Cariology

Edwina Kidd

Ole Fejerskov

Changing Concepts in Cariology:

Forty Years On
Abstract: The caries lesion is a sign or symptom resulting from numerous pH fluctuations in biofilms on teeth. The lesion may or may not
progress and lesion progression can be controlled, slowed down or arrested. Control of the biofilm is the treatment of caries, the most
important measure being to disturb the biofilm mechanically using a fluoride-containing toothpaste. The informed patient controls caries
and the role of the dental professional is to advise how this should be done. This is the non-operative treatment of caries and it is worthy
of payment. It should be mandatory as part of any operative treatment to ensure that the patient understands, and is able to perform,
adequate plaque control.
Clinical Relevance: It is very unfortunate that the current remuneration scheme (Unit of Dental Activity) in Health Service practice in
England and Wales prevents practitioners adopting a modern biological approach to caries control.
Dent Update 2013; 40: 277286

Changing concepts in
cariology: forty years on
Forty years on, when afar and asunder
Parted are those who are reading today,
When you look back, and forgetfully wonder
What you were like in your work and your play,
Then, it may be, there will often come oer you,
Glimpses of past and some of it wrong,
Visions of studies shall float them before you,
Echoes of teaching shall bear you along,
What is new for the patient our hope to fulfil,
Teeth unto death are chiefly our will.
(With apologies to Edward Ernest Bowen
and Harrow School.)

A personal introduction
Edwina Kidd was in the staff
room at the London Hospital Dental

Edwina Kidd, BDS, FDS RCS(Eng), PhD,

DSc, Emerita Professor of Cariology,
Kings College, London, UK and Ole
Fejerskov, DDS, PhD, Dr Odont,
Professor of Anatomy, Faculty of Health
Sciences, University of Arhus, Denmark.
May 2013

School when Ted Renson carried in his

baby, Dental Update, Volume 1, Number
1. It was a revelation to see such a
beautifully produced, colour illustrated
and readily understandable production.
The cariology article in that first number
concerned the white spot lesion and was
written by Leon Silverstone.1 The authors
of the current paper (EK and OF) met in
Leons laboratory (a euphemism for a
large cupboard) at the London Hospital at
that time. One (EK) was a junior lecturer
at The London whose PhD Leon was
supervising; the other (OF), already a
Professor of Oral Pathology in Denmark,
had recently been appointed to a chair in
Cariology and needed to change research
focus from soft to hard tissues. He was in
London to research aspects of fluorosis
and work with Leon, Newell Johnson and
Ron Fearnhead. Having met in a long,
thin cupboard, where communication
was inevitable, we subsequently worked
together for 40 years (Figure 1). We now
combine in this anniversary issue to take
a helicopter journey over contemporary
Cariology, discussing aspects of the subject
as understood in 2013 and highlighting
changes in understanding from the 1970s.

Figure 1. Forty years on!

The relevance of cariology

Dental caries is ubiquitous it
is omnipresent in all populations and is
as old as mankind. The caries incidence
rate varies extensively between and
within populations. With increasing
age, signs and symptoms of dental
caries accumulate and, in most adult
populations, the caries prevalence
approaches 100 percent. Prevention and
operative treatment of caries lesions, and
their sequelae, occupy the majority of the
dental profession life-long around the
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Cariology

world and the cost of dental health care

is a major societal burden. The majority of
dental restorations are made because of
dental caries. Caries and failed restorative
care are the main causes for tooth loss in
all contemporary populations.

The current concept of caries

and caries control
Dental caries is a dynamic
process. It is a chemical dissolution
brought about by metabolic activity in
a microbial deposit (biofilm) covering a
tooth surface at any given time. Over time
the outcome of these fluctuations may
result in a disturbance of the equilibrium
between the tooth mineral and the
surroundings. Mineral loss, subsequent
lesion formation and possible cavity
formation in teeth, is a symptom of
imbalance in this dynamic process.
The metabolism in the biofilm is an
ubiquitous, natural process; part of having
teeth. However, its possible consequence,
lesion formation and progression, can be
controlled so that a clinically visible lesion
never forms or an established lesion
arrests.2
The following points
encapsulate our current view of caries:3
Caries is ubiquitous;
It is a sign or symptom resulting from
numerous pH fluctuations in biofilms
on teeth. The resulting de- and remineralization of the tooth surface may
result in the formation of a clinically
detectable lesion (the sign/symptom);
These lesions may or may not progress;
Lesion progression can be controlled,
slowed down or arrested;
Everyone is at risk of lesion formation
from cradle to grave;
Caries is the predominant cause of
tooth loss in all ages.
In the 1970s, it was suggested
that caries could be prevented and
the concept of caries control was not
emphasized. The distinction between the
process in the biofilm and its reflection,
the lesion in the tooth, was not made
clear. Although it was realized that all ages
were susceptible to caries, prevention was
mainly taught in paediatric departments,
and it was suggested that periodontal
disease was the more important cause of
tooth loss in the elderly.

278 DentalUpdate

When GV Black published

his comprehensive textbook in 19084 he
emphasized that clinical diagnosis and
treatment decisions should have a sound
biologic rationale. Although it became
appreciated by the middle of the 20th
Century that dentistry is a biomedical
specialty, the technical advances with
high-speed drilling seemed to distort the
true application of biological knowledge
in the optimal treatment of dental caries.
Dental caries became synonymous with
a cavity in the tooth and the automatic
reaction was that the treatment should be
drill and fill.
In the growing field of caries
epidemiology, dental caries was recorded
as DMF teeth/surfaces where D stood
for Decay and decay meant a cavity.
The knowledge about aetiology and
pathology of caries was often taught
in dental curricula in departments of
microbiology, pathology and physiology,
as well as in the growing disciplines
of the 50s and 60s of dental public
health, departments of paediatrics and
preventive dentistry. However, the clinical
relevance of cariology to restorative
clinical departments was not emphasized
in all schools (The London being a notable
exception!) and knowledge to be applied
at the chairside was fragmented. To some
extent this was understandable because,
in a clinical department, the students
were supposed to produce fillings and
crowns and bridges. Thus the appreciation
of the need for concomitant disease
control as part of any long-term successful
restorative treatment was limited, or nonexistent.

What constitutes treatment of

caries?
This question is incredibly
important. Since lesion formation and
progression can be controlled, control of
the biofilm is the treatment of caries.
The most important control measure is
to clean teeth regularly, and thus disturb
the biofilm mechanically, with a fluoridecontaining toothpaste. If sugar intake is
high and frequent, the pH fluctuations in
the biofilm may result in overgrowth of
cariogenic micro-organisms, making lesion
formation and progression more likely.5
Thus dietary advice may have a role to play.

From these statements it is

obvious that it is the informed patient
that actually controls caries. So what then
is the role of the dental professional? It
is to advise, so that all our patients are
aware of the importance of good toothcleaning, appropriate use of fluoride and
a sensible diet. This is the non-operative
treatment of caries. Note that the
examination of the patient and giving
appropriate advice are time-consuming,
skilful and worthy of payment. However,
in the 1970s treatment (as opposed to
prevention) of caries was by filling teeth,
which is very unfortunate because fillings
mask the problem of poor plaque control
and the dentist takes responsibility away
from the patient. You have decay, let
me treat it for you by cutting it away
and replacing with a filling. Fillings are
even claimed by some to be secondary
prevention which is nonsense! For a while
fillings will appear to be successful, but
if the real cause of the problem is not
addressed, caries will recur adjacent to
the filling. To place restorations without
addressing the reason the lesion has
formed in the first place is tantamount to
repairing a fire damaged building without
extinguishing the flames. Fillings are a
part of plaque control and important in
the management of cavitated lesions, but
they are not the most important aspect of
caries control.
Forty years ago, in the United
Kingdom and Denmark, there were
departments of conservative, operative
or restorative dentistry where, although
the pathology of dental caries might
be taught, rewards were only given for
fillings. Undergraduates had points quotas
with points given for restorations. There
were no similar rewards for non-operative
treatments. Students would thus qualify
in the UK tailor-made for a National
Health Service which also gave rewards
for operative dentistry (fee per item of
operative treatment) but not for the nonoperative caries control measures.
It is now tempting to take a
sneaky look across the Atlantic where,
even today, there are few departments of
cariology and operative dentistry reigns
supreme. This is of great importance to
the young dentist who is emerging from
the dental school egg with debts of a
quarter of a million pounds. And before
May 2013

Cariology

so that the patient can disturb/remove

most of the biofilm with a fluoridecontaining toothpaste. Any lesion, at
any stage of progression, is arrestable by
cleaning alone provided the pulp is not
irreparably damaged. This diagnosis is
best performed by a careful clinical-visual
examination of clean, dry teeth. It was
realized that, while a sharp probe was
useful to feel the surface of the lesion
to detect roughness indicating activity,
the probe must be used gently. It is
not a bayonet and rough use to test for
stickiness actually damages the surface
of the lesion and encourages plaque
accumulation.
Radiographs are an aid
to diagnosis for approximal lesions.
However, while a radiograph gives some
appreciation of lesion depth, a single
radiograph cannot assess either activity
or cavitation. It must also be remembered
that there may be false positive and
negative findings on these twodimensional shadows. Radiographs do
not alone define the truth. A subsequent
picture, taken after a period of time with
a film holder and beam aiming device to
ensure comparable geometry, should be

we get too smug about this, let us remind

ourselves of what has just happened in
England and Wales to university fees, now
9000 per year in dental schools. Add
to this living costs for five years and it is
obvious that this problem is ours already.

Caries diagnosis
A diagnosis has been described
as a mental resting place on the way to
a treatment decision. What in diagnosis
is relevant to that treatment decision as
far as caries is concerned? The activity of
the lesion is of great importance (Figure
2). Lesions judged as active (by this we
mean if nothing changes, the lesion
will progress) require non-operative
treatments and a review of the efficacy of
the treatment is to check that lesions do
not progress and appear to be arrested.
The other aspect of great relevance is
whether a cavity is present that traps
plaque and precludes cleaning (Figure 3).
If the patient cannot access the plaque,
the lesion is almost bound to progress.
These lesions must either be filled or
perhaps made accessible to cleaning,6

a
a

b
b

Figure 2. (a) Active, non-cavitated, occlusal

lesion. The biofilm must be gently removed with
the side of an explorer or toothbrush otherwise
this lesion will not be seen. (b) Arrested, noncavitated pit or fissure lesions often present as
darkly stained. Removal of any biofilm important
to aid diagnosis.

280 DentalUpdate

Figure 3. (a) Active caries lesion with small cavity.

This is not cleansable and restoration is required
to aid plaque control. (b) Arrested occlusal caries
lesion. The undermined enamel margins have
fractured away and the cavity is cleansable. No
restoration needed to control caries.

examined for lesion progression or arrest.

Decisions, about activity
and cavitation, are inevitably best
guesses. This is not a disaster because
dentists should review patients and
thus review the decisions. However,
the opportunity for review should have
implications for decision-making. If a
lesion is suspected as active, it should
be treated non-operatively so as not to
miss the opportunity to arrest the lesion.
However, if a dentist is unsure whether
an approximal lesion is cavitated, and
therefore unsure whether a filling is
required, the better decision is to institute
non-operative treatment and reassess
rather than prescribe a restoration
because this is an irrevocable decision. We
know from research started at the London
Hospital by Richard Elderton in the early
70s, that placement of a restoration
may start a cascade of restoration and
re-restoration, each replacement resulting
in further tooth removal, until we simply
run out of hard tissue and the tooth is
lost.7
In the 1970s, there was no
appreciation of the relevance of lesion
activity to the treatment decision.
Approximal lesions tended to be treated
operatively when they were just in
dentine on radiograph and in Denmark
even when confined to enamel.8 The
current threshold for operative treatment,
in contemporary low caries populations,
tends to be lesions that are well into
dentine because the less advanced lesions
are often not cavitated when opened.
These should be treated non-operatively
and thus given a chance to arrest
following improved oral hygiene and
fluoride application.
In the 1980s and 1990s,
there was a flurry of activity in the use of
machines to aid diagnosis, for example
electrical conductance measurements
and fluorescence techniques, such as
DIAGNOdent (KaVo, Biberach, Germany).
The idea was to take the subjectivity
out of the task as well as to diagnose
demineralization at an earlier stage
so that non-operative caries control
measures could be instituted in a timely
fashion. After considerable research
effort, and many publications, it was
acknowledged that these machines can
only detect demineralization and not
May 2013

Cariology

make judgements on what matters most,

namely activity and cavitation. It was thus
eventually concluded that a visual-tactile
examination of clean, dry teeth, together
with careful thought, were preferable to any
machine.9
Occlusal lesions have given
particular food for thought. In the 1970s, it
was considered that the lesion formed in
the depth of the fissure and was difficult to
see and impossible to access for thorough
cleaning. In the 1980s, dentists noticed
that they were missing quite advanced
lesions on clinical examination but finding
large lesions in dentine on radiograph
(Figure 4). The term hidden caries was
used to describe lesions missed on clinical
examination but found on radiograph,
and fluoride was blamed for masking the
diagnosis. It was subsequently shown that
the occlusal lesion forms at the entrance to
the fissure and it can be diagnosed visually,
provided plaque is removed from the
fissure entrance. This was a very important
finding because it implied that these lesions
could be controlled by cleaning alone. The

erupting premolar/molar, in particular,

should be carefully cleaned by a parent,
with the brush coming in at right angles
to the arch (Figure 5). Occlusal lesions
can be prevented/controlled by careful
cleaning over the eruption period, and
fissure sealants are not required.10
Unfortunately, the profession
seems to have been very slow in adopting
a chart that allows the salient features of
lesion activity and cavitation to be visually
recorded, although such a chart has been
developed (Figure 6) and described in
Dental Update!11

Assessment of caries risk

Question: Who is at risk from
lesion development? Answer: Everyone
with teeth, from cradle to grave, because
the metabolism in the biofilm is a natural
part of having teeth. In recent years,
there has been much interest in whether
this concept of risk assessment can be
further refined so that caries control
measures may be targeted appropriately
before any lesions form. Caries risk

a
a

assessment will also guide appropriate

recall intervals. After much research, it
can be stated that no single factor or
combination of biological factors will
accurately predict risk, on an individual
patient basis, except the presence of early
non-cavitated lesions and a history of
lesions and fillings.12 This makes a careful
clinical visual-tactile diagnosis even more
important. However, all our patients
should be taught good oral hygiene with
a fluoride-containing toothpaste and the
relevance of diet to caries. This is called
a whole population approach and is
appropriate to any disease that potentially
occurs in everyone.
The one factor that will predict
increased risk is dramatically reduced
salivary flow (hyposalivation). Resting
flow should be measured when this
is suspected because, if the clinicians
suspicion is confirmed, the patient is at
risk of rapid lesion development. Frequent
recall and strenuous effort will be required
to control lesion progression in these
types of patients. The management
majors on plaque control and fluoride
(Figure 7). These are some of the most
difficult patients to manage; those one
worries about in the darker reaches of
the night.

Epidemiology

b
b

Figure 4. (a) The clinical picture shows a lesion

with a cavity in the central fossa. To see this,
the tooth must be clean and dry. The clinician
mistakenly diagnosed this lesion as arrested. (b)
However, the radiograph shows an extensive
radiolucent lesion in dentine and a restoration
is required. This makes the point that it is always
important to examine radiographs carefully. They
aid diagnosis.

May 2013

Figure 5. (a) The occlusal surface of this first permanent molar is at its most vulnerable during the
period from first eruption until it is in occlusion
(arrow points to erupting tooth). (b) Brushing the
occlusal surface of the erupting molar. The parent
assists, bringing the brush in at right angles to
the arch.

It was in the early 1980s that

data from around the developed world
showed a decline in caries prevalence and
incidence (rate of development). In UK,
decennial National Surveys have shown
this decline. In Denmark, all children
enrolled in the school dental health
service were examined annually, resulting
in unique longitudinal data. Initially, the
caries decline caused some panic. If dental
caries was solved, what were dentists
to do? Several dental schools closed in
the developed world and, ironically, in
England the school that trained therapists
was also closed. The dental profession
was climbing into the boat and pushing
off. After a few years it was realized that
the decline in caries prevalence and
incidence, far from obviating the need
for dentists, actually might require more
dental personnel because there are so
many more teeth to look after. Why have
there been changes in caries prevalence
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Cariology

fluids, delays lesion development and

progression and it does it at any age. The
fluoride does not have to be in water, it
can be in toothpaste, mouthwash, varnish,
gels. All systemic effects may result in
unnecessary development of dental
fluorosis14 but are not needed to obtain
maximum caries control. It should also be
appreciated that changing criteria for the
decision to restore has resulted in fewer
fillings and this has also played a major
role for the change in DMFT in many
countries.15

The role of diet

Figure 6. Chart with red (active) and blue (inactive) colours to indicate lesion activity. Lines and circles
differentiate non-cavitated from cavitated lesions.

Figure 7. Cancer patient who has mastered

caries control subsequent to resection of the left
mandible and radiation therapy of the head and
neck. The patient received regular professional
tooth cleaning and topical fluoride therapy in
conjunction with meticulous self-performed oral
hygiene.

and incidence? The likely explanation

would seem to be the advent of fluoride,
particularly in toothpaste. It should also be
noted that caries distribution in populations
is now more and more skew and often
concentrated in socially deprived people,
to the extent that rampant caries in a child
should make the dentist consider whether
the child is seriously neglected.

The role of plaque control

Since the metabolism in the
biofilm is responsible for caries lesion
development, plaque control is the most
important part of non-operative treatment.

282 DentalUpdate

The reader may be interested to know

that this was stressed in 1908 by GV Black
when he wrote his Textbook of Operative
Dentistry.4 Today, as in the 1970s, almost
all toothpastes contain fluoride and oral
hygiene is an ideal route for fluoride
application.

The role of fluoride

So if fluoride explains much
of this alteration, what is its mechanism
of action? In the 1970s, it was thought
that, to be effective, fluoride had to be
incorporated into developing enamel and
the fluoridated apatite so formed would
be more resistant to acid attack. Several
studies had shown the significant effect
of fluoridated water on dental caries, not
least in the United States and Holland.
This concept of incorporation into enamel
would basically mean that children, in
particular, would be the target group for
fluoride prevention. However, in 1981,
one of the cupboard companions (OF),
together with two Danish colleagues,
put together the evidence from research
works around the world to show that
the important mechanism of fluoride
was its topical effect.13 Fluoride, present
at the point of acid attack in the oral

The evidence linking sugar

and caries is irrefutable, although there
is no linear relationship between daily
sugar consumption and caries experience
on a population basis. Unfortunately,
there is less evidence that it is possible
to alter diets and persuade people to
eat differently. We only have to consider
the current obesity epidemic to realize
the difficulty. Caries decline occurs in
most populations without a concomitant
decrease in sugar consumption (Figure 8).
Changes in socio-economic conditions,
widespread use of fluorides, increased
appreciation of the role of oral hygiene
and changing restorative thresholds
have had a major impact on the caries
situation. For this reason, our major
focus in caries control should move from
diet to oral hygiene, with a fluoridecontaining toothpaste. However, this does
not mean that we should ignore diet.
All our patients should be aware of the
relationship of sugar to caries and dietary
advice is still needed in those developing
several new lesions at any stage in life.
It is especially important for those with
decreased salivary flow, where dietary
advice is mandatory.

When do we need fillings?

As discussed earlier, from a
purely cariological perspective, fillings
should be considered a somewhat strange
way of performing plaque control! Thus
they are required when the patient cannot
clean plaque out of a hole in a tooth, for
instance a cavitated occlusal (Figures
3a and 4) or an approximal surface. This
means that many root caries lesions do
May 2013

Cariology

c
Figure 8. The blue bars show the decline in caries experience (DMFT) in Denmark in 12-year-old children between 1974 and 1997. This pattern is typical of developed countries. The red bars show the
sugar consumption (kg/individual/year over the same years). The decline in caries is not likely to be due
to changed sugar consumption because this has not changed.

Figure 9. (a, b) There are 8 years between

the two photographs. In (a) the root lesions
are active, plaque-covered and soft to gentle
probing. In (b) the lesions are arrested, hard and
shiny. The non-operative treatment has involved
removal of a rim of unsupported enamel at the
occlusal aspect of the lesion, and daily plaque
removal with fluoride toothpaste. The lesions are
not visible and do not need restoration.

not require restoration because they can

be arrested by plaque control and fluoride
(Figure 9). Thus, unless appearance is a
problem (Figure 10), it is preferable to avoid
restorations. This was not practised in the
May 2013

1970s. Lesions, as seen in Figure 9, would

have been restored and this was not easy
because suitable adhesive restorative
materials were in their infancy and even
these cannot last forever.16
In the 1970s, fissure sealants
were recently developed and were
applied to sound fissures to prevent
lesion formation on molars and
premolars. Remember that the caries
prevalence was much higher in those
years. However, the contemporary
indications for sealants are much less.
Caries prevalence is reduced, it is unusual
to see occlusal lesions in premolars
and occlusal lesion formation can be
controlled by cleaning with fluoride
toothpaste. The contemporary indication
for sealants would be in patients who are
not cleaning effectively, despite advice.

Delivery of caries control

treatments in the NHS in
England and Wales
When Dental Update was
born practitioners were rewarded on
a fee per item of operative treatment
basis. There were no fees for preventive
treatments, such as oral hygiene
instruction, fluoride application, diet
analysis and fissure sealant application.

Figure 10. (a) Cervical lesions covered by plaque.

(b) The same cavities 14 days later after removing
overhanging enamel and showing the patient
how to clean. The teeth were then brushed twice
a day with a toothbrush and fluoride paste. At
this stage, from a cariological point of view, these
lesions were stable but very ugly. For this reason,
they were restored with composite (c). This was
taken immediately after removal of the rubber
dam and the teeth had dried out, which explains
a small colour difference that will disappear
rapidly as the teeth rehydrate.

There was a fee for scaling and polishing

and one of us (EK) used this fee to cover
preventive advice. In her hands money was
lost, but it did not haemorrhage.
In 2006 the fee structure was
altered, with a new contract, and fees were
divided into three bands. This system is
still in operation and, in the opinion of
one of the authors (EK), it is a problem and
should have been discontinued long ago.
Non-operative treatments are part of Band
1 which comprises diagnosis, treatment
planning and maintenance, attracting a
single Unit of Dental Activity (UDA), which
will represent about 15 minutes of surgery
time at best. For this fee the practitioner
should carry out:
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Cariology

History and examination;

Special tests such as radiographs;
Diagnosis and treatment planning;
Agreeing the plan with the patient
and gaining consent;
Scale and polish, if required;
All non-operative treatments, oral
hygiene advice, fluoride advice and
application if appropriate, diet analysis
and advice.
One of the authors is
on record asking advice from the
Department of Health as to how this can
be done for a single UDA11 but, as in the
Walrus and the Carpenter,17 answer came
there none. Literary buffs will recall that
in the poem there could be no answer
because the oysters were dead, they had
all been eaten.
This combining of diagnosis
and preventive treatment into a single
band precludes the hygienist (the
preventive therapist) from working in the
Health Service in many practices because
the dentist would then have to split the
derisory fee. Many hygienists only work
privately, which is ironic because caries is
concentrated in socially deprived people
who cannot afford to pay privately.
Band 2 treatment includes everything
in Band 1 plus simple treatment (fillings,
extractions and surgical procedures).
The fee is the same, one filling or ten, so
the dentist naturally dreads the patient
with a high level of disease and, again,
social deprivation may be relevant.
How depressing that this contract was
introduced on the watch of a socialist
government, has been running for 6
years, and it has not been suspended
by the Coalition while pilot work is
undertaken on a new contract.
Basically, we are not, as a
profession, responding to the need of
populations, but still believing that we
have to fight dental caries with metals,
composites and adhesives is this really
evidence-based dental care?18
Which brings us to a final
point: All the knowledge, evidencebased, may not be the key to success
because, in the final analysis, it comes
down to politics. The key to dental
health is simple and not expensive.
Our goal should be to ensure that, in
all populations around the world, most
people should be able to maintain a

286 DentalUpdate

functioning dentition from cradle to grave.

In the upcoming third edition of our mutual
textbook, we will soon document how
this goal is achievable today. Indeed, it has
been achievable for many years with the
knowledge that we now have about the
nature of dental caries.
Acknowledgements

Figures 2, 3, 4, 7, 8, 9, 10
are reproduced with permission from:
Dental Caries. The Disease and Its Clinical
Management. Fejerskov O, Kidd E (eds).
Oxford: Blackwell Munksgaard, 2008.
The dentist who took each
photograph and cared for the patient
is acknowledged by a signature on the
picture. This acknowledgement is important
because illustrations of this quality are
difficult to produce but invaluable teaching
material.

References
1. Silverstone LM. Dental caries: the
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an infectious disease? Diagnostic
and treatment consequences for the
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Yearbook. Schou L (ed). Copenhagen:
Quintessence Publishing, 2003:
pp141152.
3. Fejerskov O. Concepts of dental
caries and their consequences for
understanding the disease. Community
Dent Oral Epidemiol 1997; 25: 512.
4. Black GV. Operative Dentistry 1:
Pathology of the Hard Tissues of the
Teeth. Chicago, IL: Medico-Dental
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5. Marsh PD, Nyvad B. The oral microflora
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6. Kidd EAM. Should deciduous teeth be
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based) approach to quality dental care.
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Further reading

Dental Caries. The Disease and

Its Clinical Management. Fejerskov O, Kidd E
(eds). Oxford: Blackwell Munksgaard, 2008.
May 2013