1
Clinical cariology and operative dentistry in the
twenty-f¡rst century
0. Fejerskov and E.A.M. Kidd
lntroduction
From the title of this book it will be apparent that we
believe that most dental treatm ents cannot be - and
definitely should not be - performed without due consider-
ations as to the disease, dental caries, which is the predom-
inant reason why most dental restorations are performed.
Dental caries is ubiquitous in all populations throughout
the world and is the key factor responsible for dental pain
and tooth loss in populations throughout the world. The
twentieth century saw the establishment of dentistry as a
health profession which was totally occupied by the middle
of the century with pain relief and restorative treatment of
decayed teeth, in the particular in Europe and North
America. As it was gradually appreciated that major efforts
should be made to prevent cavities from developing, the
latter half of the century saw major declines in the preva-
lence and incidence of dental caries in child populations.
\{hile the dental profession at a certain stage took this as an
indication of its success in combating the disease, it never-
theless became obvious that these often dramatic changes
in disease experience in children could not easily be
explained based on the simplistic concept often underlying
preventive and treatment strategies. The change in disease
experience in children caused so much optimism in some
parts ofthe dental profession that dental caries as a disease
was claimed to have been irradicated. In other parts of the
profession the decline in dental caries was considered
frightening as it could partly undermine the economy of
the rapidly growing profession. Whatever the reason, in
several countries dental schools were closed down or num-
bers of students so severely reduced that the resources for
maintaining a high standard of research and education in
dentistry suffered.
It has now become evident, as will be apparent from the
text in this book, that dental caries is a result of a very com-
plex interplay of multiple determinants and what has been
experienced is a highly fortunate reduction in the rate by
which caries lesions develop and progress in children's den-
titions. However, much of the available evidence today
indicates that dental caries, unless carefully controlled, will
continue to develop and progress throughout life. Thus,
what has been considered an eradication of the disease
should merely be considered a postponement of the time
in life where the disease manifests itself with symptoms
from lesions penetrating so deep into the dental hard tis-
sues that cavities form.
As such, the present book aims to bring back to dentistry
an understanding of what is known about the etiology and
pathogenesis of dental caries so that diagnosis, prevention
and control oflesion progression, as well as decisions about
when and how to perform restorative treatments, can be
made based on comprehensive knowledge about the
disease and its different manifestations.
It should be realized, however, that many of the activities
presently taking place in public health dentistry and in the
dental clinic are a result of some - maybe rather unfortu-
nate - developments that occurred during the twentieth
century. This introductory chapter will therefore set the
scene by making a brief review of the major developments
in the past century which resulted in an unfortunate
dichotomy between restorative dentistry on the one side
and caries prevention and public-health activities on the
other side. By so doing it is our hope that we will enable
dental students better to comprehend why modern den-
tistry in the twenty-first century should appreciate that
what could be called clinical cariology and restorative den-
tistry should be considered as an entitywhere any restora-
tion and treatment of cavities in teeth would require a
profound understanding of what the disease is all about.
Standing on the shoulders of giants
Two remarkable individuals, W.D. Miller and G.V. Black,
managed to establish dentistry as a scientific discipline
about 100 years ago. Thus, the work by Miller entitled The
4 Dental Caries: The Disease and its Clinical Management
micro-organisms of the human mouthin the late nineteenth
century established the foundation of our present under-
standing of the complexity of microflora in the human oral
cavity. The excellent work by Black led to the foundation of
clinical dentistry. It is astonishing how much we benefit
today by returning to some of his original observations.
Indeed, we should apply his approach to control dental
caries rather than follow some of the very many ideas and
guidelines which, although widely used, have not signifi-
cantly improved oral health during the subsequent 100
years.
In his 1908 textbook Black, in two extensive volumes,
combined what was known at the time about the pathology
of dental caries with his recommendations for appropriate
restorative dentistry.
Black defined caries the following way in the German
translation ofthe text from 1914:
Caries in its simplest expression consists in a chemical
dissolution of the calcium salts of the tooth by lactic acid,
followed by the decomposition of the organic matrix, or
gelatinous body, which, in the dentin, is left after the
solution of the calcium salts. In caries of the enamel,
the whole substance of the tissue is removed by dissolving
out the calcium salts, there being so little organic matrix
in the enamel that it will not hang together, consequently
a cavity is formed by the simple solution of the calcium
salts of which it is composed. This solution always
begins upon the surface, never in the interior. Decay of
the teeth is therefore caused by an agent acting from
without the tooth, never from within the tooth. It is
something extraneous to the tooth, acting upon the
surface in the beginning and penetrating little by little into
its subsurface.
This claim is worthwhile comparing with Black's
precise description of where a dental caries lesion could
develop:
... the beginning of caries of the teeth occurs at such points
as will favor such lodgment or atfachment in which the
microorganisms will not be subject to such frequent dis-
lodgment as would prevent a fairly continuous growth.
This is the cause of the localization of the beginnings of
caries on particular par* of the surface of the tooth.
Thus, Black very precisely stressed that the processes
which dissolve dental hard tissues occur as a result ofbac-
teria which stick to tooth surfaces, particularly at stagnant
sites around the dentition. Indeed, it was Black who first
described dental plaque and used the term 'gelatinoid
plaques'. Here is a quote from his 1908 text:
For caries to begin on the teeth ar4.where the caries fungus,
which forms an acid must be attached to the surface of the
enamel in such way as to prevent the acid which it forms
from being readily washed away and dissipated in the gen-
eral fluids of the mouth.
Half a century later these carpets of microorganisms
were again described as dental plaque. This terminology is
gradually being replaced by the concept of biofilms, as it is
now evident that the biofilms in the mouth display similar
properties to those found elsewhere in nature.
From the chapters of this book it will be obvious why the
biofilm concept plays a key role in understanding both
dental caries and periodontal diseases. With modern
molecular techniques it is evident that the same types of
microorganisms may behave entirely differently depending
on whether they occur freely floating (in saliva or in a test-
tube) or whether they are established in microbial com-
munities such as a biof,lm, where entirely different genes
may be expressed. As will be apparent throughout this
book, we consider the processes in the biofilm to play a key
role in understanding the disease dental caries and how to
control and treat the disease. However, we shall for a
moment try to consider why a vety unfortunate split
between restorative dentistry and cariology occurred to
such an extent that even today many restorative depart-
ments teach the mechanics and dental materials aspects of
operative dentistry without the students having a thorough
knowledge about the disease. Moreover, many preventive
dentists have little understanding and appreciation of the
role of biofilms (dental plaque) in caries development, to
the extent that oral hygiene is by many not considered to
play an important role in caries control. How did such
distorted views gain ground?
The caries situation by the middle of the
twentieth century
By the middle of the twentieth century the caries situation
in Europe was the most severe ever observed in human
populations. Thus, in some populations it was not un-
common by the age of 14 to have lost several teeth as a
result of pulpal involvement, and among socioeconomi-
cally deprived populations it was common to have all teeth
extracted and replaced by full dentures by adolescence.
Therefore, every effort by the middle of the century was
concentrated on restorative dentistry trying to cope with
the rapidly increasing caries situation among children.
Attempts were made to improve the quality of dental mate-
rials. Even toda¡ the enormous importance of material sci-
ences in dentistry is reflected in the fact that this subject
still comprises the biggest single area of research within
dentistry. However, despite numerous fillings, secondary
caries flourished and the expectations from the profession
were that if the quality of the restorative materials could be
improved, the question of secondary caries along faulty
margins of restorations would disappear. Thus, secondary
caries was, and still is by some, considered an entity qf its
own rather than being a simple reflection of the dilease
dental caries. Too late it was appreciated that insertini fill-
ings, even at great pace, had little to do with arrestin\ or
 Clinical cariology and operative dentistry in the twenty-first
treating disease, although it had a temporary effect in
creating relief from pain and restoring the function of the
teeth. rv\/tren the concept of prevention became more and
more established, it even went so far that restoring teeth
was included in the preventive hierarchy designated as
'prevention at secondary or third level'.
Three major discoveries have also had a tremendous
impact on the way in which cariology and restorative den-
tistry developed. First, studies in the 1930s and 1940s were
focussing on the role of nutrition in making teeth more or
less susceptible to carious attacks. Then studies indicated a
strong correlation between sugar consumption in popula-
tions and caries experience. The role of sugars was firmly
established in a series of studies in mentally diseased peo-
ple in institutions in Sweden; the so-called Vipeholm stud-
ies. Secondl¡ strong scientific support for the central role of
microorganisms in dental caries development came in the
late 1940s, when it was shown in animals that occlusal
caries could be prevented using penicillin. Moreover, stud-
ies during the latter half of the 1950s clearly showed that
germ-free rodents could not develop caries lesions despite
high-sugar diets.*When animal studies also showed that
single species of streptococci consistently resulted in caries
development in gnotobiotic animals, the focus on dental
caries ás an infectious disease was established'FThese stud-
ies, showing that streptococci could be transmitted from
mother to litter and could even be transmitted from ani-
mals exhibiting caries to unaffected animals, established the
concept of dental caries as an infectious and transmittable
diseasó Before this, Iactobacilli were thought to be the
predominant caries-inducing microorganisms, but from
around 1960 and onwards if was Streptococcus mutansthat
attracted most attention.
Thirdly, when T. Dean in the early 1940s clearly demon-
strated how the presence of elevated levels of fluoride in
water supplies could significantly reduce the number and
severity of cavitated lesions in children, the scene was set
for the three major avenues followed in caries prevention
and public dental health during the latter half of the twen-
tieth century.
This can probably best be understood by looking at a
diagrammatic representation of the way the primary
(essential) factors in dental caries etiology were considered
in their most simplistic form (Fig. 1.1). This is an intriging
diagram, because it is so simple it is easy to understand and
to present to the public when arguing for the choice of
preventive strategies. However, this simplicit¡ for those
who are fully familiar with the complexity of dental caries'
may have added to an almost deterministic attitude. When
the three above-mentioned major observations from the
middle of the century are encapsulated into the diagram,
one circle represent the 'tooth" another circle the 'micro-
organisms' and the third'sugar or diet'. It will be imme-
diately understandable why much effort in research and
many arguments have been spent on either trying to
century 5
improve the resistance of the tooth to acid attack (incorpo-
rating fluoride into the tooth), presenting sugar and sugar
consumption as the 'arch criminal for dental caries' or
suggesting that caries is caused by a specific micro-
organism. Thus, even vaccines against. S. mutanshavebeen
considered a possible public-health measure.
To close the explanatory circle we have to address the
question of why dental plaque and tooth brushing did not
attract much attention for decades when dealing with den-
tal caries. While caries research and restorative dentistry
were focussed on the above developments, dentistry also
saw the growth and development of periodontology as a
research and clinical discipline of its own. The role of den-
tal plaque in gingivitis (and periodontitis) became estab-
lished in the 1950s and 1960s. Clinical studies tried to
establish the cause and effect relationship between gingivi-
tis and soft and hard deposits on teeth. To this end, the so-
called plaque and calculus indices were developed
specifically to assess the amount and distribution of micro-
bial deposits along the gingival margins. These indices soon
became established as routine tools used in clinical den-
tistry for assessing soft and hard deposits on teeth and were
uncritically used when associations were to be made
between dental plaque and dental caries. In retrospect, it is
easy to understand why plaque indices specifically devel-
oped to assess deposits along the gingival margin could not
be particularty valid when associations were made with
occlusal caries, but this was nevertheless what frequently
has been (and still is being) done. This is one of the reasons
why claims such as that'tooth brushing has no effect on
dental caries' are still perpetuated. Certainly this was not
G.V. Black's view. He noted that the growth of micro-
organisms could not be prevented, but that the gelatinious
plaques could be removed, particularly from buccal sur-
faces, by careful use of a toothbrush. He would ask the
Figure 1,1 The four circles represent the parameters involved in the carious
process. All four factors must be acting concunently (overlapping oi the circles)
for caries to occur.
6 Dental Caries: The Disease and its Clinical Management
patient to bring their brush to the surgery so he could see
how they brushed their teeth.
The comparison between the development of cariology
and restorative dentistry and that ofperiodontology is also
interesting because so far periodontology has not split into
disciplines only focussing on the etiology and pathogenesis
of the disease, without close and intimate links to the clin-
ical consequences of such studies and without implications
for treatment in periodontology. However, as stressed ear-
lier, the development of dental materials and their clinical
applications in restorative dental care have been going on
for a very long time with limited appreciation of the sub-
stantial changes occurring in our understanding of dental
caries. Likewise, much of the still perpetuated strategies in
caries prevention are based on paradigms or concepts from
the middle of the twentieth centur¡ without much appre-
ciation of the significant scientific development that has
improved our understanding of the complex interaction
befiveen the oral environment and the oral tissues. Since
the early 1990s there has been a revolution in our under-
standing of the early events in tooth morphogenesis.
Moreover, the results obtained over almost three decades
from laborator¡ animal and human studies on how
fluoride affects both mineralizing tooth tissues before
eruption, and mineralized tissues following exposure to the
oral environment, necessitate the development of more
appropriate strategies for control and preventive, non-
operative treatment of dental caries.
The aim of this book
The aim of this book is therefore to present the dental stu-
dent and the dental practitioner with an update on the
available knowledge about the disease dental caries,
the consequences of this to the diagnosis of the disease, and
how most appropriately and cost effectively to prevent
and control disease progression. Clinical decision making
and the balance among preventive, non-operative and
operative treatment become even more important parts
of daily life in clinical practice. An understanding of
the caries process is needed to estimate the prognosis
of treatment procedures and the possibility of assessing
the risk of disease development in individuals and
populations.
This book will demonstrate that in real life the processes
involved in dental caries are highly complex, with temporal
and spatial variations not only in the number and tlpe of
determinants involved, but also in their relative influence.
In an ideal world would there be a perfect deterministic
model that could relate all the potential determinants per-
fectly to caries outcome. It will appear throughout the book
that most of the determinants which influence the disease
can, at best, be measured only as proxy variables. The most
we can hope for, therefore, is to develop probabilistic mod-
els that relate determinants to risk of disease. However,
even under such circumstances, caries would still remain
unpredictable. Such inputs as the times, lengths, frequen-
cies and types of sugar consumption, the quality of tooth
cleaning, the fluctuations in salivary flow rates and compo-
sition, and the quality and composition of biofilms are
themselves so highly variable that it is likely that this vari-
ability and unpredictability of the inputs may play a crucial
role in the way in which the disease process develops ln
vivo.Butall,these factors make up the fascination and chal-
lenge ofthis aspect ofour profession.
It is our hope that this book will prepare the reader to
become a less dogmatic and more knowledgeable health
professional who strives to prevent, control and treat den-
tal caries in the most cost-effective way.
References
Black GV. Operative dentistry,Yol. I, Pathology of the hard tissues of the
teeth. Chicago, IL: Mexico-Dental Publishing Compan¡ 1 908.
Black GV. Operatfue dentisty,Yol. l, Pathology of the hard tissues of the
teeth.Londo¡: Claudius Ash, Sons & Co., 1914.
Miller WD. The micro-organisms of the human mouth. Philadelphia, PA,
1890. (Republished Basel: S. Karger, 1973.)