Introduction to dental caries

Dental teams know only too well the challenges that patients with poor oral health bring to the chair. Although practitioners can offer effective interventions to enhance their dental health, most of the ‘heavy lifting’ is done by patients in their own environment, making home care maintenance the cornerstone of optimal oral health. 

Therefore, patients must understand what is needed to ensure a healthy smile and why this has as much to do with function as it does with looks. Healthy teeth and gums are also fundamentals of overall health. Extensive evidence-based research underscoring this interconnectedness between oral health and systemic inflammatory conditions should form the foundations of patient education efforts. 

Modern dental teams are pivotal in safeguarding patients’ holistic wellbeing. But prioritising dental health isn’t just good practice; it’s an essential strategy for a sustainable and robust business model. 

In an ideal world, dental practitioners and patients are joint gatekeepers of systemic health. And whilst accountability between appointments lies at home, ensuring the best care must begin with education in the chair. A dental team’s engagement to effect change in behaviours is intrinsic to this ‘shared responsibility’ model. The concept of optimum communication is deeply embedded in the principles of good dentistry, with studies, policy documents and public health guidance material underpinning it. And it is an ongoing strategy, too. As the government’s Delivering better oral health: an evidence-based toolkit for prevention, acknowledges, whilst ‘behaviour change interventions can support, and sustain, change’ it remains more ‘a journey, rarely an event.’  

Patient education, therefore, lies at the heart of behaviour change for optimum oral health and overall wellbeing. However, this isn’t always achievable for numerous reasons; sadly, the facts speak for themselves.

The statistics

Although largely preventable, oral diseases impose a significant global health burden. The Global Burden of Disease 2019 report highlights untreated dental caries in permanent teeth as the most prevalent health issue. 

The WHO Global Oral Health Status Report (2022) estimates that nearly 3.5 billion people worldwide suffer from oral diseases, most residing in middle-income countries. Specifically, around two billion people are affected by caries in permanent teeth and 514 million children experience caries in primary teeth.

Additionally, tooth loss was independently associated with cognitive impairment and dementia, with the risk of diminished cognitive function increasing with incremental numbers of teeth lost. 

In another study that investigated the link between oral hygiene behaviours and attitudes and oral health problems in minority undergraduate students, more than half of the participants with dental caries were not supervised when brushing their teeth as children.

Poor oral health also negatively impacts the global economy. With oral diseases affecting an estimated 3.5 billion people each year, their economic burden totals $710 billion annually worldwide. The latest NHS national cost collection data have estimated the costs to the NHS of hospital admissions for tooth extractions in children aged 0-19. In the financial year 2021 to 2022, the costs were £81.0 million for all tooth extractions and £50.9 million for caries-related tooth extractions.

A joined-up approach 

The recent white paper, Time to put your money where your mouth is: addressing inequalities in oral health, published by Economist Impact and commissioned by the European Federation of Periodontology, examined the need for a joined-up approach between policy, public health initiatives and clinical practice to address the challenges facing oral health. 

It investigates the impact of poor oral health and considers the urgent need to address existing inequalities.

Top 10 key points  

1. ​Dental caries is influenced by factors such as oral hygiene, diet (particularly sugar consumption), socioeconomic status and access to dental care. ​ 

2. Community water fluoridation is recognised as an effective measure for preventing dental caries. ​ 

3. Oral health promotion and prevention strategies, including dental sealants, mechanical plaque control and oral hygiene education, are essential for preventing dental caries. ​ 

4. Oral health has a significant impact on quality of life, and there is a need for integrated approaches to oral health care and primary care. ​​ 

5. Preventive oral care is essential for establishing universal dental care and improving access to oral care. ​ 

6. The DMFT score used to determine early carious lesions has limitations, and alternative measures should be considered. ​ 

7. Awareness about prevention should be raised through education programmes to curb misinformation. ​ 

8. Governments should play a key role in investing in population-level prevention measures and addressing oral health inequalities. ​ 

9.  Preventive interventions for caries include maintaining good oral hygiene, applying fluoride, and sealing pits and fissures on teeth. ​ 

10. To address health inequalities, oral health must be included in the mainstream NCD framework and adopted as a transdisciplinary approach.  The Oral Health Foundation points out that this is despite a recent World Health Organisation (WHO) resolution urging the integration of oral care into broader healthcare.  

In response to the paper, the British Society of Periodontology and Implant Dentistry (BSP) outlined five takeaways on periodontitis and caries…

Caries management is then a dynamic and multifaceted aspect of dental care. It underscores the importance of a proactive approach, where preventive measures, early detection and tailored treatment strategies are essential in effectively addressing the disease.

Biodentine – biocompatible and bioactive

‘In paediatric dentistry, this material is going to offer the advantages of rapid application in an emergency consultation without the need for any preparation of the dentin surface, with the guarantee of imperviousness to avoid bacterial contamination (Dejou J. et al., 2005), and one that can be left in situ for up to six months. The various studies available enable us right away to add this material to our everyday treatment armamentarium, with the results of long-term clinical studies due to be available in the coming months.’

Dr Lucile Goupy, DDS, in her paper Biodentine a novel dentin substitute for use in paediatric conservative dentistry

The introduction of new materials and techniques to the minimally invasive management of caries has significantly improved patient outcomes.  

Septodont developed Biodentine nearly a decade ago. 

Initially celebrated for its efficacy in vital pulp therapy and the treatment of deep caries, it has also since established itself as an indispensable tool for managing irreversible pulpitis. 

The bio ‘bulk-fill’ procedure simplifies the process for practitioners, enabling a single material to fill the cavity efficiently.  

Biodentine, a second-generation hydraulic calcium silicate material composed mainly of tricalcium silicate, also contains a zirconium oxide radiopacifier and some additives. It is scientifically engineered for a specific purpose: to be used as a dentine replacement material.  

Research shows that Biodentine performs well as a dentine replacement and is used in other clinical applications. Thus, it is undoubtedly more than just dentine in a capsule. 

It is the first all-in-one biocompatible and bioactive crown‑root dentine substitute with unique clinical properties.  

• 1,000-plus publications with scientific evidence on Biodentine. 

• Five million patients were treated with Biodentine. 

• 10 years of research and development in Septodont laboratories. 

• In the crown: Enamel restoration (within six months), permanent dentine restoration, deep or large carious lesions, deep cervical or radicular lesions, pulp capping, pulpotomy. 

• In the root: Root and furcation perforations, internal/external resorptions, apexification, retrograde surgical filling. 

• Reverse irreversible pulpitis. 

Thanks to the patented Active Biosilicate Technology ensuring high purity of tricalcium silicate, Biodentine offers unique features:

Bioactivity

Biodentine preserves pulp vitality and can be placed directly on the pulp. Thanks to the formation of hydroxyapatite and the mineralisation process, Biodentine creates a tight seal within the dentine tubules and the dentinal bridge.

Biocompatibility

Thanks to the high purity of tricalcium silicate and the resin-free formula, Biodentine can be placed directly on the pulp and living tissues, ensuring no tissue/pulp reaction risk.  

Sealing ability

Thanks to the creation of mineral tags in the dentine tubules, Biodentine can replace dentine in the crown and root and reduce the risk of secondary caries.  

Dentine-like properties

Biodentine has the same mechanical properties as dentine and similar mechanical behaviour than dentine.  

Limitation of bacterial growth

The alkaline pH limits bacterial growth, helping to decrease post-operative pain and reducing the risk of secondary decay.  

Anti-inflammatory properties 

The anti-inflammatory potential induces adequate control of inflammation, facilitating healing, repair, and pain.

Biodentine XP

Biodentine is the first all-in-one biocompatible and bioactive crown-to-root dentine substitute.  

Thanks to its unique features, outstanding sealing, and mechanical properties, Biodentine can be used as a bio-bulk fill material by filling the cavity from the pulp to the top (with a final enamel restoration performed within six months): the procedure is easy and fast, as the same material is used. 

Now, Septodont introduces a new version of Biodentine, Biodentine XP, a new dentine-restoration system with an all-in-one cartridge, offering direct placement in the tooth to facilitate practitioners’ daily procedures. 

Biodentine XP is all of Biodentine’s science, embedded in a new and upgraded system designed to provide dentists with an optimal daily experience, from product preparation to direct placement in the tooth. 

Biodentine XP will ensure a consistently perfect mix thanks to its high-speed mixer and easy delivery with the Biodentine Gun. The all-in-one cartridges are available in two formats (XP 200 & XP 500), depending on the procedure, the cavity depth and the quantity needed.

The ease of use and multiple indications of Biodentine XP from the crown to the root will help dentists treat their patients daily. 

• With Biodentine XP, your whole procedure, from preparation to dispensing, is more straightforward than Biodentine.  

• All-in-one cartridge: the cartridge already contains both the powder and the liquid.  

• Direct placement in the tooth, thanks to the gun.  

• Choice of volume: the cartridge is available in 2 formats (XP 200 or XP 500). You choose the quantity needed depending on the procedure and the deepness of the cavity. 

• In the crown: temporary enamel restoration, permanent dentin restoration, deep or large carious lesions, deep cervical or radicular lesions, pulp capping, pulpotomy.  

• In the root: root and furcation perforations, internal/external resorptions, apexification, retrograde surgical filling. 

The first all-in-one dentine substitute to fully replace dentin, providing a more straightforward and improved daily experience from product preparation to direct placement in the tooth.

All Biodentine’s science with the experience you expect

• All-in-one cartridge: ready-to-mix power-liquid cartridge that provides fewer preparation steps, mix consistency and homogeneity at each use.  

• Choice of volume: The right amount of dentin substitute is delivered thanks to the choice between XP 200 and XP 500.  

• Direct placement: For crown indications, the gun and the orientable nozzle allow you to apply Biodentine directly in the cavity from the crown to the top. 

• Thanks to the patented Active BioSilicate Technology, which ensures high purity of tricalcium silicate, Biodentine XP offers unique features.

Case study

In this case study, Joseph Sabbagh discusses the benefits of the bio-bulk procedure, which uses the Biodentine system to maintain pulp vitality.

Introduction  

This case study aims to discuss two clinical situations treated with Biodentine and Biodentine  XP with a 12-year follow-up. This emphasises the evolution and improvement made to the Biodentine system. 

Methods 

This is the protocol for using Biodentine as a bio-bulk capping material in one or two sessions and the different clinical steps to follow.  

Discussion  

Bio-bulk fill is indicated in deep cavities, reducing pulpal damage risks and maintaining vitality.  

Vital pulp therapy 

While Biodentine XP maintains the exact formulation and indications as Biodentine, it makes the application technique and handling much easier for the dentist. 

Management of deep caries and preservation of pulp vitality represents daily challenges for the dentist and the patient concerned with avoiding root canal treatment. The American Academy of Paediatric Dentistry defines vital pulp therapy as ‘the placement of a protective barrier over exposed or unexposed pulp to induce the formation of a dentinal bridge and maintain its vitality and function’.

Direct and indirect pulp capping 

Direct and indirect pulp capping are the main techniques to maintain pulp vitality in permanent teeth. Two groups of materials are used: calcium hydroxide and tricalcium silicate. 

A recent meta-analysis compared the two types in deep cavities with exposed pulp. Better long-term outcomes were achieved using the tricalcium silicate-based materials MTA and Biodentine. Biodentine has been used for over 12 years for different indications in deciduous and permanent teeth. It shows high success rates at different recall times. 

Biodentine  XP was recently launched, offering the same composition in a pre-dosed, ready-to-mix capsule format. The system includes a mixer and a dispensing gun, ensuring uniform consistency and easy delivery directly into the cavity. Two capsule volumes are available according to the clinical indication and quantity needed: Biodentine XP 200 and Biodentine XP 500.  

On the other hand, the bulk-filling approach has gained wide popularity in dentistry in recent years. It can be approached with inert bulk-fill materials, like the composites that are used in layers of 4 mm, or ‘bio-bulk fill’ materials mainly based on tricalcium silicate.  

Bio-bulk filling 

The bio-bulk filling approach involves applying bioactive cement in the deep part of the cavity. This will interact with the pulp and induce repair and bridge formation, thus maintaining pulp vitality and avoiding root canal treatment. 

The application is completed by placing a 1.5-2mm conventional or bulk-fill resin composite on the top. This can be placed either during the first or the second session. Bulk-fill resin composites allow the application of layers up to 5 mm thick, aiming to shorten the restorative procedure time in posterior cavities and make it easier for dentists. 

Today, more than 50 bulk-filling systems from different companies are available. They are classified into four categories relying on various technologies – flowable resin composite, sonic energy, fibre-based resin composite, and high-density filler composites. This clinical paper aims to present the concept of ‘bio-bulk fill’ in cases of deep cavities using Biodentine XP, reducing the risk of pulpal damage and maintaining pulp vitality.

Preventive strategies in caries management

Addressing underlying dental issues like caries is crucial, as they can significantly affect a patient’s health and wellbeing. Therefore, preventive strategies in caries management are essential in enhancing their patients’ quality of life. 

This includes: 

• Regular examinations 

• Sharing dietary advice 

• Advising on lifestyle modification, such as smoking and alcohol consumption 

• Helping patients leverage the best tools for maintaining their oral health and ensuring optimum techniques  

• Emphasising the critical connection between what happens in the mouth and the rest of the body.  

Other information that empowers patients to take charge of their oral health includes: 

1. Fluoride plays a crucial role in preventing and remineralising early carious lesions. Regular use of fluoride toothpaste and professional fluoride treatments are effective strategies for reducing the incidence of caries. 

2. Reducing the frequency and amount of fermentable carbohydrate intake is also essential in caries prevention. Educating patients about the impact of sugar consumption on oral health is a critical component of preventive care.  

3. Effective oral hygiene practices, such as regular toothbrushing with fluoride toothpaste and interdental cleaning, are fundamental. Patient education and motivation are vital to ensure adherence to proper oral hygiene routines and correct methods. 

4. Lifestyle choices significantly impact oral health. Discussing habits such as smoking and alcohol consumption with patients and providing strategies for modification can lead to improved oral and overall health. 

Innovation, research and digital technology have created opportunities for new oral hygiene products that enhance dental care delivery. Smart toothbrushes that harness AI technology, apps and sensors guide patients to better brushing techniques and track progress, offering a new dimension to home care.  

Effective communication with patients about their oral health can significantly improve outcomes. Social media has become a valuable communication tool for engaging patients and providing them with easy-to-digest reminders, tips and insights about the importance of good oral health.   

Arming patients with high-quality care, essential information, and cutting-edge at-home oral hygiene products will help them sustain their smiles and prevent systemic diseases. These efforts contribute to the growth and success of dental practices, as satisfied patients are more likely to recommend them.

Other preventive strategies dental professionals can harness include:

High-fluoride toothpaste

Identifying patients who can benefit from high-fluoride is important in caries prevention. These might include: 

• Individuals with a history of tooth decay or active caries. 

• Elderly patients. 

• Patients on sugar-containing medication. 

• Patients with xerostomia. 

• The systemic effects of diabetes can exacerbate oral health issues for diabetic patients. 

• Orthodontic patients who wear fixed orthodontic appliances. 

• Patients with receding gums or insufficient restorations with exposed root surfaces. 

• Those struggling to maintain adequate oral hygiene (people with dexterity issues or SEND patients. 

• Patients with high sugar diets. 

• Infrequent dental visitors. 

Pit and fissure sealants

For decades, pit and fissure sealants have been used to prevent and control dental caries on permanent teeth. Materials include resin-based, glass ionomer, polyacid-modified resin and resin-modified glass-ionomer cement. Compared with unsealed teeth, there is moderate certainty evidence that resin-based fissure sealants effectively prevent and arrest dental caries for up to 48 months. The evidence for glass-ionomer-based sealants remains inconclusive. 

The DBOH toolkit suggests that, in line with the philosophy that children at increased risk of dental caries should receive additional preventive interventions, resin-based sealants be applied to the eruption of permanent teeth, particularly molar teeth, if a clinician judges a child to be at higher risk of dental caries. 

Whilst there is limited research evidence on the benefits of proximal sealants, it is best practice to seal a surface if it is exposed and at risk. For example, the mesial surface of a first permanent molar may be sealed when the deciduous molar has been lost or when a surface is exposed whilst carrying out an interproximal restoration on an adjacent tooth. 

The placement of sealants is highly technique-sensitive, with poor operative technique and/or a challenging environment affecting the sealant’s retention and, therefore, its success. It is vital to check sealants for wear, integrity and leakage at every visit and re-seal where necessary to maintain their role in caries prevention.

Sugar-free chewing gum

Sugar-free chewing gum has been suggested as a dental caries-inhibiting activity. A recent systematic review provided tentative evidence that chewing sugar-free gum reduces dental caries compared to ‘not chewing’. However, the effect was considerably variable and the trials included were generally of moderate quality.  

The National Institute for Health and Care Excellence (NICE) guidance on oral health for adults in care homes does include SFG as an option for dental caries risk management amongst dentate frail older adults in care homes.

Risk assessment and diagnosis

Dental caries is a multifactorial disease caused by the interaction of cariogenic bacteria with fermentable carbohydrates. This process results in demineralisation and destruction of the teeth’s hard tissues. It affects individuals of all ages across different populations and is influenced by multiple factors, including diet, poor oral hygiene practices, socioeconomic status and access to dental care. 

According to the UK government’s Delivering Better Oral Health, an evidence-based toolkit for prevention, ‘assessing the level of dental caries risk for an individual patient is key to tailoring appropriate preventive care’. 

This involves evaluating factors such as past caries experience, dietary habits, fluoride exposure, salivary flow rate and oral hygiene practices.  

A comprehensive approach includes addressing modifiable risk factors such as: 

• Excessive sugar consumption. 

• Tobacco and alcohol use. 

• Poor hygiene practices.  

Patients who are at higher risk of dental caries include: 

• Children presenting with tooth decay. 

• Children who have had dental caries in their primary dentition and first permanent molars. 

• Children who have been admitted to the hospital for the removal of their teeth. 

• Children who are medically compromised or have a disability. 

• Adults with medically compromising conditions or disabilities. 

• Older adults, particularly as they become physically or cognitively impaired. This includes people for whom treating dental caries can be difficult or present a health risk. 

Additionally, patients with specific teeth or areas of their mouth may be at higher risk of developing dental caries. For example, hypo-mineralised teeth are at increased risk of dental caries in children. Adults with partially erupted third molars are also at higher risk of developing dental caries in the impacted third molar itself or mesioangular impacted third molars on the distal surface of the preceding second molar tooth. 

Risk assessment tools, like the Caries Management by Risk Assessment (CAMBRA) protocol, help clinicians identify patients at high risk for caries and tailor preventive strategies accordingly. This evidence-based approach helps clinicians determine the many causes of caries – including bacteria, carbohydrate diet and host response – and take appropriate action. It involves evaluating the etiologic and protective factors and establishing the risk for future disease, followed by developing a patient-centred, evidence-based caries management plan. 

More recently, diagnostic technology advancements have enhanced the detection of early carious lesions, focusing on functional integrity. As a result, caries risk assessment has evolved massively, moving on from a visual examination and visual-tactile screening to include radiographic caries detection and transillumination (particularly in identifying and assessing approximal caries).  

Following the advancement of fibre optics utilising visible light for early caries detection, the near-infrared light transillumination (NILT) technique has been devised to facilitate tooth transillumination. This method combines near-infrared (NIR) light and digital camera systems, offering enhanced light penetration capabilities. Transillumination relies on the principle of light transmittance disparities between healthy and carious tooth tissues, offering a promising technique for identifying caries, especially in approximal regions.  

Optical coherence tomography (OCT) uses infrared light to create cross-sectional images of dental tissues, offering non-invasive and high-resolution tomographic imaging. Integrated with image processing methodologies, OCT provides enhanced objectivity in diagnosing demineralised lesions, potentially revolutionising caries diagnosis in dentistry. 

Laser fluorescence techniques, including laser fluorescence (DIAGNOdent) and quantitative light-induced fluorescence (QLF), exploit fluorescence properties to identify caries. These methods exhibit high sensitivity, especially in early caries detection and offer the potential for monitoring lesion progression over time. 

LED-based devices like Midwest Caries ID employ reflectance and refraction technologies to identify optical property variations within teeth. These devices are sensitive and specific in detecting caries. However, limitations exist in accurately assessing lesion depth. 

Alternating current impedance spectroscopy, employed in devices like CarieScan PRO, measures electrical impedance changes in dental tissues to detect initial caries, although with moderate sensitivity and specificity levels. 

Cutting-edge technologies like Terahertz imaging, multiphoton imaging microscope and Raman spectroscopy offer high-resolution caries diagnosis methods. 

Deep learning-based convolutional neural network algorithms hold promise in automating caries detection through computer vision. They leverage advancements in artificial intelligence to enhance accuracy and reliability in identifying carious lesions, potentially revolutionising the field of caries diagnosis. 

Differentiating dental caries from other conditions, such as developmental defects of enamel, erosion and attrition, is also crucial for appropriate management. Clinicians must consider these conditions in the differential diagnosis to avoid misdiagnosis and inappropriate treatment.

Minimally invasive treatment approaches

According to the paper, Dental Caries and Its Management ‘non-invasive, micro-invasive, and minimally invasive approaches should be considered, especially when the carious lesions are not cavitated. The selective caries removal approach is viable for preventing caries progression, but careful case selection is required to achieve a good outcome’. 

Non-operative caries management focuses on arresting and reversing early carious lesions through remineralisation techniques, such as fluoride therapy, silver diamine fluoride application, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) products. 

Microinvasive treatments, including resin infiltration and atraumatic restorative treatment (ART), aim to manage carious lesions with minimal removal of tooth structure. These approaches are particularly beneficial for early carious lesions and patients with high caries risk. 

When carious lesions progress to cavitation, restorative treatments become necessary.  

Choosing the appropriate restorative material, such as composite resin, glass ionomer, or amalgam, depends on factors like lesion location, patient preferences, and aesthetic considerations.

Comprehensive caries management plan

A comprehensive caries management plan involves thoroughly assessing the patient’s caries risk, diagnosis and treatment needs. An individualised plan should include preventive strategies, minimally invasive treatments and restorative care tailored to individual circumstances. 

Educating patients about the causes and prevention of dental caries is crucial for effective management. Motivational interviewing techniques can enhance patient adherence to recommended oral hygiene practices and dietary modifications. 

Regular monitoring and follow-up appointments are essential to assess the effectiveness of the caries management plan and make necessary adjustments. Early detection of new carious lesions and reinforcement of preventive measures are critical components of ongoing care. 

Special considerations in caries management

Managing dental caries in children requires special consideration due to their unique developmental and behavioural needs. Techniques such as behaviour management, appropriate use of fluoride, and dietary counselling are crucial for effective caries prevention and treatment in paediatric patients. 

Older adults may face challenges such as xerostomia, cognitive decline, and physical limitations that affect their oral health. Tailoring caries management strategies to address these issues is essential for maintaining oral health in the geriatric population. 

Patients with special needs may require modified approaches to caries management due to physical, intellectual, or sensory impairments. Collaborative care involving caregivers and other healthcare professionals is often necessary to ensure optimal oral health outcomes.

Managing deep caries: Why do my patients thank me? Richard M Foxton 

It is now acceptable practice to remove only ‘softened’ carious dentine using hand excavators, initially adjacent to the enamel-dentine junction, keeping away from the deeper caries. This will lessen the likelihood of pulp exposure. 

However, it is essential to understand that the cavity does not need to be completely caries-free. This will result in sound dentine being present on the cavity floor, which will expose dentinal tubules and cause pain for the patient. 

Fusayama undertook important research in the late 1970s, and his group classified carious dentine into two zones; ‘caries-infected” dentine and “caries-affected” dentine. This provides guidance on how the histology of the dentine carious lesion can be related to the clinical situation. Fusayama advocated removing caries-infected dentine, which is substantially demineralised, consists of irreversibly denatured collagen fibrils and is physiologically un-remineralisable. Caries-affected dentine is left behind because it is minimally infected with bacteria, partially demineralised and physiologically remineralisable. 

There is no solid evidence that it is necessary to remove all the caries-infected dentine. If there is enamel present at the cavity margins, then the deeper caries can be ‘sealed’ after removal of only superficial soft caries if an adhesive restorative material is used. 

Fusayama also introduced the concept of ‘painless dentistry’.  His rationale for leaving the cavity floor consisting of caries-affected dentine is that the tubules are filled with whitlockite crystals formed by reprecipitation of calcium and phosphate ions lost during the carious process and forms a so-called ‘barrier’ to the underlying pulp.  He wrote in 1991: ‘Although dentists have heretofore believed that dental caries treatment must surely be accompanied by pain, our new concept of dental caries pathology reveals that the pain is caused by removing tissue that should not be removed.’ 

Fusayama thereby introduced the concept of ‘painless’ dentistry. If only the ‘soft’ caries is carefully removed with an excavator then this will not cause pain to the patient and this is all the operative intervention that is required on the carious dentine. This will also minimise the risk of post-operative sensitivity because open dentine tubules present in sound dentine will not be exposed as mentioned earlier. 

Therefore, we should consider adopting a biological approach to managing caries and cavity restoration and aiming to preserve pulp vitality at all costs. 

An additional risk nowadays is undertaking aerosol-generating procedures on patients who may have been infected with COVID-19. 

It would make sense, therefore, if access cavities for caries are kept as small as possible if an air turbine is used, thus minimising its’ use followed by careful excavation of only superficial, soft, wet, ‘infected’ carious dentine. 

If we are thinking biologically when we are managing carious dentine then we should also be thinking what the health of the pulp might be, particularly if the caries is deep. And it could be that if deep caries is present then the pulp could be ‘stressed’ even if it has responded positively to a vitality test. (1982, Abou-Rass). If we believe this concept then, when we proceed to restoration of the tooth, efforts should be directed at minimising further stress on the tooth and consideration given to trying to remineralise the carious dentine remaining on the cavity floor prior to placing an adhesive direct restorative material. 

The Bio bulk-fill procedure will allow placing Biodentine from the pulp to the top regardless of the cavity’s depth. The setting reaction of calcium-silicate materials is unlikely to stress the pulp further, and the calcium-silicate cement, in particular Biodentine (Septodont, Saint-Maur-des-Fossés, France), may have a therapeutic effect of ‘pulp-healing’. 

When managing teeth with deep caries, it makes sense from a biological point of view to attempt remineralisation and provisionalisation with a ‘bioactive’ calcium silicate cement such as Biodentine (and my patients will thank me for that) and a subsequent restoration with a restorative material such as direct composite resin. This may allow the odontoblasts to lay down tertiary dentine and potential pulpal healing. 

Even if the direct composite resin restoration subsequently fails, the option for a partial coverage restoration may still remain. This may then delay more invasive dental treatment such as endodontics and restoration with a post and core and a full-coverage crown, which could ultimately fail and necessitate extraction of the tooth.  

*References available on request

The future of caries management

Emerging diagnostic technologies promise to improve early detection and monitoring of carious lesions.  

Research into the potential applications of microbial preparations in preventing and treating dental caries is an essential research avenue in oral microbiology. 

Studies into novel preventive and therapeutic agents, such as probiotics, prebiotics, synbiotics and postbiotics, offer the potential for enhancing caries management.   

These microbial preparations can modulate the balance of oral microbiota by introducing beneficial microorganisms or inhibiting pathogenic ones.  

Personalised medicine approaches, including genetic testing and microbiome analysis, may also enable more targeted and effective caries management strategies. Understanding individual susceptibility to caries can lead to tailored preventive and treatment plans. 

Continuing advancements in minimally invasive techniques and materials will further improve patient outcomes. 

Dental professionals are critical in managing dental caries through evidence-based practices, patient-centred care and continuous education. Staying updated with the latest research and technological advancements is essential for optimal care. 

The future of caries management lies in integrating advanced diagnostic tools, innovative preventive and therapeutic approaches, and personalised medicine. Embracing these advancements will enhance our ability to effectively prevent and treat dental caries, ultimately improving oral health outcomes for patients worldwide.