcium phosphate (ACP) and can promote
remineralization of subsurface enamel lesions. At neutral pH or with a high concentration of calcium and
phosphate ions, the concentration gradient favors the diffusion of ions back into the tooth causing
remineralization. Because it may provide some buffering along with amorphous calcium and phosphate,
this product attempts to mimic healthy saliva
Recaldent:
It is derived from casein, part of the protein found in cow's milk. It is technically called casein
phosphopeptides-amorphous calcium phosphate, or CPP-ACP. Research shows that CPP-ACP binds well
to plaque and provides a large calcium phosphate reservoir within plaque that will likely restrict mineral
loss during a cariogenic episode, and provide a source of calcium for subsequent remineralization.
Amorphous Calcium Phosphate (ACP):
ACP requires a two-phase delivery system to keep the calcium and
phosphorous from reacting with each other before use. This is done through a dual compartment tube in
the Enamel Care toothpaste. The calcium and phosphorous sources are two salts, calcium sulfate and
dipotassium phosphate. When these are mixed together, they rapidly form ACP that can precipitate onto
the tooth surface, dissolve into the saliva and be subsequently available for tooth remineralization.
SensiStat:
This technology is made of arginine bicarbonate, an amino acid complex, and particles of calcium
carbonate, a common abrasive in toothpaste. The arginine complex is responsible for adhering the
calcium carbonate particles to the dentin or enamel surface.

Sensistat seals the dentinal tubules

NMTD Toothpaste:
The NMTD Toothpaste contains a mixture of ion-exchange resins, which supplies calcium, fluoride,
phosphate, and zinc ions, to promote remineralization and/or inhibit demineralization of dental human
enamel in a pH cycling. Ion-exchange resins are insoluble high molecular weight compounds carrying
ionic functional groups that can react with ions in solution through the ion-exchange mechanism.
The application of ion-exchange materials has advantages in comparison with the conventional chemical
reagents. These materials do not introduce undesirable ions into the solution, ions release is carried out
only by the ion-exchange mechanism, they are characterized by practically neutral pH values, and they
can also adsorb bacteria on the surface. On the other hand, it provides a controlled release system for the
anti-carious treatment of dental tissues.
Icon kit:
The most recent remineralizing agent introduced by DMG American company.
25

6. Placement of restorations in teeth with cavitated lesions, using minimal cavity

designs
Steps of cavity preparation have been modified due to:
1.
2.
3.

The increased knowledge of the nature of dental caries & healing factors in the mouth.
Great improvement of dental tools.
Proper understanding of the materials properties.
So a comparison between Black's principles & the conservative approach must be considered.

I-The outline form:

According to Black

According to the conservatism

-An extension for prevention concept was

performed.
-Margins
area.

are

placed

in

-Caries
outline.

and

convenience

dictate

the

self-cleansable

-The mesial and distal extensions were

midway between the crest of the marginal
ridge and depth of the triangular fossa.

-The margins just past the fissure, Till

convenience
&
instrumentation
are
achieved.

-Buccally
and
lingually
the extensions
were midway between cusp tips and central
fissures.
- In proximal surfaces, the facial and lingual
margins extended midway between axial line
angles and facial or lingual margin of contact
area.
-The gingival margin extended below the crest
of the healthy gum margin.
- In facial or lingual surfaces, the mesial and
distal walls were extended up to the axial line
angles.
While incisally or occlusally the
walls were located above the height of
contour.

-In proximal surfaces, the facial and lingual

margins are extended Just beyond the
contact to free it with a clearance of 0.5
mm.
-The gingival margin is extended just to
include the defect.
-In facial and lingual surfaces,
All margins are dictated by the outline of
the defect.

II-Obtaining the resistance and retention forms:

Resistance form
26

According to Black,
The cavity width is governed by margin placement midway between the cusp tip and depth of the fissure.
The cavity depth was about 0.5mm pulpal to the DEJ.
Alternatively, the conservative approach allows the cavity width to be extended just to provide
convenience. The cavity depth is located just below the DEJ for amalgam while it can be in dentin or
enamel in modified cavities for composite.
Retention form
According to Black.
The retention was mainly macro-mechanical.
According the conservative approach:
Bonding offers a micromechanical level of attachment to tooth structure thus minimizing the need for
cutting to create retentive features.

III. Convenience form:

It is the form given to the cavity to be easily seen, reached & restored.
According to Black:
Cutting of sound tooth structure was sacrificed to improve the visibility & accessibility.
According the conservative approach:
The recent magnification tools, micro-sized cutting tools & recent cavity designs allow extreme
preservation of sound tooth structure.

IV- Removal of remaining carious dentin:

According to Black:
All caries must be eliminated completely and if the pulp becomes exposed (called pathological exposure)
& then it has to be treated endodontically.
According the conservative approach:
Pulp capping can be made in case that the pulp does not show any clinical manifestation of pulpitis or
degeneration; by making secondary dentin.
The differentiation between infected dentin and affected dentin is facilitated by the use of:

Caries detection dyes.

,
Using the chemico-mechanical caries removal (Carisolv)
The use of Smart prep burs: malleable polymers which remove the diseased tissues only (does
not remove sound tissues).

IV- Finishing of E-walls:

The same in both approaches.

V- Toileting:
The same preparation of the substrate tooth surface to receive the restoration.
Non invasive cutting tools:(Banerjee et al., 2008)
Requirements of the ideal cutting instrument:
1.
2.
3.
4.

Comfort, Ease of use and Ability to discriminate and remove diseased tissues only.
It has to be Painless, silent, requires minimal pressure for optimal use.
Does not generate heat or vibration during work.
Affordable and easy to maintain.

27

All this lead to the appearance of several tools that possess certain of these benefits:
I-Air-abrasion Technology:
Disadvantages:
1.

Its use was limited at that time due to the presence of restorative materials that did not suit this
technology.
2.
No bonding was adequately achieved to tooth structure and hence large cavities were required to
be cut to provide enough resistance and retention.
3.
Large cavities with definite walls and floors could not be cut with air abrasion.
4.
Cannot be used for tooth preparation & removal of amalgam.
Mode of action:
This technique allows the flow of a stream of compressed air (40-140psi) that carries aluminium oxide
particles (20- 50m) which strike the tooth surface.
uses:
1.
2.

Effectively cut sound enamel, dentin and defective restorations.

It is less effective in caries removal.
It has shown its safety concerning:
-Tooth vitality
-Not hazardous to the patient nor to the operator
Nowadays bondodontics have paved the way to the emergence of this technology, as very conservative
cavities could be prepared by it and restored with resinous material.
II-Chemico-mechanical removal of tooth tissues (CARISOLV):
The aim of micro dentistry is to identify diseased tooth structure, and then remineralize or remove those
structures with minimal disruption of the surrounding tooth structure.
Mode of action:
Chemical methods of caries dissolution were based on the combined use of an organic acid and sodium
hypo-chlorite. Now they use the combination of amino acids and a weak solution of sodium hypo-chlorite
in a gel form.
Apply the gel over the diseased tissue for several minutes until it performs its action then gentle scrapping
is done using specially designed instruments that resemble excavators.
It does not affect healthy dentine or soft tissue nor does it affect enamel. Consequently, it should be used
in combination with other cutting techniques.
Used:
In root caries, coronal caries with open access and in deep caries approaching the pulp.
III-Ultrasonic cutting:
The early generations SonicSys could not preserve tooth structure and tend to dictate a wider cavity
preparation owing to their large sizes. Later on SonicSys micro with oscillating working tips was
introduced. It permits extremely precise preparation without damage to healthy tooth substance owing to
its smaller sizes.
IV-Laser Technology:
The most commonly used types are excimers, which are special ultraviolet lasers. CO2 and Nd: YAG
lasers have also shown to be promising.
28

Lasers are used with caution for cavity preparations, as they are inefficient at removing large amounts of
enamel and dentin and result in generating extensive amounts of heat.
Waterlase Technology:
Alternatives to the drill for tooth preparation; the dental laser has emerged as a powerful tool in this
progression, helping dentist to prepare hard and soft tissue.
Laser technology has helped to address such high-speed hand piece related issues as vibration- and heatinduced micro fractures, the removal of unnecessary tooth structure, and dentin without a smear layer.
The Waterlase system is a dual-purpose hard- and soft-tissue laser. It is able to cut hard tissue effectively
and, at the appropriate setting, to cut and coagulate soft tissue precisely with direct laser energy.
DIODE Laser:
We use the diode laser to treat soft tissue problems such as gum disease and to perform minor surgical
procedures. It is a precision instrument that stops bleeding, seals lymphatic and nerve endings, and
minimizes inflammation. Many procedures can be done without anaesthesia, and most post-operative
discomfort.
ERBIUM Laser:

5.

The erbium laser enables us to "vaporize" tooth decay in preparation for fillings rather than using
a traditional drill. There is no vibration and noise as compared to the dental drill, so the procedure
typically requires no dental anaesthesia. Compared to the traditional drill, the erbium laser is more precise
and can therefore preserve more of the healthy tooth structure.
V-Ozone Technology
Advantages:
Simple, time saving, effective and efficient approach.
No cutting is performed.
It rapidly penetrates the bacteria and kills them in their protected niches.
It could alter the metabolic products of bacteria that inhibit reminerlization and thus allows
clinical reversal of the lesion.
It used in treatment of root and deep caries.

Mode of action:
It is supplied through a medical device known as heal ozone that produces ozone in the unit by passing air
through a high voltage. Ozone reaches the lesion via a hand piece covered by a cup that is placed on the
lesion for a period of 10 seconds. This results in deactivation of 99% of bacteria, fungi and viruses.
OzonyTron:
It is one of the newest devices for the generation of ozone.
The basic principle is the partial production of pure ozone in the spot that is to be treated. By means of
probes, the active agent ozone is directly and immediately directed to the inflamed spot or wound. Within
seconds or minutes, the ozone reduces and eliminates the pathogen either bacteria, viruses or fungi.
As there are different probes available, they can be used quickly, safely, painlessly and without side
effect.
CA probe:
Apply to caries to eliminate the bacteria causing the decay. And it is used in conjunction with a good
fluoride gel to promote remineralization.
AV probe:
Killing of bacteria after extraction.
Treatment of wounds.
Stopping oozing bleeding.

1.
2.
3.
4.

29

Disinfection of the dental pulp.

CR probe:
Root canal treatment.
VI-Enzymes:
-This approach is still surrounded with extensive researches.
- Pronase enzyme successfully disintegrates decayed dentin.
Mode of action:
It said to perform digestion of carious dentin. Pronase does not attack sound dentin but solubilizes more
than 90% of the nitrogen present in carious dentin. It has no ability to remove sound or carious enamel.

Recent conservative cavity designs:

Simple box preparation:
Indication:
-It's used to restore small proximal lesion without either occlusal fissures or previous occlusal restoration.
-Class II cavity without involving the intact occlusal surface.
-The outline could have rounded margin as in resinous material or could be in the form of definite walls
as in case of amalgam restoration.
Outline:
Buccal and lingual walls of the box should be almost facing each other to maximize retention. It is done
without an occlusal step.
- In simple box preparation Retention is a problem, SO:
1. Axio-proximal grooves on the expense of the buccal & lingual walls to prevent pulp exposure.
2. If resin composite is used no problem is found due to the Micro-Mechanical Bonding.
Slot preparation:
Indication:
This type of preparation is used in:
1. Old patients who have gingival recession and cavities are on the proximal exposed cementum on the
root surfaces that is gingival to the contact area.
[

2. It is used with wide embrasures that allow easy access.

Advantages:
1. It offers better esthetic.
2. It does not alter occlusal relationships.
3. It may preserve a natural proximal contact.
Preparation:
1.
2.

The occlusal and gingival walls should be perpendicular to the long axis of the tooth.
Two retentive grooves could be placed along the occluso-axial and gingivo-axial line angles if
retention is required for non-bonded restoration.
Restoration:
This could be done using amalgam, resin composite or glass-ionomer and its modifications.
Tunnel preparation:

30

This type of preparation is also termed internal fossa, internal oblique preparation, internal occlusal
diagonal preparation or simply internal preparation.
The tunnel approach for proximal lesion preparation allows preservation of the marginal ridge without
undermining it.
-Air-abrasion can perform such a design.
Disadvantages:
1. Pulp Exposure risk
2. Extension of carious tissues which is different to be seen.
3. Residual carious can be left leading to recurrence & failure of restoration.
4. The solubility of the glass ionomer is inevitable even with the enhanced physical properties.
"Partial tunnel"
This preparation when this proximal enamel is left intact as it's neither carious nor cavitated but left
supported by sound dentin.
Restoration:
Closed sandwich technique
"Total tunnel"
This occurs when enamel has been perforated by the carious lesion and removed during the preparation.
Restoration:
Open sandwich technique

Preventive resin restorations (PRR:)

Features:
1.
2.
3.
4.

No special retentive areas.

No extension into sound pits or fissures.
It's not necessary to prepare beyond the lesion.
When caries is limited to enamel, there's no need to prepare into dentin as is necessary for
amalgam restoration.
5.
Small cavities could be restored with a flowable composite as a fissure sealant but it is
recommended to use filled wear-resistant composites followed by fissure sealants to seal the adjacent
fissures.
Atraumatic restorative treatment (ART):
It involves the removal of carious lesions by hand instruments such as spoon excavators, followed by
restoring the cavities with glass ionomer material, but other adhesive restorative materials would also be
feasible. Advantages:
It allows restorative treatments in locations with no electricity and without the aid of sophisticated dental
equipments.

31

Everyone can apply the biological model

through
Caries Management by Risk Assessment
(CAMBRA)
(Jenson et al. 2007)
Jenson et al. in 2007 provided a practical clinical guide for managing dental caries based upon risk group
assessment. It is based upon the best evidence at this time and can be used in planning effective caries
management for any patient.
CAMBRA consists of two parts:
Part 1: Caries disease management.
It includes both therapeutic treatments according to the CAMBRA protocol.
Part 2: Caries lesion management.
The decision to manage an existing carious lesion by chemotherapeutic means or by surgical means
may at times be influenced by the site or location, the depth or the extent of lesion, and the activity status
of the lesion.
Although surgical repair of cavitated carious lesions may not alter the disease risk level of a patient, it
does remove niches that harbour caries-causing bacteria and, of course, restores the function of the tooth.

32

Nanotechnology
What is Nanotechnology?
In its most basic form, nanotechnology refers to the manipulation of materials at the atomic or molecular
level.
The name derives from the nanometer, a scientific measurement unit representing a billionth of a meter,
or three to four toms wide.
Scientists are learning how to connect atoms and molecules together to create nano-scale mechanisms
that create switches or transistors, or even small machines that can perform complex tasks.
Nanotechnology gives scientists the ability to create new materials, atom by atom.
Most discussions about nanotechnology deal with the futuristic concept of nanomachines or nanobots:
microscopic devices that can themselves carry out tasks at the atomic or sub-atomic level.
The goal of nanotechnology is to be able to manipulate materials at the atomic level to build the smallest
possible electromechanical devices, given the physical limitations of matter.
Nanorobot
Nanorobot is a computer-controlled robotic device constructed of nanometer-scale components to
molecular precision, usually microscopic in size (often abbreviated as "nanobot"),
Nanodentistry:
Nanodentistry will make possible the maintenance of near-perfect oral health through the use of
nanomaterials, biotechnology including tissue engineering and nanorobotics
Uses of Nanodentisty:
1. Local anaesthesia
2. Hypersensitivity cure
3. Nanorobotic dentifrice [dentifrobots]
4. Dental durability and cosmetics
5. Orthodontic treatment
6. Diagnosis of oral cancer
7. Treatment of oral cancer
Products of Nanodentistry:
1. Nanocomposites
The nanofillers used include an alumino silicate powder having a mean particle size of 80 ran and a 1:4 M
ratio of alumina to silica and a refractive index of 1.508.
Advantages
Superior hardness
Superior flexural strength, modulus of elasticity and translucency
50% reduction in filling shrinkage
Excellent handling properties
Trade name: Filtek-Supreme Universal Restorative
33

2. Nanoionomers
3. Nanosolution
Nanosolutions produce unique and dispersible nanoparticles, which can be used in bonding agents.
Trade name: Adper O Single Bond Plus Adhesive Single Bond
4. Impression materials
The material has better flow, improved hydrophilic properties and enhanced detail precision.
Trade name: Nanotech Elite H-D
5. Nanoneedles
Suture needles incorporating nano-sized stainless steel crystals have been developed.
Nanotweezers are also under development which will make cell-surgery possible in the near future.
6. Bone replacement materials
Hydroxyapatite nanoparticles used to treat bone defects.
7. Nanogold
8. G-Coat Plus
9. Nanoceramics

Conclusion
Technology is still going on, the future perspectives in restorative dentistry is very
promising. Thanks to the recent advancements which have introduced a true
revolution in the field of operative dentistry which has enable the dental clinicians
to perform better and to present high quality service for their patients.

34

References

Ali Riza CETIN and Nimet UNLU, One-year clinical evaluation of direct
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