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Dental caries is a multifactorial microbial disease that affects tooth hard tissue leading to destruction of its mineral and organic components. The current work reviewed the development of caries assessment methods and excavation concepts in the past two centuries. In the late ninetieth century, G.V. Black introduced a classification of dental caries, as well as established the principals of tooth preparation, based on his understanding of the nature of the disease. However, due to the great development of dental materials and caries detection methods, most of Black’s principals are no longer valid nowadays. In light of the minimal invasive philosophy, several new caries excavation concepts were introduced. These concepts converts ‘old’ Black’s caries excavation concept of “extension for prevention” to “prevention of extension”. Since 2000 the concepts of caries excavation have greatly changed due to the popularity of the ‘partial caries removal’ concept. As an example of this new ‘conservative’ vision, the “Fédération Dentaire Internationale” (FDI) (World Dental Federation) approved the atraumatic restorative technique (ART) as one of the caries excavation methods in 2002.
Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015) Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts. Int J Dentistry
Oral Sci. 2(8), 120-125. 120
International Journal of Dentistry and Oral Science (IJDOS)
ISSN: 2377-8075
Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts
Review Article
Hamdi H. Hamama1*, Cynthia K.Yiu2, Michael F. Burrow3
1 Clinical Assistant Professor, Aesthetic and Restorative Dentistry Department, Faculty of Dentistry, Mansoura University, Egypt.
2 Clinical Professor, Paediatric Dentistry and Orthodontics Department, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
3 Professor and Chair of Biomaterials, Melbourne Dental School, Australia.
*Corresponding Author:
Dr. Hamdi Hosni Hamdan Hamama,
Clinical Assistant Professor, Aesthetic and Restorative Dentistry Depart-
ment, Faculty of Dentistry, Mansoura University, Po (box) 35516, Egypt.
Tel: +201145177662
Received: June 24, 2015
Accepted: July 29, 2015
Published: August 03, 2015
Citation: Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015)
Caries Management: A Journey between Black’s principals and Minimally
Invasive Concepts. Int J Dentistry Oral Sci. 2(8), 120-125.
Copyright: Hamdi H. Hamama© 2015. This is an open-access article
distributed under the terms of the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution and reproduction in
any medium, provided the original author and source are credited.
Dental Caries
Caries is from the Latin word that means “rottenness”. Dental
caries is dened as “an infectious microbiological disease of the
teeth that results in localized dissolution and destruction of the
calcied tissue” [1]. In the early nineteenth century, many the-
ories were developed to explain the aetiology of dental caries;
the psychic condition theory (Ancient Greeks), dental gangrene
theory (Bell,1825), fungi theory (Leber and Rottenstein, 1867),
and chemical theory (Magitot, 1878). However, most of them
were rejected [2]. In 1932, Williams [2] isolated the bacterial lms
which covered the carious enamel and he referred to it as “bacte-
rial plaque”. He assumed that caries was initiated by the fermenta-
tion of organic materials, which were present inside these lms
[2]. Williams ndings introduced the most plausible explanation
of the occurrence of dental caries, which is known as the “dental
plaque theory”. This theory correlated the occurrence of dental
caries with the presence of dental plaque [1].
Dental plaque(biolm) is dened as “a soft thin lm of food de-
bris, mucin and epithelial cells that adheres to the tooth surface,
providing the medium for the growth of various bacterial spe-
cies” [1]. However, the presence of dental plaque alone doesnot
cause dental caries. This has led to a new modication of the
dental plaque theory, which is now known as the “Specic dental
plaque hypothesis” [3]. This theory considers dental plaque as an
etiological factor for dental caries when pathogenic bacteria are
also present.
The term “cariogenic bacteria” refers to certain pathogenic mi-
croorganisms, which have the ability to ferment the carbohydrates
and produce acids as a by-product [1]. Those acids can dissolve
dental hard tissues; while the accumulated plaque layers act as an
insulator protecting the pathogenic organisms from the buffer-
ing, antibacterial and washing actions of saliva [1]. Much evidence
supports the specic dental plaque hypothesis; for example the
absence of dental caries in un-erupted and germ-free animal’s
teeth [1]. Furthermore, many studies reported the presence of
cariogenic bacteria within oral biolms, which covered active cari-
ous lesions.
The cariogenic microorganisms within oral biolms
The cariogenic bacterial species within the dental plaque are
mainly streptococci, Lactobacilli and Actinomyces. The Streptococci spe-
Dental caries is a multifactorial microbial disease that affects tooth hard tissue leading to destruction of its mineral and
organic components. The current work reviewed the development of caries assessment methods and excavation concepts
in the past two centuries. In the late ninetieth century, G.V. Black introduced a classication of dental caries, as well as
established the principals of tooth preparation, based on his understanding of the nature of the disease. However, due
to the great development of dental materials and caries detection methods, most of Black’s principals are no longer valid
nowadays. In light of the minimal invasive philosophy, several new caries excavation concepts were introduced. These con-
cepts converts ‘old’ Black’s caries excavation concept of “extension for prevention” to “prevention of extension”. Since
2000 the concepts of caries excavation have greatly changed due to the popularity of the ‘partial caries removal’ concept.
As an example of this new ‘conservative’ vision, the “Fédération Dentaire Internationale” (FDI) (World Dental Federation)
approved the atraumatic restorative technique (ART) as one of the caries excavation methods in 2002.
Keywords: Caries; Extension For Prevention; Caries Excavation; Minimally Invasive Technique; Atraumatic Restorative
Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015) Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts. Int J Dentistry
Oral Sci. 2(8), 120-125. 121
cies are S.mutans, S. circetus, S. rattus, S. ferus, S. sanguis and S. sobri-
nus [4]. The cariogenic lactobacilli species are L. casei, L. acidophilus,
L. plantarum, and L. salivarius. The Actinomyces group includes A.
naeslundii, A. viscosus, A. israelii, A. meyeri, and A. odontolyticus [4].
In spite of the capability of Actinomyces to produce acids, they are
considered as a bi-functional microorganism due to its great role
in the maturation of dental plaque.
Pathogenesis of dental caries
An organic 10µm thick, cell-free, lm called “acquired enamel
pellicle” mainly consisting of salivary proteins adsorbs to newly
erupted or recently cleaned tooth surfaces [1, 5]. One hour later,
specic highly adherent bacteria (streptococcus sanguis, Actinomyces
naeslundii, and Actinomyces viscosus) invade the pellicle [1, 5]. Then,
the Actinomyces starts to mature and help other poorly adhesive
bacteria to colonize and accumulate within the successive biolm
layers. Due to a lack of oxygen in deep biolm layers, bacteria
start to metabolize carbohydrates through the glycolytic pathways
producing lactic acid as a by-product, which consequently de-
creases the pH level within the biolm. When the pH drops below
the critical level, the tooth starts to demineralize to buffer the high
acidic environment by losing its calcium and phosphate ions [1].
This process is considered as the trigger point of the destruction
and dissolution of dental hard tissues. This procedure is initiated
in the enamel and when left without treatment, it may lead to
complete loss of the enamel matrix. Accordingly, dentine will be
directly exposed to the action of bacterial enzymes [13]. Unlike
enamel, the acidity of the biolms can easily demineralize calcium
from dentine, which leads to exposure of the collagen framework
to the proteolytic enzymes produced by the bacteria [13]. How-
ever, the immediate destruction of the tissue does not occur in
dentine compared to that in enamel lesions [6]. The persistence
of the cariogenic factors for a long time will result in permanent
damage of the collagen bres (denatured collagen) [13]. In these
circumstances, when the aetiological factors are eradicated and
a favorable environment of remineralization is maintained, the
softened dentine could be preserved and remineralization of par-
tially-demineralized collagen can take place [5-8].
Histopathology of dentine caries
Successful treatment of dentine caries depends on a good un-
derstanding of the nature of the lesion. The histological features
are associated with the progression rate of the lesion; slow, mod-
erate and rapidly progressing caries. Slowly progressing carious
lesions are characterized by continuous demineralization and
remineralization cycles, which results in deposition of “whitlock-
ite”1* crystals into dentinal tubule lumens until they become fully
obliterated leading to “sclerotic dentine” [5, 9]. While in the mod-
erately progressing carious lesions, odontoblasts undergo a fatty
degeneration process, which leads to characteristic histological
phenomenon named as “dead tracts” (empty dentinal tubules) [5].
Furthermore, in active carious sites (rapidly progressing), the pulp
responds to the external stimulus and starts to lay down a reactive
type of dentine referred to as “reparative dentine”.
Histologically, dentine caries consists of ve zones; normal, the
sub-transparent, transparent, the turbid and infected dentine
zones respectively [1]. The “normal” zone is the deepest layer
of the lesion, in which, the dentinal tubules are un-altered with
no crystal formation or bacteria present in the lumen. The next
zone is the subtransparent layer, which is characterized by demin-
eralization of the intertubular dentine, deposition of ne crystals
“whitlockite” in the tubule lumen and absence of bacteria inside
the tubules. The next zone is the transparent dentine, which is
similar to the sub-transparent dentine, but the dentinal tubule lu-
men contains large crystals due to excess demineralization of the
intertubular dentine, however, there is no destruction of the colla-
gen bres, and no bacterial penetration. Following the transparent
layer is the turbid layer, which shows dentinal tubule destruction,
denaturation of collagen bres and marked bacterial inltration.
The most supercial zone is the infected dentine, which is charac-
terized by complete decomposition of the dentine (complete ab-
sence of mineral and collagen content) with signicant bacterial
inltration. These features of dentine caries introduced two im-
portant terms used in restorative dentistry, namely, “caries-infect-
ed” and “caries-affected” dentine [6]. The “caries-affected” (inner
carious) dentine is the demineralized dentine that is not invaded
by bacteria and includes sub-transparent, transparent and turbid
dentine zones [1, 6]. The bacterially invaded dentine is called
“caries-infected” (outer carious) dentine which includes the in-
fected dentine zone and a very small area of the turbid zone [1, 6].
Fusayama [6] reported that one of the main differences between
the two layers of dentine caries is the collagen structure; collagen
in the caries-infected dentine zone is characterized by irrevers-
ible destruction of cross-linking sites. Also, the cross-banding
structure of collagen is well-maintained in caries-affected dentine
regions, in comparison with caries-infected dentine regions [6].
Caries-disclosing dyes and its relevance to Fusayama’s his-
tological ndings
The clinical differentiation between “caries-affected” and “caries-
infected” dentine is one of the most difcult challenges encoun-
tered clinically [6, 10]. Conventional means of detection are based
on visual and the tactile sensation;[1] however, these methods are
subjective and variable amongst practitioners. In 1983, an attempt
was made to differentiate between the two layers of dentine caries
using a chemical dye named as “caries-disclosing dye” or “caries
detector”. This was theoretically based on the histological features
of dentine caries observed by Fusayama [6, 11].
Caries-disclosing dyes were introduced to overcome the draw-
backs of visual and tactile methods. Kuboki et al. [11] reported
that caries-disclosing dyes could only stain the denaturated col-
lagen bres; however, the dyes could not stain either sound den-
tine powder or demineralized intact collagen. The rst caries-dis-
closing dye consisted of 0.5% basic fuchsin in a propylene glycol
base [12, 13]. Radiographic examination and laboratory study out-
comes showed that this formula was not efcient in differentiat-
ing both dentine-caries layers [14]. Due to the carcinogenicity of
fuchsin (magenta), a new generation of caries detectors was intro-
duced [6, 15, 16]. The replacement of fuchsin by 1% acid-red in a
propylene glycol base was the most characteristic feature of these
newer caries detector dyes [17]. However, some authors showed
disagreement with the efciency of this type of caries-disclosing
dye, and reported that it can give false positive results [13, 18, 19].
This consequently led to over cutting of healthy dental tissues
(over preparation) [13, 18, 19]. To solve this dilemma, some au-
1. Whitlockite is a transformed crystalline form of calcium phosphate, characterized by lower calcication and hardness than normal hydroxyapatite crystals.
Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015) Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts. Int J Dentistry
Oral Sci. 2(8), 120-125. 122
thors recommended leaving the lightly-stained (pale pink) tissues,
because this represents the caries-affected dentine [13, 20]. More-
over, these false positive results may be attributed to the use of
low molecular weight propylene glycol (76 MW) [21]. Therefore,
in the next generation, the propylene glycol (76 MW) was replaced
by a high molecular weight poly-propylene glycol (300MW) base
[13, 21]. Later on, two studies [21, 22] compared laser oures-
cence recording from the DIAGNOdent (KaVo, Bibberach, Ger-
many) of residual dentine following caries removal guided with
both propylene glycol-based dyes and they concluded that the
poly-propylene glycol-based dye is much more conservative of
tooth structure than the original low molecular weight propylene
glycol dye.
Classications of dental caries based on the histologic fea-
tures of carious tissues and in light of the minimally inva-
sive philosophy
Mount classication:
In the early twentieth century, G.V Black
established the conventional classication of dental caries lesions,
based on the most common carious lesion sites and the available
restorative materials [23]. In 1998, Mount [24] introduced a new
classication based on the recent minimally invasive concepts
and contemporary restorative techniques. Mount demonstrated
that any carious lesion can be identied by using two parameters;
the affected site and stage (size) of the lesion [24, 25]. Based on
Mount’s classication, caries can affect the following sites, site 1;
pits, ssures and enamel defects on the exposed enamel surface
of all teeth, site 2; approximal enamel surfaces immediately cervi-
cal to the contact areas, site 3; the cervical one-third of the crown
or the exposed roots [25]. Each of the previously mentioned
sites can be further classied based on the size of the lesion into
5 stages; stage 0, incipient lesions, which can be treated by the
medical model of treatment (remineralization), stage 1, minimal
cavities involving the dentine just beyond the level of treatment
by the remineralization methods alone, stage 2, moderate cavi-
ties involving dentine, while the remaining surrounding enamel is
sound, well supported and not likely to fail under normal occlusal
load, stage 3, is an enlarged cavity beyond the moderate one and
the remaining tooth structure is likely to fail under occlusal func-
tion, stage 4, is an extensive cavity with bulk loss of tooth struc-
ture [25]. Although Mount’s classication is based on the recent
minimally invasive concepts, it has not been widely adopted be-
cause it seems to be more descriptive and the boundaries between
the stages are not clearly elaborated.
International Caries Detection and Assessment System (IC-
A new set of standardized clinical visual criteria for detec-
tion of carious lesions, referred to as International Caries Detec-
tion and Assessment System (ICDAS), was introduced in 2003
[26]. The rationale of the ICDAS system was to create a stand-
ardized caries detection system following the World Health Or-
ganization (WHO) guidelines and based on the most up-to-date
Caries Research studies [26]. The main objective of this system
was to unify the measuring criteria of caries activity among epide-
miological and clinical studies [26]. Also, it was designed to detect
caries on both enamel and dentine surfaces, as well as, coronal and
root surfaces [26].
The ICDAS system was introduced in 2003, and modied in
2005, at the ICDAS workshop in Baltimoreto ICDAS-II [27, 28].
The full code two-digit system is commonly used in the epidemio-
logical studies. The rst digit identies the restorative status of
the tooth; unrestored, restored or sealed; while, the second digit
describes the severity of the lesion (cavitated or non-cavitated)
and its activity (arrested or active) [35]. It has been recommended
to use a ball-end explorer for diagnosis of carious lesions, to avoid
damage of the incipient caries regions [27]. Although the original
ICDAS-II system consists of 6 codes, Ricketts et al. [29] have sug-
gested to reduce them to 4, based on the histological ndings of
Ekstrand et al. [30] and Lussi et al., [31] for simplifying the clinical
use of the system. According to the most updated ICDAS-II cri-
teria [32], caries can be classied into three stages; early-detected
(scores 1 and 2), established (scores 3 and 4) and severe (scores 5
and 6), and these stages are referred to as ICDAS’s International
Caries Classication and Management System (ICCMS).
Caries Excavation Concepts
Extension for prevention
Caries excavation concepts were established at the end of the
nineteenth century. The rst published work was by Webb [33]
in 1883, who mentioned in his textbook that “every cavity must
be so prepared that no decalcied tissue remains, except where
there be a little discolored dentine near the pulp, and that should
be left for its protection”. Webb supported the extension of the
preparation into the contact-free “self-cleansing” areas to avoid
the accumulation of food, especially on the proximal surface and
he called this process “prevention of extension of decay” [33]. In
1891, Black [34] introduced the term “extension for prevention”,
and then he described it in his following publications as: “In no
case should any decayed and softened material be left. It is better
to expose the pulp of the tooth than leave it covered only with
softened dentine” [2, 35]. Although, extension for prevention was
a widely accepted concept at this period [36-38], some authors
raised many arguments about it, seeking more conservation of
the tooth structure to achieve better aesthetics by reducing the
display of metallic restorations [39, 40].
Extension for retention
As a result of the inferior mechanical properties of the metallic
restorative materials used during this period, the “extension for
retention” concept was introduced by Slagle [41]. This concept
focused more on the “anchorage” or retention of the restora-
tive material inside the prepared cavities after careful evaluation
of occlusal forces. Also, this concept introduced some secondary
features to cavity preparation for increasing the retention of the
restorative materials (e.g. grooves, locks and coves). Most of these
concepts were acceptable during the last century; however, in the
last two decades, most concepts have been modied due to the
success of aesthetic restorations and the revolution of adhesive
Minimally invasive concept “Prevention of extension”
A new conservative philosophy called “minimally invasive den-
tistry” (MID) is more acceptable nowadays. The main purpose
of MID is to achieve as much conservation of dental tissue as
possible. MID includes early detection of dental caries, assess-
ment and management of caries-risk, remineralization of early
caries lesions, only restoring cavitated lesions, restriction of the
excavation to the caries-infected areas and using adhesive-based
technologies [42, 43].
Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015) Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts. Int J Dentistry
Oral Sci. 2(8), 120-125. 123
Nowadays, cavity preparation should no longer follow the con-
ventional outline that G.V. Black rst introduced or it many other
variations. Instead, it should follow the extent of a carious le-
sion and only eliminate caries-infected tissue with the preserva-
tion of both caries-affected and sound tissues [44]. Moreover,
signicant improvement of amalgam alloys and introduction of
bonded amalgam restorations have modied the cavity prepara-
tion for amalgam to be more conservative of tooth structure [45].
Also, introduction of conservative cavity designs; such as slot
and tunnel preparations, are one of the characteristic features of
MID [46]. Furthermore, retentive features changed from macro-
mechanical to micro-mechanical (resin adhesives) and chemical
(e.g. resin-modied glass ionomer adhesives) retention [44, 47].
However, toileting of cavities has not changed a lot from Black’s
principals, some chemical agents (e.g. 2% chlorhexidine digluco-
nate) are highly recommended because of its antibacterial effects
and the possibility to increase the durability of the bond between
resin adhesives and tooth structure [48]. Black’s convenience form
principle is still useful; however, the advances in diagnosis, use of
magnication and cavity preparation instrumentation, allow easy
access for excavation of infected tissue with maximum preserva-
tion of the sound tooth tissue [44]. Finally, MID converts Black’s
concept from “extension for prevention” to “prevention of ex-
tension” [44, 49].
Stepwise caries excavation
The stepwise excavation technique is a method used in removal
of caries-infected tissue in deep cavities of asymptomatic vital
teeth [5]. In this technique, the caries excavation is performed in
two stages with a time lag period [5]. In the rst stage, the soft
caries should be removed leaving the deepest “rm” layer of car-
ies-infected tissue, which will be covered with a cavity lining and
interim lling restorative material [50]. After a certain period of
time, “4-12 months” [51], the cavities are re-entered to excavate
the residual carious tissue [50]. The rationale of using stepwise
excavation is to stop the acute phase of the lesion, reduce the irri-
tation of pulp tissue and giving it the chance for the formation of
reparative dentine [5, 50]. Therefore, using this excavation tech-
nique, most likely, reduces the risk of accidental pulp injuries [50].
In 1938, Bodecker [52] was the rst author who described the
stepwise excavation technique and his histological ndings
showed the formation of reparative dentine after indirect pulp
capping with a temporary lling consisting of zinc-oxide-eugenol
lining mixed with “Vialidol-comphorata” and gutta-percha-based
material. Many agents have been used in indirect pulp capping
such as; zinc-oxide-eugenol [53], calcium hydroxide [54, 55], and
mineral trioxide aggregate (MTA) [56]. Several randomized con-
trolled clinical trials showed that using stepwise excavation re-
duced the chance of pulp exposure during the re-entry phase of
treatment [50, 57, 58]. Despite the type of lining, several studies
showed that the most important factor of success is to create
well-sealed temporary restorations [51, 59-61].
Concept of partial caries removal
In 2000, an argument was raised about the benets of “re-open-
ing” of cavities after the rst stage of stepwise excavation and
this argument was published under the theme “Dentine caries:
Take it or leave it?” [62]. Accordingly, Banerjee and coworkers
introduced a new concept of leaving portions of caries-infected
dentine after excavation, particularly in deep carious lesions as
means to reduce the incidence of accidental pulpinjuries [62-64].
This concept states that: “any grossly softened caries-infected-
dentine must be excavated, nevertheless, in deep carious lesions
where the inner most layer of dentine, which directly covers the
pulp, contains a high concentration of bacteria” provided to cre-
ate well-sealed restorations [63, 65]. Banerjee assumed that the
remaining portion of a carious lesion is the most supercial layer
of “caries-affected” dentine, which can contain some bacteria and
partially denatured collagen bres [74]. This assumption was in
agreement with Fusayama’s conclusions, who stated that the clini-
cal differentiation between caries-affected and -infected dentine
is very difcult to distinguish [6]. Several microbiological stud-
ies showed that good sealing of cavities reduces the nutritional
supply to the residual bacteria following caries excavation [66-70].
Also, the outcomes of several studies [71-73] (evaluated stepwise
excavation) showed that the hardness of the residual dentine
had increased during there-entry phase of the treatment, com-
pared to the rst stage, which supports Banerjee’s “partial caries
removal (PCR)”philosophy. A recent clinical trial by Maltz et al.
[70] showed that the mean survival rate of restorations following
PCR (91%) was signicantly higher than the rate after stepwise
excavation (69%)(p < 0.05). Hence, the results of this trial were in
total agreement with the PCR concept and the authors have sug-
gested to avoid re-opening of cavities for maximum preservation
of pulp vitality.
Atraumatic restorative treatment
Atraumatic restorative treatment (ART) is an example of the 1-step
partial caries excavation technique. The rst pilot ART study was
performed in the rural areas of Tanzania (due to lack of electric-
ity, which is required for operating complicated dental equipment)
and the study was presented at the Tanzanian dental association
meeting in 1986 [5]. Later on, similar trials were performed in
China, Vietnam, South Africa, Mexico, Ecuador and Brazil [5].
Although, ART was introduced earlier (1986) than the PCR con-
cept, it was approved as one of the caries excavation methods
from “Fédération Dentaire Internationale” (FDI) (World Dental
Federation) in 2002, due to the popularity of the PCR concept at
that time [5]. The ART restorative protocol includes the following
steps: (i) slightly widening of the access opening of small cavities
using specially designed pyramidal-shaped hand instruments (to
improve the accessibility to the carious lesion), (ii) excavation of
grossly softened caries-infected dentine using a hand excavator,
(iii) caries removal is veried by tactile sensation method using a
ball-end explorer, then (iv) cavities are cleaned with chlorhexidine
cleaners and restored with high viscosity glass ionomer restorative
materials [5]. The outcomes of several long-term follow-up clini-
cal studies (2-6 years) revealed that restorations following ART,
showed satisfactory survival rates in both primary (67-94%) [74-
77] and permanent (81-96%)[78-81] molars.
Conclusion and Clinical Signicance
Conservation of dental hard tissues has become the milestone
for any recent caries excavation technique. Furthermore, leaving
the caries-infected dentine in some critical regions of the cavity is
now regarded as acceptable by many, nowadays, provided that cre-
ation of a proper marginal seal can be achieved and maintained.
Hamdi H. Hamama, Cynthia K.Yiu, Michael F. Burrow (2015) Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts. Int J Dentistry
Oral Sci. 2(8), 120-125. 124
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... The interaction of environmental, behavioral, and host factors lead to the development of this complex disease. It causes the organic portion of the tooth's structure to be destroyed and its inorganic component to become demineralized [1]. ...
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Carisolv is the only NaOCl-based chemical-mechanical caries removal product that is currently available on the market with a pH 11. Participants in the study who had primary caries lesions on their teeth were divided into two groups. The experimental group received chemical-mechanical treatment with Carisolv® gel (N=54) whereas the control group received traditional treatment model- by drilling and excavation (N=47). Children who were participating in the study had at least two primary caries lesions in the same group of teeth and were being treated by a pediatric dentist at a specialty dental clinic. Children with two or more identical caries lesions in the same set of teeth took part in this study. Using Carisolv® gel on one of the selected teeth (the experimental tooth), while drilling and excavating the other tooth as usual, both the experimental and control teeth were placed on the left side of the jaw. It was successful in getting the parents of the children to agree to have them participate in the study. Using Carisolv® gel, we conducted a clinical comparison of the traditional and chemical-mechanical approaches in this study. The aim of this research was to compare a chemical-mechanical approach of caries removal with rotary instruments for children's deciduous and permanent teeth using Carisolv® gel and determine whether anesthesia is required.
... It is a complex illness brought on by the interaction of host, environmental, and behavioral variables. It results in the decalcification of the tooth's inorganic components and the destruction of its organic components [1]. ...
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Background: Chemomechanical caries removal (CMCR) is a noninvasive procedure that uses a chemical substance to remove the diseased dentin. The natural dental architecture is also preserved using this technique, preventing patient discomfort and pulp irritation. This method of eliminating caries is based on disintegration. This method removes soft carious dentin using chemical agents and non-traumatic mechanical force. This study was carried out to evaluate the clinical and microbiological evaluation of the chemomechanical caries removal agents in primary molars. Methods: For the elimination of caries, teeth in category I (polymer bur category) were treated with Smartburs II® (SS White Dental, Lakewood, New Jersey, United States) (n = 40). Teeth treated with the new Carisolv® technology (Mediteam, Sweden) to remove caries (n = 40). Teeth were treated for removal cavities in category III (conventional group) using excavators and carbon steel low-speed round burs from Dentsply Maillefer in Switzerland (n = 40). There was an evaluation of the efficacy of caries removal, the time required for caries removal, patient satisfaction, and microbial culture assessment. Results: In comparison to the other two categories, the conventional category median caries detector dye values were considerably lower (p value<0.05). There was no substantial difference observed between study participants belonging to category I and category II with a p-value greater than 0.05. Time taken during the removal of caries was substantially greater in category I (455.46±73.7) as compared to category II (129.21±44.18) and the traditional category (113.26±37.7). The value of significance was less than 0.05. Contrarily, no discernible difference was observed between category I and category III (the p-value was greater than 0.05). In comparison to the other two categories, the conventional group's median facial expression scale scores were substantially higher (p = 0.02). In comparison, there was no discernible difference between categories I and II (p = 0.65). It was observed that there was no substantial variation in three categories regarding the number of colonies of bacteria prior to the eradication of caries (p-value greater than 0.05). After caries had been removed, the number of living bacterial colonies in category I was noticeably greater than those in the other two categories. However, there was no discernible variation between category II and category 1 (p-value greater than 0.05). Conclusion: The mechanical approach has the highest clinical efficacy for removing caries. Carisolv required the most time to remove cavities. Patient satisfaction levels were greater with Carisolv than with the mechanical approach. It was also observed that Carisolv as well as the mechanical technique had greater antibacterial effectiveness.
... Compared with the traditional method, a more irregular surface is obtained after chemo-mechanical caries removal. Hamama et al. 40 reported that the remaining dentin layer was the main difference between Papacarie and rotary instruments. In this layer, the mineral density is lower than that of intact dentin, but higher than that of infected dentin. ...
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Purpose: The purpose of this study was to evaluate dentin mineral density before and after caries removal with the traditional caries removal technique and chemo-mechanical method, with or without the use of caries detection dye. Our null hypothesis was that the chemo-mechanical method with minimally invasive treatment would achieve an effect similar to that of conservative pediatric dentistry treatment. Materials & Methods: Forty-eight medium-sized, interfacial decayed primary molar teeth without pulpal perforation were selected. Two groups were formed by Papacarie Duo and conventional method; then four subgroups were formed by two caries detection dye applied or not applied groups, twelve teeth were randomly divided into each group. The teeth were then treated with chemo mechanical and traditional caries removal approach. Teeth were scanned with the same voxel sizes using micro-computed tomography images to figure out the difference dentin mineral density and to calculate the removed dentinal volume after chemo-mechanical or traditional method application. Results: The results showed increase of cavity volume in the chemo-mechanical and traditional method groups. No significant difference was found for cavity volume and dentinal carious volume in both groups (p>0.05). The mineral density values of demineralized dentin were between 0.52-0.66 g/cm 3 before caries removal, and 1.39-1.59 g/cm 3 after removing caries. These values were found to be within the range of healthy dentin mineral density values again without any significant difference between groups (p>0.05). Conclusion: In conclusion, chemo-mechanical methods can be used effectively for removing the caries in the primary molar teeth similar to conservative treatments.
... It results in demineralization of inorganic part and destruction of organic part of the tooth structure. 1 Usually, dentinal caries consists of two distinct successive layers, which are different in their clinical features as well as their chemical and microscopic structures. The outer layer (infected dentin) shows the distortion of the microstructure of dentinal tubules, irreversible degradation of collagen fibers, and significant bacterial penetration. ...
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Aim and objective: To assess the efficacy of the new Carisolv system and Polymer bur (SmartbursII®) for selective caries removal in primary molars clinically and microbiologically, compared with the conventional mechanical method. Materials and methods: Sixty children with class I active carious lesions were selected. The children were randomly allocated to three groups (n = 20) according to the caries removal method. Under rubber dam isolation, dentin samples were taken before and after caries removal for microbial culture. Time spent in each technique was recorded. The clinical efficacy of caries removal was verified using caries detector dye. Patient satisfaction toward the treatment was evaluated using a facial image scale. Results: The median of caries detector dye scores was significantly lower in the conventional group compared to others (p value < 0.05). The mean time for caries removal was the longest with Carisolv (p value < 0.05). The median of facial image scale scores was significantly higher in the conventional group compared with others (p value < 0.05). The mean total viable bacterial count after caries removal was significantly higher in polymer bur group compared with others (p value < 0.05). While, there was no significant difference between Carisolv and conventional groups (p value > 0.05). Conclusion: The clinical efficacy of caries removal was highest with the mechanical method. Carisolv took the longest time for caries removal. Patient satisfaction was higher with Carisolv and polymer bur than the mechanical method. The antimicrobial efficacy of Carisolv and the mechanical method was higher than the polymer bur. Clinical significance: Carisolv is a viable alternative to the mechanical method in the management of dental caries, especially in children. Further studies are needed to assess the efficacy of caries removal by SmartbursII®. How to cite this article: Asal MA, Abdellatif AM, Hammouda HE. Clinical and Microbiological Assessment of Carisolv and Polymer Bur for Selective Caries Removal in Primary Molars. Int J Clin Pediatr Dent 2021;14(3):357-363.
... Організація комплексної прогностичної моделі ефективності використання мінімально інвазивних методів лікування карієсу з урахуванням відповідних критеріїв можлива за умов установлення прогностичного впливу ятрогенних і біологічних факторів, рівень яких може бути визначений у процесі відповідного моніторингу за змінами стоматологічного статусу пацієнтів. Сучасні теорії прогнозування розвитку карієсу передбачають аналіз впливу сукупності чинників на ризик виникнення чи прогресування патології, однак досі не встановлено чітких закономірностей щодо прогнозу виникнення ускладнень після лікування карієсу й оцінки рівня ефективності проведеного лікування за використання різних терапевтичних підходів [9][10][11]. При цьому прогноз ефективності лікування за умов реалізації мінімально інвазивного підходу характеризується наявністю не тільки загальноприйнятих предикатів прогресування чи припинення розвитку каріозного процесу, а й специфічних їхніх видів, доцільність включення яких у структуру прогностичної моделі обґрунтована особливостями проведення мінімально інвазивних ятрогенних втручань [12][13][14]. ...
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The research presents a prognostic model of the effectiveness of minimally invasive interventions in the dental patients’ treatment of carious pathology, which was developed to reduce the impact of iatrogenic interventions, increase the results of biological, biomechanical and financial feasibility of treatment. The aim of research is to develop a mathematical representation of a comprehensive prognostic model of the minimally invasive treatment effectiveness of carious pathology. Materials and methods of research. Comprehensive prognostic model of comparative efficiency of minimally invasive implementation of treatment protocols of carious pathology included consideration of relative risk indicators of biological complications (secondary caries and affected tissue pulp), decreased biomechanical forecast of the tooth (based on the performance index IROPZ and IHRKCHZ) and the financial feasibility of these methods, taking into account the ratio of material costs and unit labor intensity of the biological level and biomechanical forecast of the functioning of the dentition unit. Results of the research. The factors were identified during the scientific research; it was provided that the volume of iatrogenic interventions in the dental patients’ treatment of caries can be minimized. The structure of a complex prognostic model of the effectiveness of realization minimally invasive methods of treating caries of hard tooth tissues was developed. A comparative assessment of the biological, biomechanical and financial feasibility of treatment of carious pathology depending on the depth of damage to the hard tissues of the tooth using classical (invasive) and mini-invasive methods of treatment was held. The study showed that the implementation of minimally invasive approaches to the treatment of carious pathology in terms of risk and complications in secondary destructive changes of dental hard tissues and pulp tissue damage contributes to the effectiveness of limited nuclear interventions with controlled enamel reduction and determination of connection of restoration with the bottom of the formed cavity. The highest biomechanical feasibility of minimally invasive dissection protocols has been established in the defects treatment within the enamel in order to minimize unreasonable enamel reduction and dentin tissues, carious cavities treatment at the border of medium-deep types of lesions to limit the caries spreading in the cavities deep localization in order to prevent the development of associated lesions of the pulp complex, which in terms of biological prognosis can provoke the development of irreversible changes. Conclusion. As a result of scientific research and comparative analysis of the effectiveness of caries treatment by mini-invasive methods of intervention, the fact of improving the biological and biomechanical prognosis of the affected units of the dentition compared to the results of treatment of pathological lesions by surgery in accordance with classical protocols, confirming the developed complex prognostic model of efficiency of use of minimally invasive methods of treatment of carious pathology of dental patients. However, the creation of a unified comprehensive forecasting model, which would include the most complete reflection of all these criteria and was at the same time reliable, is impossible. Biological stacking relative risk indicators in the process of secondary development and pulpitis indicate the excess of minimally invasive treatment in all analyzed clinical cases, cases of initial treatment in relation to the risk of pulp production and cases in the center of caries relative to the risk of the previous year.
... Although technical resources destined to oral health care are still mostly directed to the treatment of cavitated dental caries lesions, a contemporary and more conservative approach, based on minimally invasive treatments, has been proposed to preserve diseased, but repairable dental tissue, supported by the remineralization potential of new restorative materials [1][2][3]. ...
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Objectives: To evaluate the potential of conventional glass ionomer cement (GIC), Biodentine™, MTA, and Portland cement to induce mineral density changes in carious dentin compared to zinc oxide eugenol control cement (ZOE). Materials and methods: Fifty blocks of bovine root dentin were prepared and a biofilm model using ATCC strains of S.mutans, S.sobrinus, and L.casei was used to promote artificial dentin lesions. After demineralization, the blocks were randomly divided into the five cement groups. Half of the surface of each specimen received the tested material and the other half was covered with wax (control). Samples were stored in phosphate buffered saline solution for 30 days and after that were scanned in a micro-CT with standardized parameters. Dentin mineral density changes were calculated using differences in plot profiles of the exposed and control carious dentin. Friedman's test, followed by Wilcoxon signed-rank test was used with 5% significance. Results: Mean ΔZ values for the cements were 48.63 ± 19.09 for the control (ZOE), 63.31 ± 32.59 for Biodentine™, 114.63 ± 72.92 for GIC, 109.56 ± 66.28 for MTA, and 106.88 ± 66.02 for Portland cement. All cements showed a statistically significant increase in ΔZ values compared to the control, but Biodentine™ values were statistically significantly lower compared to GIC and the other calcium silicate cements. Conclusions: Tested materials present potential to induce mineral density changes in carious bovine dentin. MTA, Portland, and GIC showed higher bioactivity potential than Biodentine™. Clinical relevance: Based on minimally invasive concept, materials with remineralization potential can be used to preserve diseased but still repairable dental tissue.
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Objective: To determine the prevalence of dental caries among children and young adults with disabilities attending a special needs school in Sokoto, Nigeria. Methods: This study was a descriptive cross-sectional survey among children and young adults with disabilities attending a special needs school in Sokoto, Nigeria. Data collected were the social demographic and dental caries status of the participants. Data were analysed using IBM SPSS Statistics for Windows, Version 23.0. The socio-demographic characteristics, as well as the dental caries prevalence of the participants, were determined using descriptive statistics. The results were presented in frequency tables and charts. A p-value less than 0.05 was considered significant. Results: Prevalence of caries was 35.6%. Participants with hearing impairment had the highest caries prevalence (16.5%, n= 39). The highest caries prevalence per age group was amongst the 20 years and above age group (50.0%), followed by the 6-12year old group (46.2%). The Pearson chi-square test result for prevalence per age group was statistically significant (p= 0.029). Analysis by grade (class) showed a higher prevalence in the primary school section (39.3%) than in the secondary school section. Conclusion: The prevalence of dental caries was 35.6%. It was significantly higher in the hearing and intellectually impaired groups than in their visually and physically impaired counterparts. Also, it was higher among the age group 20 years and above than in other age groups.
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Increased concerns about the safety of amalgam restorations in children have resulted in many dental schools emphasizing the teaching of alternative dental materials. This study investigated the current teaching of different dental materials for use in posterior teeth in the United States predoctoral pediatric dentistry programs. In 2011, the authors invited the chairs of the predoctoral pediatric dentistry departments in all accredited dental schools at that time (N = 57) to participate in an internet‐based survey. Descriptive statistics were calculated to describe the frequency of using different restorative materials. Regression models were developed to explore the factors related to the use of dental restorations in predoctoral pediatric clinics. Among the 44 dental schools that responded (77% response rate), 74% used amalgam, and 93% used composite in primary posterior teeth. Glass ionomer was used by 61% of the schools in primary posterior teeth. Placing amalgam in primary posterior teeth was associated with programs that treated more 3–5‐year‐old patients (β = .302, p < .043), whereas the use of glass ionomer was associated with having students serving at off‐site satellite dental clinics (β = .015, p < .012). In general, having departments with chairs who had positive attitudes towards Minimal Invasive Dentistry (MID) used composite (β = .091, p < .0001) and glass ionomer (β = 103, p < .0001) more frequently and were less likely to use amalgam (β = −.077, p < .005) in primary posterior teeth. Although teaching MID concepts in predoctoral pediatric clinics in dental schools is increasing, the use of amalgam in posterior primary and permanent teeth is still widely practiced.
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Unlabelled: The aim of this study was to evaluate the reproducibility and differences in diagnostic outcomes by practicing dental clinicians previously inexperienced in using the Nyvad criteria and the ICDAS II criteria with the Lesion Activity Assessment system (ICDAS II + LAA). Four volunteer dentists were randomly allocated to one of two groups. Both groups of dentists examined the same voluntary sample (n = 140) of caries active young adults using Nyvad and ICDAS II + LAA criteria in different sequences. The first group used the Nyvad criteria during period 1, followed by ICDAS II + LAA during period 2; the second group did the examinations in the opposite sequence. Before the period 1 and 2 examinations, dentists from both groups were trained with the Nyvad or ICDAS II + LAA criteria, depending on the group to which they were assigned. Intra-examiner agreement for lesion severity was high for both diagnostic instruments (weighted kappa 0.62-0.80). For lesion activity the intra-examiner unweighted kappa values ranged from 0.31 to 0.61 for ICDAS II + LAA and from 0.36 to 0.51 for Nyvad. The mean number of active non-cavitated caries lesions was significantly higher for ICDAS II + LAA (6.14 ± 5.4) than for Nyvad (3.90 ± 3.9) (p < 0.001). Active cavitated/dentinal caries lesions were significantly higher for ICDAS II + LAA (4.14 ± 4.1) than for Nyvad (2.13 ± 3.1) (p < 0.001). Both the Nyvad and ICDAS II + LAA diagnostic criteria showed high reproducibility for lesion severity assessment. The mean number of active caries lesions among high caries risk subjects was significantly higher using the ICDAS II + LAA criteria, which may subsequently lead to more caries treatment. Trial registration: ISRCTN65592532.
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When patients present with cavities causing pain, poor aesthetics and/or functional problems restorations will need to be placed. Minimally invasive caries excavation strategies can be deployed depending on the patient's caries risk, lesion-pulp proximity and vitality, the extent of remaining supra-gingival tooth structure and clinical factors (for example, moisture control, access). Excavation instruments, including burs/handpieces, hand excavators, chemo-mechanical agents and/or air-abrasives limiting caries removal selectively to the more superficial caries-infected dentine and partial removal of caries-affected dentine when required, help create smaller cavities with healthy enamel/dentine margins. Using adhesive restorative materials the operator can, if handling with care, optimise the histological substrate coupled with the applied chemistry of the material so helping to form a durable peripheral seal and bond to aid retention of the restoration as well as arresting the carious process within the remaining tooth structure. Achieving a smooth tooth-restoration interface clinically to aid the cooperative, motivated patient in biofilm removal is an essential pre-requisite to prevent further secondary caries.
This Elsevier title is a Pageburst product which provides you with the printed volume PLUS an e-book. Pageburst (formerly Evolve eBooks) allows you to quickly search the entire book, make notes, add highlights, and study more efficiently. Buying other Pageburst titles makes your learning experience even better: all of the eBooks will work together on your electronic 'bookshelf' so that you can search across your entire electronic library. Advanced Operative Dentistry: A Practical Approach is a brand new volume that addresses the use of fixed prosthodontics in a single handy reference source. Prepared by editors and contributors of international renown, this volume places unique emphasis on the biological basis of effective treatment planning by describing the diagnosis, aetiology, risk assessment and preventive management of diseases and disorders and how these factors are integral to predictable long-term patient outcomes. Advanced Operative Dentistry: A Practical Approach also gives clear advice on the selection and use of modern dental materials and describes how teeth are prepared - and to what extent - for indirect restorations such as crowns, bridges, veneers, inlays and onlays. The book also explores the use of complex indirect fixed prosthodontics which brings with it specific issues of restoration design, retention and occlusal management. Recognising that great deal of emphasis is placed on aesthetic dentistry by patient and dentist alike, this text also discusses factors which can impact upon aesthetics and how the aesthetic demands of patients can be met in a realistic and ethical manner. Clearly written and fully illustrated throughout, this practical step-by-step guide will be ideal for undergraduate dental students, vocational trainees and practitioners undertaking post-graduate exams. Prepared by editors and contributors of international renown Contains an abundance of full colour, clinical illustrations to show the results that can be achieved in real life Describes how to achieve the best appearance in order to meet increasing patient expectations Discusses the use of fixed prosthodontics in one volume and how fixed and removable prosthodontics can be integrated Gives unique emphasis on the preventative, biological approach to the use of fixed prosthodontics in order to ensure positive long-term treatment outcomes Clearly illustrates why aspects of tooth preparation are necessary and how the construction of restorations influences their fit Provides an integrated, multidisciplinary step-by-step guide to the provision of indirect fixed restorations Provides guidance on effective communication with laboratory staff to ensure high-quality tooth preparation Describes the correct handling of materials and restorations when being fitted Presents the latest findings regarding the use of contemporary materials and techniques - such as the use of Expasyl, Protemp temporary crowns, CAD and CAM crowns Comprehensive coverage of the subject area makes cross-referencing to other books unnecessary.
Conference Paper
Objective: Clinical, radiographic, and microbiologic changes in deep caries lesions were assessed after incomplete carious dentin removal and tooth sealing. Method and materials: Thirty-two teeth with deep caries lesions were studied. Treatment consisted of incomplete excavation of the demineralized dentin, application of calcium hydroxide, and sealing for a 6- to 7-month period. The color and consistency of the dentin were clinically assessed. Differences in radiographic density were assessed by digital image subtraction. Microbiologic samples were obtained from the demineralized dentin before the temporary sealing and after the experimental period. The samples were cultivated on blood agar under aerobic and anaerobic conditions, in Mitis Salivarius agar, and Rogosa selective Lactobacillus agar. Results: Two cases were lost during the study; one presented pulpal necrosis. In the other case, there was pulpal exposure during removal of provisional sealing. In all teeth, the initial demineralized dentin was soft and wet; one lesion was yellow, 21 were light brown, and eight were dark brown. After treatment, the dentin was dry, and 80.00% of specimens were hard, 16.67% were leathery, and 3.33% remained soft. The dentin was light brown in five teeth and dark brown in 25. There was a statistically significant mean difference in radiographic density (pixel intensity), 88.77+/-7.02 in the control areas and 94.66+/-6.75 in the test areas. The counts of anaerobic and aerobic bacteria, lactobacilli, and Streptococci mutans had decreased significantly by the end of treatment. Conclusion: Incomplete removal of carious dentin and subsequent tooth sealing resulted in the arrest of the lesions, suggesting that complete dentinal caries lesion removal is not essential to the control of caries lesions.
The purpose of the study was to evaluate, in a clinical study over 2 years, the deterioration of two glass ionomer cements used with the atraumatic restorative treatment (ART) technique or approach. Fifty-five Fuji IX and 45 ChemFil Superior restorations were placed randomly in 23 adult patients, mainly in small occlusal preparations in molar teeth. The restorations were placed in a dental hospital by one dentist using the ART technique. Photographs, radiographs and replicas were obtained at baseline and subsequent recalls. Both cements were easy to mix and place, but the radiolucency of ChemFil Superior was a disadvantage. Bath cements also showed early high losses of sealant and restorative material. After 2 years, 34.5% of the sealants appeared to be completely lost, with caries recorded in 5.3% of the exposed fissures. In some instances, these small lesions may have been present, but not detected clinically, at the time of sealing. Restoration failures of 7.0% were from wear and fracture of the cements and recurrent caries. Mean cumulative wear was 83.1 mu m for Fuji IX and 104.0 mu m for ChemFil Superior, which was not statistically significant. The cements became darker after their placement to more closely match the restored teeth, but there were few exact matches. There was no surface staining and only minor marginal discrepancies and staining associated with the restorations. Although the short-term clinical performance of the two glass ionomer cements was reasonable, the materials require further improvements in their mechanical properties, to reduce sealant losses and wear. The cements evaluated appear suitable for restricted use only, in posterior teeth.
This study investigates the potential of a novel guided tissue regeneration strategy, using fully demineralized dentin infiltrated with silica and hydroxyapatite (HA) nanoparticles (NPs), to remineralize dentin collagen that is completely devoid of native hydroxyapatite. Dentin blocks were fully demineralized with 4N formic acid and subsequently infiltrated with silica and HA NPs. The remineralizing potential of infiltrated dentin was assessed following a twelve week exposure to an artificial saliva solution by means of TEM, EDS and micro-CT. Measurements were taken at baseline and repeated at regular intervals for the duration of the study to quantify the P and Ca levels, the mineral volume percentage and mineral separation of the infiltrated dentin specimens compared to sound dentin and non-infiltrated controls. Infiltration of demineralized dentin with nano-HA restored up to 55% of the P and Ca levels at baseline. A local increase in the concentration of calcium phosphate compounds over a period of twelve weeks resulted in a higher concentration in P and Ca levels within the infiltrated specimens when compared to the non-infiltrated controls. Remineralization of demineralized dentin with silica NPs by immersion in artificial saliva was the most effective strategy, restoring 20% of the P levels of sound dentin. Micro-CT data showed a 16% recovery of the mineral volume in dentin infiltrated with silica NPs and a significant decrease in the mineral separation to levels comparable to sound dentin. Demineralized dentin infiltrated with silica NPs appears to encourage heterogeneous mineralization of the dentin collagen matrix following exposure to an artificial saliva solution.
Remineralization of demineralized dentin is important for improving dentin bonding stability and controlling primary and secondary caries. Nevertheless, conventional dentin remineralization strategy is not suitable for remineralizing completely demineralized dentin within hybrid layers created by etch-and-rinse and moderately aggressive self-etch adhesive systems, or the superficial part of a caries-affected dentin lesion left behind after minimally invasive caries removal. Biomimetic remineralization represents a different approach to this problem by attempting to backfill the demineralized dentin collagen with liquid-like amorphous calcium phosphate nanoprecursor particles that are stabilized by biomimetic analogs of noncollagenous proteins.