Ultraconservative and Cariostatic Sealed Restorations
Ultraconservative and Cariostatic Sealed Restorations
Ultraconservative and Cariostatic Sealed Restorations
cavity. Thus, a properly placed lars be paired only with perma- tor removed all soft demineral-
bonded and sealed Class I nent molars and premolars with ized dentin only in the localized
restoration has the potential to premolars. There were 131 area of the carious lesion, but
preclude the progression of a molar pairs and 25 premolar the preparation was not extend-
carious lesion sealed within the pairs. The procedures, possible ed into unaffected fissures and
tooth. discomforts or risks, and possi- grooves. If two separate occlusal
The purpose of this con- ble benefits were explained lesions were present, they were
trolled clinical study was to use fully to subjects, and their in- not combined into a single larger
two modalities to evaluate the formed consent was obtained amalgam restoration. Instead,
effectiveness of treating frank before the investigation. two small localized cavity prepa-
cavitated lesions: Lesion characteristics. We rations were made, except when
dsealed composite restorations screened patients who had at the distance between the two
placed over the carious lesion; least two clinically obvious cavi- cavity preparations would be
dremoval of the carious lesion tated lesions with bitewing ra- less than 0.5 millimeters. After
and placement of ultraconserva- diographs to confirm that each the amalgam was placed, the
tive, localized sealed amalgam lesion extended into the dentin operator applied sealant over
restorations without an exten- but was no deeper than halfway the restoration and all pits and
sion for prevention. into it. The judgment that a le- fissures of the tooth.
We then compared these two sion on a radiograph was halfway Cariostatic sealed composite
modalities with the traditional into dentin was estimated as restorations. For each patient,
unsealed Class I amalgam half the distance between the we paired one of these amalgam
restoration, including the exten- dentinoenamel junction, or restorations with a bonded and
sion-for-prevention cavity out- DEJ, and the pulp chamber or sealed composite, or CompS/C,
line form. This article summa- between the DEJ and the near- restoration placed over caries,
rizes the observed results for est pulp horn. We did not accept for a total of 156 pairs of study
each of the three restorative ap- lesions confined to the enamel teeth, or a total of 312 teeth.
proaches over a 10-year clinical and we excluded teeth with Treatment assignment
trial period. proximal caries. (CompS/C and AGS or AGU)
Restorations. Conventional was statistically randomized for
MATERIALS AND
METHODS
amalgam restorations. At base- each study tooth.
line, 123 patients (43 males, 80 The only preparation for the
The materials and methods females), aged 8 to 52 years (the CompS/C restorations consisted
used in this study have been de- median age was 23 years), re- of placing a 45- to 60-degree
scribed elsewhere,5-10 but de- ceived either a localized sealed bevel in the enamel surround-
scriptions of the patient selec- amalgam, or AGS, restoration ing the frank cavitated lesion.
tion criteria, lesions, procedures that was not extended for pre- This occlusally divergent bevel
and materials follow. All opera- vention or an unsealed amal- had to be at least 1 mm wide
tors and evaluators were den- gam, or AGU, restoration that and placed in sound enamel. We
tists. The operators were trained was prepared using the tradi- removed all of the crumbly,
regarding the specific restora- tional principles for Class I cav- opaque demineralized enamel
tive techniques and the evalua- ity form in which the preparation with a bur until we reached
tors were calibrated to enhance was extended into noncarious fis- translucent sound enamel. We
interexaminer reliability. sures to prevent future caries ac- did not remove undermined
Patient selection criteria. tivity. We completely removed enamel or caries below the
To be included in the study, soft demineralized dentin and bevel.
each person must have had at chalky white demineralized During the operative proce-
least two Class I lesions in pre- enamel for both types of amal- dures at baseline, if the opera-
molars or permanent molars, gam preparations. We did not tor inadvertently removed all of
and the carious lesions must remove dentin or enamel that the soft dentin, the potential
have been clinically and radio- was stained and hard. study tooth was disqualified for
graphically obvious. Conservative amalgam the CompS/C restoration be-
The selection of study lesions restorations. For the AGS cause a carious layer of soft
required that permanent mo- restorations, the dentist opera- dentin had to remain below the
the operator washed the cavity Teeth with sealed amalgam Teeth with unsealed amal-
(AGS) restorations (n = 77) gam (AGU) restorations
and dried the bevel. Some of the (n = 79)
previously observed hanging
shreds were washed out, but *Groups 1 and 3 and groups 2 and 4 were compared directly in the same patients. Different
others remained. A layer of soft patients in Group 1 were compared with different patients in Group 2. Likewise, different
patients in Group 3 were compared with different patients in Group 4.
and wet-looking dentin in the
pulpal area of the cavity re-
mained intact, and there was ed it to ensure that all of the groups of restorations, with the
absolutely no instrumentation pits and fissures and the entire added advantage that Group 1
below the enamel bevel. The op- restoration with the adjacent (n = 77) and Group 2 (n = 79)
erator next thoroughly dried enamel were completely sealed. CompS/C restorations could
and etched the bevel and the If they were not completely also be combined into a
adjacent enamel for 60 seconds. sealed, the area or areas in CompS/C study cell consisting
The bonding agent was placed question were re-etched for 30 of 156 CompS/C restorations.
on the bevel and the adjacent seconds and resealed. The rub- This double-sized CompS/C cell
etched enamel. The operator ber dam was removed and the represented the greatest devia-
then used hand instruments to dentist made necessary occlusal tion from the traditional ap-
place a self-curing composite adjustments. proach to treating pit and fis-
material. Materials. The materials sure caries and was designed to
After a final shaping of the used included Delton yellow- test not only the clinical
occlusal anatomy with rotary tinted, chemically cured pit and longevity of service but also to
instruments, the operator then fissure sealant (L. D. Caulk, monitor any progression of the
etched all of the occlusal, buccal Dentsply Division [at the time carious lesions under the sealed
and lingual pits and fissures for of the study, the sealant was composite restorations.
60 seconds, washed the etchant manufactured by Johnson & Criteria for clinical evalu-
thoroughly and applied a chem- Johnson Dental Products Co.]), ation. The three types of study
ically cured sealant. The radiopaque chemically cured restorations were evaluated
sealant, which was applied with Miradapt composite restorative clinically according to the modi-
an applicator supplied in the material (Johnson & Johnson fied Ryge criteria10 and accord-
sealant kit, was placed over the Dental Products Co. [the mate- ing to further subcategories of
entire restoration and adjacent rial is no longer manufactured]) the marginal integrity, or MI,
etched enamel as well as over and Dispersalloy amalgam criteria.8 The Ryge criteria,
all of the pits and fissures of the (L. D. Caulk, Dentsply Division ranging from the best rating to
tooth. [at the time of the study, the the worst, are as follows:
When the sealant was set in amalgam was manufactured by dOscar is excellent;
the mixing well, the operator Johnson & Johnson Dental dAlfa is very good;
waited another 30 seconds to Products Co.]). dBravo means a defect is pres-
ensure that the sealant was Study design. The study de- ent but the restoration is still
also set on the tooth. The opera- sign was four-celled, as shown clinically acceptable and does
tor then wiped the sealed tooth in the box (“Four-Celled Study not require replacement;
with a wet cotton roll, dried it Design”). This type of design al- dCharlie is a clinical failure of
with an air syringe and inspect- lowed us to compare the four the restoration involving ex-
Figure 2A. Clinical photograph of a mirror image of Figure 2B. Tooth no. 30 immediately after the
two preparations (bevels in the central and mesial restorative procedure.
pit areas) of tooth no. 30 shown in Figure 1. There
was no excavation of soft caries below the bevels.
Part of the mesiolingual aspect of the tooth is cut subcategory the explorer tip encountered a
off in this photograph. (Oscar/Alfa) crevice, the explorer tip entered
consisted of it and then was blocked from
restorations that remained continuing in either direction
partly sealed; that is, more than (that is, from the tooth to the
50 percent of the margins re- restoration or from the restora-
mained sealed and there were tion to the tooth). Table 1 shows
no open margins. This subcate- the percentage of open margins
gory had a wide range of for the CompS/C and AGS
sealant retention (that is, 51 to restorations that remained in
99 percent of margins remain- single digits after 10 years.
ing sealed) over restoration According to the Ryge crite-
margins. At year 10, 36 percent ria, some restorations with open
of the CompS/C restorations margins are clinically accept-
and 45 percent of the AGS able; that is, they require obser-
restorations were in this largest vation rather than replacement.
subcategory. Seven percent of CompS/C
At year 10, the percentage of restorations and 9 percent of
remaining sealed restorations AGS restorations had open
that had no open margins and margins that remained partly
varying amounts of sealant (rat- sealed after 10 years. In addi-
ings of Alfa, Oscar/Alfa, Oscar) tion, 1 percent of CompS/C
Figure 2C. Tooth no. 30 at year 10. was 70 percent for the CompS/C restorations lost all of the
restorations and 84 percent for sealant and had an open mar-
restorations. the AGS restorations. As shown gin (Bravo MI), which means
Other subcategories of MI in Table 1, only 56 percent of that a total of 8 percent of
among the sealed restora- the AGU restorations had the CompS/C restorations had an
tions. As of the third year of Alfa rating at year 10. open margin. Thus, 8 percent of
the study, we subdivided the Open margins. Although CompS/C, 9 percent of AGS and
Ryge MI criteria into additional the margins of the restorations 29 percent of AGU restorations
subcategories to better differen- were never forcibly probed, the had open margins at year 10.
tiate the marginal status of the explorer tip would perceptibly Because the percentage of open
sealed restorations.8 Among the drop into the defect as it was margins in the sealed restora-
sealed restorations, the largest moved across the margin. Once tions remained in single digits,
Figure 3A. Clinical postoperative photograph of tooth Figure 3B. Tooth no. 31 at year 6.
no. 31, which was shown in the radiographs of
Figure 1.
TABLE 1
156 Comp- 86 4 10 0 0 0 0 0
S/C
Base-
line 77 AGS 90 6 4 0 0 0 0 0
85 Comp- 16 54 0 7 1 13 4 5
S/C
10
44 AGS 25 57 2 9 0 0§§ 2 4
41 AGU NA NA 56 NA 29 15 0 0
* CompS/C: bonded and sealed composite restoration over caries; AGS: sealed amalgam restoration; AGU: unsealed amalgam
restoration.
† Restoration, including all margins, is completely sealed.
‡ Restoration is partly sealed and has no open margin—that is, the restoration has no visible crevice and either the explorer does not catch or
it catches only one way.
§ There is no sealant but no open margin.
** The restoration is partly sealed and there is an open margin (a visible v-shaped crevice at the margin or one determined by an explorer catch
in both directions), but no dentin or base is exposed. (The terms open margin and crevice are interchangeable.)
†† There is no sealant and there is an open margin.
‡‡ NA: not applicable.
§§ There was a single clinical failure in the group that received the bonded and sealed amalgam restorations. The failure occurred at year 4, but
the patient did not come for an evaluation at year 10.
Statistically, there was no failures, including five failures occur in subsequent years.
significant difference through that were unrelated to the study. (Years 7 and 8 of the study were
year 10 in the number of open Clinical failures of restorations unsupervised, so no data are
margins, compared with the through year 9 have been de- available for that period.)
number of closed margins, for scribed elsewhere.7-10 Table 2 Sealant failure. We defined
the AGS and CompS/C groups shows the number of failures per sealant failure as occlusal pit
of restorations (χ2 = 0.0133, restoration type. The cumula- and fissure caries that occurred
P = .91). The AGS group had a tive number of clinical failures at a site other than the margin
significantly lower number of at year 10 that were related to of a study restoration. Through
open margins than did the AGU the study included 12 in the year 10, three sealant failures
group (χ2 = 6.8356, P = .009). double-sized CompS/C group, had occurred in the CompS/C
The CompS/C group also one in the AGS group and seven group. The first was observed at
showed a significantly smaller in the AGU group. year 2; the second and third
number of open margins than Caries. Over the 10-year pe- were observed at year 9. In the
the AGU group (χ2 = 8.6189, riod, caries occurred at the mar- AGS group, there were two
P = .003). These findings dem- gin of only one CompS/C sealant failures, one of which
onstrate that the traditional restoration and one AGS was observed at year 3 and the
AGU restorations fared the restoration. However, caries other at year 9.
worst of the three groups with was the only reason that the Restoration failure. For
regard to the occurrence of open seven AGU restorations failed. the AGU restorations, develop-
margins. As shown in Table 2, the clini- ment of occlusal caries that was
Clinical failures of study cal failures in the AGU group not at the margin of the study
restorations. Over the 10-year started to appear in year 4 of restoration was considered a
period, there were 25 clinical the study and continued to failure of the extension-for-pre-
TABLE 2
pain or other
OCCURRENCE OF CLINICAL FAILURES OF RESTORATIONS THROUGH YEAR 10. symptoms.
The AGS
TIME NO. OF FAILURES
tooth of one
Bonded and Sealed Sealed Amalgam Unsealed Amalgam
patient was
Composite Restorations Restorations Restorations avulsed in a
Over Caries (n = 77 at Baseline) (n = 79 at Baseline)
(n = 156 at Baseline)
car accident.
At year 10, we
Six months- 1 0 + 1 U* 0 saw some of
two years these pa-
Three years 3 + 1 U* 0 0 tients, and
Four years 4 1 2
again four (5
percent) of the
Five years 1 0 1 80 CompS/C
Six years 0 + 1 U* 0 1 restorations
Nine years 3 + 2 U* 0 2
that remained
and two (4
Ten years 0 0 1 percent) of the
Cumulative 12 + 4 U* 1 + 1 U* 7 50 AGS
failures through (14%)† (n = 85) (2%)† (n = 44) (17%)† (n = 41) restorations
year 10
that remained
* U: clinical failure unrelated to the study. could not be
† The percentage is calculated by dividing the number of cumulative failures related to the study by the number of
restorations evaluated at year 10. evaluated.
Wear.
vention concept, and, therefore, study, was significantly better Table 4 shows the anatomic
it was a restoration failure. One than the longevity of the form, or the modified Ryge cri-
of these was observed in an restorations in the other two teria for wear of restorations
AGU restoration at year 9. groups. (one criterion, Hotel, was devel-
Unrelated clinical fail- Others. At year 9, six (8 per- oped by one of the authors). At
ures. Five clinical failures un- cent) of the 75 CompS/C year 10, 10 percent of the AGU
related to the study occurred. restorations that remained and restorations showed clinically
Three intact study restorations two (5 percent) of the 40 AGS acceptable wear (Bravo). We
had to be removed to achieve restorations that remained saw this same level of wear in
access to unrelated proximal could not be evaluated because only 3.5 percent of the CompS/C
caries, and two teeth were even- of circumstances that could not restorations and in none of the
tually extracted as a result of be controlled during the unsu- AGS restorations.
unrelated gingival (Class V) le- pervised years 7 and 8 of the The CompS/C restorations in
sions. study. During that period, four two patients had abnormally
Restoration survival. We CompS/C restorations had been high occlusal stresses and
used Wilcoxon’s test to analyze replaced for unknown reasons showed a complete loss of
the survival of the restorations (probably because they had ap- sealant and generalized wear.
to determine the homogeneity of peared radiographically unusu- Once the entire enamel bevel
the survival curves of the mate- al to dentists who were unfamil- was completely exposed, these
rials.11 Table 3 shows the re- iar with this study). two CompS/C restorations lost
sults of this analysis. We found In addition, one CompS/C their bond to enamel and were
that the longevity of the study restoration and one AGS missing at the next evaluation
restorations in the AGU and restoration had been placed in (Delta anatomic form failures).
CompS/C groups was the same. third molars that were extract- Thus, the dentist evaluators did
Furthermore, the longevity of ed between years 6 and 9 of the not see the Charlie anatomic
the restorations in the AGS study. Neither patient knew form, in which dentin is exposed
group, which recorded only one why the teeth were extracted as a result of wear. We should
clinical failure related to the since neither had experienced note that these two CompS/C
TABLE 4
4 123 CompS/C 93 0 2 A, B 7 0 0
62 AGS 95 2 0 2 2 0
61 AGU 93 3 0 3 0 0
5 116 CompS/C 88 3 2 A, B 8 1 0
60 AGS 97 0 0 2 2 0
56 AGU 93 2 0 5 0 0
6 100 CompS/C 90 0 2 A, B 9 2 0
51 AGS 96 0 0 2 2 0
49 AGU 92 4 0 8 0 0
9 75 CompS/C 68 0 3 A, B 16 5 8
40 AGS 91 0 0 2 2 5
35 AGU 80 3 0 17 0 0
* CompS/C: bonded and sealed composite restoration over caries; AGS: sealed amalgam restoration; AGU: unsealed amalgam
restoration.
† Restoration is neither undercontoured nor discontinuous.
‡ Restoration is neither undercontoured nor discontinuous, and it remains completely sealed.
§ Restoration is undercontoured and discontinuous, but neither the dentin nor the base is exposed.
** Restoration is mobile, fractured or missing as a result of the amount of material that has been lost to wear.
†† A: At year 2, loss of sealant and generalized wear below the cavosurface margin of the bevel (Bravo anatomic form), followed by loss of the
CompS/C restoration (Delta anatomic form) at year 3. (The patient had abnormally heavy occlusion, as described elsewhere.8,9)
‡‡ B: At year 3, generalized wear (Bravo anatomic form), followed by loss of the CompS/C restoration (Delta anatomic form) at year 4.
(The patient had abnormally heavy occlusion, as described elsewhere.8,9)
dictated. We observed no thin- such as that which occurs when hesive dentistry, prevention of
ning of undermined enamel eating utensils are shared.15-18 caries and greater conservation
around any other CompS/C Historically, dental caries has of tooth structure are possible.19
restorations on the radiographs. been treated by surgical exci- Even more important, there is
Dental caries is a globally sion. Sound tooth structure had evidence that a shift in philoso-
prevalent symptom of an infec- to be sacrificed to make up for phy from the traditional surgi-
tious bacterial disease transmit- the shortcomings in the physi- cal model of excision to a more
ted in early childhood (as soon cal properties of various modern medical model of treat-
as primary teeth start erupting) restorative materials. ing caries may be occurring.20-26
from parents or caretakers Medical model of treating Edelstein27 said that this reori-
through an exchange of saliva, caries. With the advent of ad- entation advances the dentist to
a new role as clinical cariolo- International Association for carious dentin as a precursor to
gist. He also discussed one of Dental Research and the restorative procedures.
the barriers to an information American Association of Dental
CONCLUSIONS
transfer, which could be related Schools, Brown35 stressed the
to a lack of shared language be- need for a longitudinal clinical Bonded and sealed composite
tween scientists and clinicians. risk assessment to discriminate restorations placed over frank
Even the word caries is used between progressive and remin- cavitated lesions (CompS/C) ar-
differently by scientists and eralized lesions. He stated that rested the progress of these le-
clinicians; scientists refer to a treating caries restoratively in- sions over a period of 10 years.
process and clinicians use it to volves the probability of more Caries at the margin occurred
identify the lesions that result costly retreatment, and that in only one CompS/C restora-
from that process. overtreatment of caries is possi- tion and one AGS restoration.
Other investigations. bly the norm. All failures of the AGU restora-
Many investigators28-32 have sug- Hume36 stated that dentists tions occurred as a result of
gested altering traditional diag- should modify their 200-year- caries at the margin. Because of
nostic techniques and ceasing to old philosophy that caries the high occurrence of open
use a sharp explorer to examine should be treated like gangrene margins leading to caries at the
the enamel for evidence of cari- by extracting or excavating and margins of AGU restorations,
ous changes. A sharp explorer filling. He advocated a treat- we recommend that Class I
might destroy the enamel over- ment approach based on the amalgam restorations be sealed
lying the initial surface lesion, structure and behavior of the immediately after they have
thus jeopardizing the possibility carious lesion. He further noted been placed.
of remineralization. A sharp ex- that carious lesions in dentin At year 10, 10 percent of the
plorer might also carry cario- and cementum are reversible to AGU restorations, 3.5 percent
genic microorganisms from an some degree and recommended of the CompS/C restorations
infected to a noninfected site. that clinicians include nonsur- and none of the AGS restora-
Thus, a dentist who is perform- gical healing of these lesions in tions showed wear. Insofar as
ing a dental examination with the treatment plan. the literature has reported wear
an explorer may be inoculating Bader and Brown33 reported in composite restorations, we
the sound teeth of the patient that the prevalence of caries conclude that the unfilled
with infectious cariogenic bacte- has decreased and that carious sealant used in this study pro-
ria. In summarizing presenta- lesions may progress more slow- tected the posterior composite
tions given by several speakers ly. These changes in disease restorations from any clinically
at a 1993 symposium, Bader patterns make it important to obvious wear, as evaluated ac-
and Brown33 suggested that determine the activity status of cording to modified Ryge
there is no overall improvement a carious lesion and its poten- anatomic form criteria.
in diagnostic accuracy when an tial for remineralization and The sealed restorations were
explorer is used compared with sealing. Anusavice37 provided superior to the unsealed restora-
a detailed visual examination insight into the decision-making tions in conserving sound tooth
involving careful drying of the processes related to restorative structure, protecting margins,
tooth. dental care. preventing recurrent caries and
Wenzel34 discussed newer Pitts38 suggested that for prolonging the clinical survival
methods of diagnosing caries, proper treatment decisions, it of the restorations. ■
such as direct digital radiogra- may be logical to differentiate Dr. Mertz-Fairhurst is professor emerita,
phy, fiber-optic transillumina- “LANIMA” (that is, lesions for Department of Oral Rehabilitation, Medical
tion and electrical resistance which appropriate noninvasive College of Georgia, School of Dentistry,
Augusta.
measurements. However, these management is advised) caries
technologies need to be evaluat- from “LOCA” (that is, lesions Dr. Curtis is an associate professor,
Department of Oral Rehabilitation, Medical
ed further before they are rou- for which operative care is ad- College of Georgia, School of Dentistry, 1120
tinely adopted in clinical prac- vised) caries. Fifteenth St., Augusta, Ga. 30912-1260.
Address reprint requests to Dr. Curtis.
tice. Perhaps in the future, re-
During a joint symposium at search might focus on the possi- Ms. Ergle is a research assistant, Department
of Oral Rehabilitation, Medical College of
the 1993 meeting of the bility of remineralization of the Georgia, School of Dentistry, Augusta.
Dr. Rueggeberg is an associate professor, restorations: three-year results. J Public 22. Elderton RJ. Implications of recent den-
Department of Oral Rehabilitation, Medical Health Dent 1991;51(4):239-50. tal health services research on the future of
College of Georgia, School of Dentistry, 7. Mertz-Fairhurst EJ, Williams JE, Pierce operative dentistry. J Public Health Dent
Augusta. KL, et al. Sealed restorations: 4-year results. 1985;45(2):101-5.
Am J Dent 1991;4(4):43-9. 23. Schaanschieff SG, Shovelton DS, Toulmin
Dr. Adair is an associate professor and 8. Mertz-Fairhurst EJ, Richards EE, JK. Report of the committee of enquiry into un-
chairman, Department of Pediatric Dentistry, Williams JE, et al. Sealed restorations: 5-year necessary dental treatment. London: Her
Medical College of Georgia, School of results. Am J Dent 1992;5(1):5-10. Majesty’s Stationery Office; 1986:23-4.
Dentistry, Augusta. 9. Mertz-Fairhurst EJ, Smith CD, Williams 24. Elderton RJ. Variability in the decision-
JE, et al. Cariostatic and ultraconservative making process and implications for change
The first six years of this investigation were sealed restorations: six-year results. toward a preventive philosophy. In: Anusavice
supported financially by NIH/NIDR grant No. Quintessence Int 1992;23(12):827-38. KJ, ed. Quality evaluation of dental restora-
DE 06112; years 9 and 10 were supported by 10. Mertz-Fairhurst EJ, Adair SM, Sams tions: criteria for placement and replacement.
the NIH/NIDR Shannon award. Additional fi- DR, et al. Cariostatic and ultraconservative Chicago: Quintessence Publishing; 1989:211-9.
nancial support and clinical supplies were sealed restorations: nine-year results among 25. Anusavice KJ. Criteria for selection of
provided by Johnson & Johnson Dental children and adults. ASDC J Dent Child restorative materials: properties versus tech-
Products Co., New Windsor, N.J. 1995;62(2):97-106. nique sensitivity. In: Anusavice KJ, ed.
11. Lee ET. Statistical methods for survival Quality evaluation of dental restorations: cri-
The authors gratefully acknowledge the sig- data analysis. Belmont, Calif: Lifetime teria for placement and replacement. Chicago:
nificant contributions of the following people Learning Publications; 1980:78-88. Quintessence Publishing; 1989:53.
in conducting this research: W. Frank 12. Mertz-Fairhurst EJ, Schuster GS, 26. Anderson MH, Bales DJ, Omnell K.
Caughman, D.M.D., M.Ed.; Gene L. Williams JE, et al. Clinical progress of sealed Modern management of dental caries: the cut-
Dickinson, D.D.S., M.S.; I. Kin Hawkins, and unsealed caries. Part II: standardized ra- ting edge is not the dental bur. JADA
D.D.S., Ph.D.; J. Rodway Mackert Jr., diographs and clinical observations. J 1993;124(6):37-44.
D.M.D., Ph.D.; Norris L. O’Dell, D.D.S., Prosthet Dent 1979;42(6):633-7. 27. Edelstein BL. The medical management of
Ph.D.; E. Earl Richards, D.D.S., M.P.H.; Carl 13. Mertz-Fairhurst EJ, Schuster GS, dental caries. JADA 1994;125(Supplement):31S-
M. Russell, D.M.D., M.S., Ph.D.; Deirdre R. Williams JE, et al. Arresting caries by 9S.
Sams, D.D.S., M.S.; George S. Schuster, sealants: results of a clinical study. JADA 28. Merrett MCW, Elderton RJ. An in vitro
D.D.S., M.S., Ph.D.; Jack D. Sherrer, D.D.S.; 1986;112(2):194-7. study of restorative dental treatment decisions
C. Douglas Smith, D.D.S.; and J. Earl 14. Mertz-Fairhurst EJ, Newcomer AP. and dental caries. Br Dent J 1984;157(4):128-33.
Williams, D.D.S., Dr.P.H. Interface gap at amalgam margins. Dent 29. Kidd EAM. Caries diagnosis within re-
Mater 1988;4(3):122-8 [June issue; see also stored teeth. In: Anusavice KJ, ed. Quality
The authors also thank Dr. S. Julian Gibbs erratum, editor’s note in the October issue evaluation of dental restorations: criteria for
of Vanderbilt University, Nashville, Tenn., for Dent Mater 1988;4(5):312]. placement and replacement. Chicago:
his assistance as a radiology consultant in the 15. Berkowitz RJ, Turner J, Green P. Quintessence Publishing; 1989:111-21.
design of the study and Mr. Warren Twiggs Primary oral infection of infants with strepto- 30. Lussi A. Validity of diagnostic and treat-
for designing the computer database input cocci mutans. Arch Oral Biol 1980;25(4):221-4. ment decisions of fissure caries. Caries Res
and report formats. 16. Caufield PW, Cutter GR, Dasanayake 1991;25(4):296-303.
AP. Initial acquisition of mutans Streptococci 31. Löe H. Caries and periodontal diseases—
1. Black GV. Cavity preparation. Volume II: by infants: evidence for a discrete window of do we know enough? Paper delivered at the
The technical procedures in filling teeth. In: A infectivity. J Dent Res 1993;72(1):37-45. meeting of the Federation Dentaire Interna-
work on operative dentistry in two volumes. 17. Kohler B, Bratthall D, Krasse B. tionale, Göteborg, Sweden: September 1, 1993.
Chicago: Medico-Dental Publishing Co.; Preventive measures in mothers influence the 32. Mandel ID. Caries prevention: current
1908:110-1. establishment of the bacterium Streptococcus strategies, new directions. JADA 1996;127
2. Keyes PH. Present and future measures mutans in their infants. Arch Oral Biol (10):1477-88.
for caries control. JADA 1969;79(6):1395-404. 1983;28(3):225-31. 33. Bader JD, Brown JR. Dilemmas in
3. Jensen ME, Chan DCN. Polymerization 18. Kohler B, Andreen I, Jonsson B. The ef- caries diagnosis. JADA 1993;124(6):48-50.
shrinkage and microleakage. In: Vanherle G, fect of caries preventive measures in mothers 34. Wenzel A. New caries diagnostic meth-
Smith DC, eds. Posterior composite resin den- on dental caries and the oral presence of the ods. J Dent Educ 1993;57(6):428-32.
tal restorative materials. Utrecht: Peter Szulc bacteria Streptococcus mutans and lactobacilli 35. Brown JP. Introduction to the sympo-
Publishing Co.; 1985:243-62. in their children. Arch Oral Biol sium. J Dent Educ 1993;57(6):407-8.
4. Anusavice KJ. Bonding. In: Phillips’ sci- 1984;29(11):879-83. 36. Hume WR. Need for change in stan-
ence of dental materials. 10th ed. 19. Gendusa NJ. Adhesion dentistry—its ef- dards of caries diagnosis—perspective based
Philadelphia: Saunders; 1996:301-13. fect on treatment planning: a point of view. on the structure and behavior of the caries le-
5. Mertz-Fairhurst EJ, Call-Smith KM, Quintessence Int 1994;25(1):69-71. sion. J Dent Educ 1993;57(6):439-43.
Schuster GS, et al. Clinical performance of 20. Elderton RJ. Management of early den- 37. Anusavice KJ. Decision analysis in
sealed composite restorations placed over caries tal caries in fissures with fissure sealant. Br restorative dentistry. J Dent Educ 1992;
compared with sealed and unsealed amalgam Dent J 1985;158(7):254-8. 56(12):812-22.
restorations. JADA 1987;115(5):689-94. 21. Elderton RJ. Scope for change in clinical 38. Pitts NB. Current methods and criteria
6. Mertz-Fairhurst EJ, Williams JE, practice. J Royal Soc Med 1985;78(Supplement for caries diagnosis in Europe. J Dent Educ
Schuster GS. et al. Ultraconservative sealed 7):27-32. 1993;57(6):409-14.