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)
Caries Management: A Journey between Black’s principals and Minimally Invasive Concepts
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.
Dr. Hamdi Hosni Hamdan Hamama,
Clinical Assistant Professor, Aesthetic and Restorative Dentistry Depart-
ment, Faculty of Dentistry, Mansoura University, Po (box) 35516, Egypt.
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.
Caries is from the Latin word that means “rottenness”. Dental
caries is dened as “an infectious microbiological disease of the
teeth that results in localized dissolution and destruction of the
calcied tissue” . 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 . In 1932, Williams  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
. 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 .
Dental plaque(biolm) is dened 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” . However, the presence of dental plaque alone doesnot
cause dental caries. This has led to a new modication of the
dental plaque theory, which is now known as the “Specic dental
plaque hypothesis” . This theory considers dental plaque as an
etiological factor for dental caries when pathogenic bacteria are
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 . 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 . Much evidence
supports the specic dental plaque hypothesis; for example the
absence of dental caries in un-erupted and germ-free animal’s
teeth . Furthermore, many studies reported the presence of
cariogenic bacteria within oral biolms, which covered active cari-
The cariogenic microorganisms within oral biolms
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 classication 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 . 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 .
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,
specic 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 biolm
layers. Due to a lack of oxygen in deep biolm 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 biolm. 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 .
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 . Unlike
enamel, the acidity of the biolms can easily demineralize calcium
from dentine, which leads to exposure of the collagen framework
to the proteolytic enzymes produced by the bacteria . How-
ever, the immediate destruction of the tissue does not occur in
dentine compared to that in enamel lesions . The persistence
of the cariogenic factors for a long time will result in permanent
damage of the collagen bres (denatured collagen) . 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) .
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 . 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 inltration.
The most supercial zone is the infected dentine, which is charac-
terized by complete decomposition of the dentine (complete ab-
sence of mineral and collagen content) with signicant bacterial
inltration. These features of dentine caries introduced two im-
portant terms used in restorative dentistry, namely, “caries-infect-
ed” and “caries-affected” dentine . 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  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 .
Caries-disclosing dyes and its relevance to Fusayama’s his-
The clinical differentiation between “caries-affected” and “caries-
infected” dentine is one of the most difcult challenges encoun-
tered clinically [6, 10]. Conventional means of detection are based
on visual and the tactile sensation; 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.  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 efcient in differentiat-
ing both dentine-caries layers . 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 . However, some authors showed
disagreement with the efciency 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 calcication 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) . 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
Classications of dental caries based on the histologic fea-
tures of carious tissues and in light of the minimally inva-
In the early twentieth century, G.V Black
established the conventional classication of dental caries lesions,
based on the most common carious lesion sites and the available
restorative materials . In 1998, Mount  introduced a new
classication based on the recent minimally invasive concepts
and contemporary restorative techniques. Mount demonstrated
that any carious lesion can be identied by using two parameters;
the affected site and stage (size) of the lesion [24, 25]. Based on
Mount’s classication, 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 . Each of the previously mentioned
sites can be further classied 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 . Although Mount’s classication 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
. 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 . The main objective of this system
was to unify the measuring criteria of caries activity among epide-
miological and clinical studies . Also, it was designed to detect
caries on both enamel and dentine surfaces, as well as, coronal and
root surfaces .
The ICDAS system was introduced in 2003, and modied 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 identies 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) . It has been recommended
to use a ball-end explorer for diagnosis of carious lesions, to avoid
damage of the incipient caries regions . Although the original
ICDAS-II system consists of 6 codes, Ricketts et al.  have sug-
gested to reduce them to 4, based on the histological ndings of
Ekstrand et al.  and Lussi et al.,  for simplifying the clinical
use of the system. According to the most updated ICDAS-II cri-
teria , caries can be classied 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 Classication 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 
in 1883, who mentioned in his textbook that “every cavity must
be so prepared that no decalcied 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” . In
1891, Black  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 . 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 modied 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].
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 . Moreover,
signicant improvement of amalgam alloys and introduction of
bonded amalgam restorations have modied the cavity prepara-
tion for amalgam to be more conservative of tooth structure .
Also, introduction of conservative cavity designs; such as slot
and tunnel preparations, are one of the characteristic features of
MID . Furthermore, retentive features changed from macro-
mechanical to micro-mechanical (resin adhesives) and chemical
(e.g. resin-modied 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 . Black’s convenience form
principle is still useful; however, the advances in diagnosis, use of
magnication and cavity preparation instrumentation, allow easy
access for excavation of infected tissue with maximum preserva-
tion of the sound tooth tissue . 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 . In this technique, the caries excavation is performed in
two stages with a time lag period . 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 . After a certain period of
time, “4-12 months” , the cavities are re-entered to excavate
the residual carious tissue . 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 .
In 1938, Bodecker  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 , calcium hydroxide [54, 55], and
mineral trioxide aggregate (MTA) . 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 benets 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?” . 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 supercial layer
of “caries-affected” dentine, which can contain some bacteria and
partially denatured collagen bres . This assumption was in
agreement with Fusayama’s conclusions, who stated that the clini-
cal differentiation between caries-affected and -infected dentine
is very difcult to distinguish . 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.
 showed that the mean survival rate of restorations following
PCR (91%) was signicantly 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 . Later on, similar trials were performed in
China, Vietnam, South Africa, Mexico, Ecuador and Brazil .
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 . 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 veried 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 . 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 Signicance
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.
Oral Sci. 2(8), 120-125. 124
. Heymann HO, Swift EJ, Ritter AV, Sturdevant CM (2013) Sturdevant's art
and science of Operative Dentistry. In Dental caries: etiology, clinical char-
acteristics, risk assessment, and management. (6th edtn), Elsevier/Mosby, St.
Louis, Mo. 41-88.
. Black GV (1936) Black's Work on operative denistry with which his special
dental pathology is combined. (7th edtn), Medico Dental Publishing Com-
pany, Chicago. 322-335.
. Loesche WJ (1979) Clinical and microbiological aspects of chemothera-
peutic agents used according to the specic plaque hypothesis. J Dent Res
. Newbrun E (1983) Cariology. (2nd edtn), Williams & Wilkins, Baltimore.
. Fejerskov O, Kidd EAM (2009) Dental caries : the disease and its clinical
management. (2nd edtn), Blackwell Munksgaard, Oxford, UK. 356-388.
. Fusayama T (1993) A simple pain-free adhesive restorative system by mini-
mal reduction and total etching. Ishiyaku EuroAmerica Inc., Tokyo. 23-45.
. Besinis A, van Noort R, Martin N (2014) Remineralization potential of fully
demineralized dentin inltrated with silica and hydroxyapatite nanoparti-
cles. Dent Mater 30(3): 249-262.
. Niu LN, Zhang W, Pashley DH, Breschi L, Mao J, et al. (2014) Biomimetic
remineralization of dentin. Dent Mater 30(1): 77-96.
. Nayif MM, Shimada Y, Ichinose S, Tagami J (2010) Nanoleakage of current
self-etch adhesives bonded to articial carious dentin. Am J Dent 23(5):
. Ogawa K, Yamashita Y, Ichijo T, Fusayama T (1983) e ultrastructure and
hardness of the transparent layer of human carious dentin. J Dent Res 62(1):
. Kuboki Y, Liu CF, Fusayama T (1983) Mechanism of dierential staining in
carious dentin. J Dent Res 62(6): 713-714.
. Fusayama T, Terachima S (1972) Dierentiation of two layers of carious
dentin by staining. J Dent Res 51(3): 866.
. de Almeida Neves A, Coutinho E, Cardoso MV, Lambrechts P, Van Meer-
beek B (2011) Current concepts and techniques for caries excavation and
adhesion to residual dentin. J Adhes Dent 13(1): 7-22.
. Sato Y, Fusayama T (1976) Removal of dentin by fuchsin staining. J Dent
Res 55(4): 678-683.
. Poole-Wilson DS (1960) Occupational tumours of the bladder. Proc R Soc
Med 53(10): 801-814.
. National Cancer Institute (1954-1960) Survey of compounds which have
been tested for carcinogenic activity. Public Health Service No.149, Wash-
ington DC, USA. 2: 655.
. Yip HK, Stevenson AG, Beeley JA (1994) e specicity of caries detector
dyes in cavity preparation. Br Dent J 176(11): 417-421.
. Boston DW, Liao J (2004) Staining of non-carious human coronal dentin by
caries dyes. Oper Dent 29(3): 280-286.
. Kidd EA, Joyston-Bechal S, Smith MM, Allan R, Howe L, et al. (1989)
e Use of a Caries Detector Dye in Cavity Preparation. Br Dent J 167(4):
. Iwami Y, Shimizu A, Narimatsu M, Kinomoto Y, Ebisu S (2005) e rela-
tionship between the color of carious dentin stained with a caries detector
dye and bacterial infection. Oper Dent 30(1): 83-89.
. Hosoya Y, Taguchi T, Tay FR (2007) Evaluation of a new caries detecting dye
for primary and permanent carious dentin. J Dent 35(2): 137-143.
. Kinoshita J, Shinomiya H, Itoh K, Matsumoto K (2007) Light intensity
evaluation of laser-induced uorescence after caries removal using an experi-
mental caries staining agent. Dent Mater J 26(3): 307-311.
. Black GV (1908) A work on Operative Dentistry. Medico-Dental Publish-
ing Company, Chicago.
. Mount GJ, Hume WR (1998) A new cavity classication. Aust Dent J 43(3):
. Mount GJ, Tyas JM, Duke ES, Hume WR, Lasfargues JJ, et al. (2006) A
proposal for a new classication of lesions of exposed tooth surfaces. Int
Dent J 56(2): 82-91.
. Pitts N (2004) "ICDAS"-an international system for caries detection and
assessment being developed to facilitate caries epidemiology, research and
appropriate clinical management. Community Dent Health 21(3): 193-198.
. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, et al. (2007) e Inter-
national Caries Detection and Assessment System (ICDAS): an integrated
system for measuring dental caries. Community Dent Oral Epidemiol 35(3):
. Tikhonova SM, Feine JS, Pustavoitava NN, Allison PJ (2014) Reproduc-
ibility and diagnostic outcomes of two visual-tactile criteria used by dentists
to assess caries lesion activity: a cross-over study. Caries Res 48(2): 126-136.
. Ricketts D, Bartlett DW (2011) Advanced Operative Dentistry: a practi-
cal approach. In Management of dental caries. Churchill Livingstone, New
. Ekstrand KR, Ricketts DN, Kidd EA (1997) Reproducibility and accuracy
of three methods for assessment of demineralization depth of the occlusal
surface: an in vitro examination. Caries Res 31(3): 224-231.
. Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E (1999) Perfor-
mance and reproducibility of a laser uorescence system for detection of
occlusal caries in vitro. Caries Res 33(4): 261-266.
. International Caries Detection and Assessment System (ICDAS) co-ordi-
nating committee. ICDAS-II. (2014) [cited 1/3/2014]; Available from:
. Webb MH (1883) Notes on Operative Dentistry. S.S. White Manufacturing
Co., Philadelphia. 72-88.
. Black GV (1891) e managment of enamel margins. Dental Cosmos 33:
. Black GV, Black AD (1924) A work on special dental pathology : devoted
to the diseases and treatment of the investing tissues of the teeth and the
dental pulp, including the sequelae of the death of the pulp, also, systematic
eects of mouth infections, oral prophylaxis and mouth hygiene. (3rd edtn),
Medico-Dental Publishing Co., Chicago. 204-207.
. Trallero MM (1900) Treatment of dental caries. Dental Cosmos 42(10):
. Meyer JM (1903) Principles for cavity preparation. Dental Cosmos 45: 187-
. Black AD (1909) Cavity preparation, based on the pathology of dental car-
ies. Dental Cosmos 51: 957-962.
. Hofheinz RH (1902) Extension for Prevention. Dental Cosmos 44: 914-
. Noyes FB (1904) Extension for prevention: A study of conditions in the
mouth. Dental Cosmos 46: 832-837.
. Slagle CE (1904) e Fundamental Principles of Extension in Approximal
Cavities in Bicuspids and Molars. Dental Cosmos 46: 443-445.
. Ericson D (2007) e concept of minimally invasive dentistry. Dent Update
. Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, et al. (2012)
Minimal intervention dentistry for managing dental caries - a review: report
of a FDI task group. Int Dent J 62(5): 223-243.
. Peters MC, McLean ME (2000) Minimally invasive operative care. I. Mini-
mal intervention and concepts for minimally invasive cavity preparations. J
Adhes Dent 3(1): 7-16.
. Bonsor SJ (2011) Bonded amalgams and their use in clinical practice. Dent
Update 38(4): 222-224.
. Peters MC, McLean ME (2000) Minimally invasive operative care. II. Con-
temporary techniques and materials: an overview. J Adhes Dent 3(1): 17-31.
. Mitra SB, Lee CY, Bui HT, Tantbirojn D, Rusin RP (2009) Long-term ad-
hesion and mechanism of bonding of a paste-liquid resin-modied glass-
ionomer. Dent Mater 25(4): 459-466.
. Hiraishi N, Yiu CK, King NM, Tay FR (2009) Eect of 2% chlorhexidine
on dentin microtensile bond strengths and nanoleakage of luting cements. J
Dent 37(6): 440-448.
. Burke FJ (2003) From extension for prevention to prevention of extension:
(minimal intervention dentistry). Dent Update 30(9): 492-498.
. Leksell E, Ridell K, Cvek M, Mejare I (1996) Pulp exposure after stepwise
versus direct complete excavation of deep carious lesions in young posterior
permanent teeth. Endod Dent Traumatol 12(4): 192-196.
. Hilton TJ (2009) Keys to clinical success with pulp capping: a review of the
literature. Oper Dent 34(5): 615-625.
. Bodecker CF (1938) Histologic evidence of the benets of temporary llings
and successful pulp capping of deciduous teeth. J Am Dent Assoc 25(5):
. Kerkhove BC Jr, Herman SC, Klein AI, McDonald RE (1967) A clinical and
television densitometric evaluation of the indirect pulp capping technique. J
Dent Child 34(3): 192-201.
. Maltz M, de Oliveira EF, Fontanella V, Bianchi R (2002) A clinical, micro-
biologic, and radiographic study of deep caries lesions after incomplete caries
removal. Quintessence Int 33(2): 151-159.
. Casagrande L, Bento LW, Dalpian DM, Garcia-Godoy F, de Araujo FB
(2010) Indirect pulp treatment in primary teeth: 4-year results. Am J Dent
. Leye Benoist F, Gaye Ndiaye F, Kane AW, Benoist HM, Farge P (2012)
Evaluation of mineral trioxide aggregate (MTA) versus calcium hydroxide
cement (Dycal®) in the formation of a dentine bridge: a randomised con-
trolled trial. Int Dent J 62(1): 33-39.
. Magnusson BO, Sundell SO (1977) Stepwise excavation of deep carious le-
sions in primary molars. J Int Assoc Dent Child 8(2): 36-40.
. Bjorndal L, Reit C, Bruun G, Markvart M, Kjaeldgaard M, et al. (2010)
Treatment of deep caries lesions in adults: randomized clinical trials com-
paring stepwise vs. direct complete excavation, and direct pulp capping vs.
partial pulpotomy. Eur J Oral Sci 118(3): 290-297.
. Handelman SL, Washburn F, Wopperer P (1976) Two-year report of sealant
Oral Sci. 2(8), 120-125. 125
eect on bacteria in dental caries. J Am Dent Assoc 93(5): 967-970.
. Oliveira EF, Carminatti G, Fontanella V, Maltz M (2006) e monitoring
of deep caries lesions after incomplete dentine caries removal: results after
14-18 months. Clin Oral Investig 10(2): 134-139.
. Franzon R, Casagrande L, Pinto AS, Garcia-Godoy F, Maltz M, et al. (2007)
Clinical and radiographic evaluation of indirect pulp treatment in primary
molars: 36 months follow-up. Am J Dent 20(3): 189-192.
. Banerjee A, Watson TF, Kidd EA (2000) Dentine caries: take it or leave it?
Dent Update 27(6): 272-276.
. Banerjee A (2013) Minimal intervention dentistry: part 7. Minimally in-
vasive operative caries management: rationale and techniques. Br Dent J
. Bjorndal L, Kidd EA (2005) e treatment of deep dentine caries lesions.
Dent Update 32(7): 402-413.
. ompson V, Craig RG, Curro FA, Green WS, Ship JA (2008) Treatment
of deep carious lesions by complete excavation or partial removal: a critical
review. J Am Dent Assoc 139(6): 705-712.
. Foley J, Evans D, Blackwell A (2004) Partial caries removal and cariostatic
materials in carious primary molar teeth: a randomised controlled clinical
trial. Br Dent J 197(11): 697-701.
. Kidd EA (2004) How 'clean' must a cavity be before restoration? Caries Res
. Borczyk D, Piatowska D, Krzeminski Z (2006) An in vitro study of aected
dentin as a risk factor for the development of secondary caries. Caries Res
. Maltz M, Henz SL, de Oliveira EF, Jardim JJ (2012) Conventional caries
removal and sealed caries in permanent teeth: a microbiological evaluation.
J Dent 40(9): 776-782.
. Maltz M, Garcia R, Jardim JJ, de Paula LM, Yamaguti PM, et al. (2012)
Randomized trial of partial vs. stepwise caries removal: 3-year follow-up. J
Dent Res 91(11): 1026-1031.
. Bjorndal L, Larsen T (2000) Changes in the cultivable ora in deep carious
lesions following a stepwise excavation procedure. Caries Res 34(6): 502-
. Maltz M, Oliveira EF, Fontanella V, Carminatti G (2007) Deep caries lesions
after incomplete dentine caries removal: 40-month follow-up study. Caries
Res 41(6): 493-496.
. Hayashi M, Fujitani M, Yamaki C, Momoi Y (2011) Ways of enhancing
pulp preservation by stepwise excavation--a systematic review. J Dent 39(2):
. Yee R (2001) An ART eld study in western Nepal. Int Dent J 51(2): 103-
. Taifour D, Frencken JE, Beiruti N, van 't Hof MA, Truin GJ (2002) Eec-
tiveness of glass-ionomer (ART) and amalgam restorations in the deciduous
dentition: results after 3 years. Caries Res 36(6): 437-444.
. Ibiyemi O, Bankole OO, Oke GA (2011) Assessment of Atraumatic Re-
storative Treatment (ART) on the permanent dentition in a primary care
setting in Nigeria. Int Dent J 61(1): 2-6.
. Ersin NK, Candan U, Aykut A, Oncag O, Eronat C, et al. (2006) A clinical
evaluation of resin-based composite and glass ionomer cement restorations
placed in primary teeth using the ART approach: results at 24 months. J Am
Dent Assoc 137(11): 1529-1536.
. Ho TF, Smales RJ, Fang DT (1999) A 2-year clinical study of two glass iono-
mer cements used in the atraumatic restorative treatment (ART) technique.
Community Dent Oral Epidemiol 27(3): 195-201.
. Lo EC, Holmgren CJ, Hu D, van Palenstein Helderman W (2007) Six-year
follow up of atraumatic restorative treatment restorations placed in Chinese
school children. Community Dent Oral Epidemiol 35(5): 387-392.
. Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF (2011) Ten-
year survival of ART restorations in permanent posterior teeth. Clin Oral
Investig 15(2): 265-271.
. Frencken JE, Taifour D, van 't Hof MA (2006) Survival of ART and amal-
gam restorations in permanent teeth of children after 6.3 years. J Dent Res