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

Authoritative and comprehensive resource on the disease process and clinical management of dental caries. Dental Caries: The Disease and Its Clinical Management, 4th Edition maintains the same focus on high-level coverage of the disease etiology and process, clinical assessment and prognosis and wider public health issues connected with dental caries management, including an enhanced focus on caries control. Fully updated throughout, the chapters that discuss theory emphasize how the knowledge can be applied in both the clinic and in the public health domain to improve oral health. The new edition also includes up-to-date and validated diagnostic and management options for caries whilst ensuring that the tools provided allow practitioners to serve the needs of different socio-economic populations. All sections are complimented by high-quality color photographs, clear line drawings and references for further study. With contributions from international experts in research and clinical practice, Dental Caries includes information on: Acquisition and establishment of the oral microbiome, metabolism of the microbiome in caries, and the essential role of saliva for dental caries and erosionInitiation and progression of dental caries in dental hard tissues and the relationship between sugar, diets, and dental cariesThe caries control concept and consequences for minimally invasive management of cariesCaries control in children, adults, and the elderly, including root surface caries and oral health care in the elderlyImplication of caries control for the dental profession, including best practices for assessment of lesion activity, prognosis and risk for developing dental caries Dental Caries, Fourth Edition is an unrivaled guide to tooth decay, and a must-have resource for undergraduate and postgraduate students in dental public health, paediatric and restorative dentistry as well as all practitioners looking to develop their clinical skills.