Cavity Preparation in Pediatric Dentistry PDF

Cavity Preparation in Pediatric Dentistry Abdulhamid Al Ghwainem, BDS, MSc, DClinDent Pediatric Dentistry Assistant Professor of Pediatric Dentistry [email protected] Friday, 23 February 2024 Pre-Clinical Pediatric Dentistry DSV 342 Copyright © 2023 by PSAU, Abdulhamid Al Ghwainem DISCLAIMER...

Cavity Preparation in Pediatric Dentistry Abdulhamid Al Ghwainem, BDS, MSc, DClinDent Pediatric Dentistry Assistant Professor of Pediatric Dentistry [email protected] Friday, 23 February 2024 Pre-Clinical Pediatric Dentistry DSV 342 Copyright © 2023 by PSAU, Abdulhamid Al Ghwainem DISCLAIMER The information presented in this lecture is offered for educational and informational purposes and should not be construed as medical, dental, or research advice. While the amount of information in this handout is vast, and I make every effort to be as current and thorough as possible, the information cannot be taken as a reference manual or textbook. Please note that you should read the required textbooks as specified in the course curriculum and lecture references. WARNING Materials used in connection with this course or lecture may be subject to copyright protection. This material has been reproduced and communicated to you by or on behalf of Prince Sattam Bin Abdulaziz University. 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Do not remove this notice Learning outcomes: By the end of this lecture, you should be able to: § Highlight the burden of dental caries nationally and globally. § Describe the caries process and highlight how the caries etiopathogenesis changes the management of dental caries in modern dental practice. § Differentiate between traditional caries management and the modern concepts of dental caries management. § Describe the rationale and importance of restoring primary teeth. § Identify and relate different restorative dental materials and critically assess their evidence and suitability for restoring the primary dentition. § Describe the principles of cavity preparation in primary dentition. § Recognize anatomical considerations when restoring primary teeth. § Design and cut cavities in primary teeth in relation to the tooth anatomy and the characteristics of the restorative material used. Outline: § Introduction § Caries overview, prevalence and etiopathogenesis § Conventional vs contemporary caries management § Importance of restoring caries § Restorative materials and their evidence § Cavity preparation of primary teeth and its anatomical consideration § Class I, II, III, IV, and V cavity preparations in primary teeth. § Concluding remarks Introduction § Worldwide, dental caries is one of the most prevalent diseases, with significant variations in its prevalence among countries, regions, areas, and social and ethnic groups. § According to WHO, Global Oral Health Status Report, (2022): The estimated global average prevalence of caries of primary teeth is 43%. The estimated global average prevalence of caries of permanent teeth is 29%, and case numbers reach more than 2 billion cases. Untreated dental caries in permanent teeth is the most common health condition, according to the Global Burden of Disease 2019. Introduction (WHO Global Oral Health Status Report, 2022) Introduction § In KSA, numerous studies have been conducted to measure the prevalence of dental caries. However, the prevalence of dental caries varies in KSA. § Overall, most studies concluded that there is a high prevalence of caries among children and adults in KSA. § According to Al Agili (2013), which includes 26 studies from 1988 to 2010: The average prevalence of caries in Primary Teeth is 80%. The average prevalence of caries in Permanent Teeth is 70%. Introduction § According to Alshammari et al. (2021), which includes 49 studies from 1999 to 2019: The nationwide caries prevalence among Primary Teeth ranged from 21% to 100%. The nationwide caries prevalence among Permanent Teeth ranged from 50% to 99%. § According to MOH (2023), The percentage of children with dental caries at the ages of 6 years was 96%, and 12 years was 93.7% Introduction (Alshammari et al., 2021) Primary Teeth ranged from 21% to 100% Permanent Teeth ranged from 50% to 99% Why do we have a high caries prevalence? Why the caries prevalence in KSA is high § This is usually linked to relatively unsuccessful caries prevention and management. The conventional management of dental caries § G. V. Black, the father of modern dentistry, changes dentistry from a trade to a profession. § He stated, “The day is surely coming...when we will be engaged in practicing preventive rather than reparative dentistry”. § Since that time, dentistry has continuously evolved in cariology, new materials, diagnosis, and treatment techniques. § Therefore, dentistry is committed to update and use the most recent preventive and restorative management techniques. This Photo by Unknown Author is licensed under CC BY-NC-ND The conventional management of dental caries Class I: Occlusal surfaces of molars and premolars Class I: Lingual pits of anterior teeth Class I: Buccal/Lingual pits of molars Class II: Proximal surfaces of premolars Class V: Cervical third of buccal or lingual surfaces of anterior and posterior teeth with incisal edges Class II: Proximal surfaces of molars Class III: Proximal surfaces of anterior teeth without incisal edges This Photo by Unknown Author is licensed under CC BY-SA-NC Class IV: Proximal surfaces of anterior teeth with incisal edges The conventional management of dental caries § The conventional treatment of dental caries was based on the concept of “extension for prevention” and the restoration needs rather than on preserving the sound tooth structure. § This paradigm, originally outlined by G. V. Black and others, has been the standard in clinical dentistry for over 100 years. § This technique usually involves the removal of substantial healthy tooth structure in order to provide mechanical retention. The contemporary management of dental caries § By understanding the pathogenesis of carious lesions at the molecular level, dentists started a change in treatment philosophy in order to meet the caries prevention and restorative needs of children and adults. Dynamic process pH TIEMPO (Fejerskov, 1997; Kidd & Fejerskov, 2004) § The caries process, where there is a normal fluctuation of pH within a limit, where deand remineralization occurs at an ionic level. The contemporary management of dental caries When the imbalance between biofilm and dental structure leads to a higher number and time periods of demineralisation against remineralization, a net loss of minerals occurs, leading to an initial caries lesion. The contemporary management of dental caries (Koch et al., 2017) The contemporary management of dental caries Enamel critical pH 5.2 – 5.7 Biofilm Dentine/Cementum critical pH 6.0 – 6.5 The contemporary management of dental caries § This understanding of dental caries as a result of the demineralization/remineralization process gives rise to a new paradigm in modern dental practice, which could be called “prevention of extension”. (Castellanos et al., 2013) If demineralization prevails: DENTAL CARIES PROCESS From 1st Subclinical to 1st Clinical signs – Structural effects The contemporary management of dental caries Scientific concepts that lead the development of prevention 1. Bacterial plaque is a complex oral biofilm. 2. Dental caries results from an ecological modification in the biofilm from a healthy to a pathogenic flora. 3. Dental caries is a process that can be arrested or reversed. 4. The caries process is a dynamic imbalance between the pathologic and the protective factors that can progress if the pathologic factors are dominant and can reverse if the protective factors prevail. The contemporary management of dental caries The contemporary management of dental caries (Casamassimo et al., 2013, p.305) The contemporary management of dental caries Schulze, F. (2023). Global Dental Amalgam tracker. EnvMed Network. https://environmentalmedicine.eu/mercury-free-dentistry-for-planet-earth/# § The Minamata Convention on Mercury (2013) calls for a phase-down of dental amalgam. The contemporary management of dental caries § Also, with an increased use of adhesive restorative materials and bonding systems, there has been a shift to more conservative preparations and restoration. This Photo by Unknown Author is licensed under CC BY This Photo by Unknown Author islicensed under CC BY-SA The contemporary management of dental caries 0 No evidence of caries 1 Initial caries 2 Distinct visual change in enamel 3 Localised enamel breakdown due to caries with no visible dentine 4 Underlying dark shadow from dentine 5 Distinct cavity with visible dentine 6 Extensive distinct cavity with visible dentine (Koch et al., 2017) The contemporary management of dental caries 0 No evidence of caries 1 Initial caries 2 Distinct visual change in enamel 3 Localised enamel breakdown due to caries with no visible dentine 4 Underlying dark shadow from dentine 5 Distinct cavity with visible dentine 6 Extensive distinct cavity with visible dentine (Young et al., 2015, p82) Management Of Dental Caries Non-Operative Caries Management Complete Caries Removal/ Two-step Caries Removal/ Selective Caries Removal Stepwise Caries Removal Removal No caries removal and restore (Hall technique) Preventive Resin Restoration Sealants Caries Infiltration Atraumatic Restorative Treatment (ART) Interim Therapeutic Restorations (ITR) Non-selective Caries Removal brushing with fluoride toothpaste, other fluoride treatments, dietary modification, oral hygiene measures, etc. Operative (Restorative) Caries Management Partial Caries Removal/ One-step Caries Removal/ Benefits of restoring primary teeth? § The aim of pediatric operative dentistry is to maintain the tooth in the dental arch in a healthy state so as to prevent its loss and the subsequent problems that will result. § The overall aim is to repair or limit the damage from caries, protect and preserve the tooth structure, and maintain pulp vitality whenever possible. Prevent pain and discomfort. Prevent local infections. Prevent general infections. Prevent negative attitudes. Promote good oral health. Restore oral health, function, and appearance of teeth. Maintain arch length. Prevent malocclusion. Prevent caries in permanent teeth Maintain overall well-being. Risks of restoring primary teeth? § Reducing the longevity of teeth by making them more susceptible to fracture. § Recurrent lesions. § Restoration failure. § Pulp exposure during caries excavation. § Future pulpal complications. § Risk of iatrogenic damage to adjacent teeth. What should we consider when restoring primary teeth? § The developmental stage of the child § Caries risk assessment § Oral hygiene § Caries lesion extent and activity § Degree of radicular resorption of the tooth § Condition of the bone support § Parent compliance § Child compliance § Restorative materials What should we consider when restoring primary teeth? § Restorative materials Amalgam Composite Glass ionomer cement Resin-modified glass ionomer cement Compomers (Polyacid modified composite resin) Stainless steel crown § Restorative materials Amalgam Composite Glass ionomer cement Resin-modified glass ionomer cement Compomers (Polyacid modified composite resin) Stainless steel crown What does the evidence say? Evidence of Restorative Materials American Academy of Pediatric Dentistry. Pediatric restorative dentistry; 2023:443-56. Evidence of Restorative Materials American Academy of Pediatric Dentistry. Pediatric restorative dentistry; 2023:443-56. Cavity Preparation According to Black (1914): A mechanical treatment of the injuries to the teeth produced by dental caries as would best fit the remaining part of the tooth to receive a filling restoring the original form, giving it strength, and preventing recurrence. OR The part of procedures to arrest the carious process: Elimination of the heavily infected dentin and preservation of the residual affected dentin were thus defined as prerequisites for effectively arresting the carious process without harming the long-term survival of the pulp and the restoration (Neves et al., 2011). Anatomic Considerations of Primary Teeth Is the cavity preparation for primary teeth the same as the permeant teeth? Deciduous and permanent molars Courtesy of FSL Wong and G Davis at QMUL Anatomic Considerations of Primary Teeth § Although some primary teeth resemble their permanent successors. § There are several anatomic differences that must be distinguished before restorative procedures are begun. Shorter clinical crown height More bulbous crown buccal and lingual converge to occlusal Marked cervical constriction Narrower occlusal table Wider contact area Larger pulp chamber and pulp horns Finer canals Anatomic Considerations of Primary Teeth A. The enamel thickness is thinner (uniform thickness around 1mm) B. Thinner dentine with a comparatively greater thickness of dentin is over the pulpal wall at the occlusal fossa C. Larger pulp and higher pulp horns, especially the mesial horns; Pulpal outline follows DEJ more closely than in the permanent tooth. Anatomic Considerations of Primary Teeth D. The cervical ridges are more pronounced, especially on the buccal aspect of the first primary molars E. The enamel rods are directed occlusally instead of gingivally F. The primary molars have greater cervical constriction. Anatomic Considerations of Primary Teeth G. The roots of the primary teeth are longer and more slender in comparison with the crown size H. The roots of the primary molars flare out nearer the cervix. Consideration in cavity preparation Anatomical features of primary teeth Clinical significance Shorter Limited room for cavity preparation Narrower occlusal table The cavity preparation should be conservative, bucco-lingual width not greater than 1/3 of the width of the occlusal table Thinner enamel and dentine The cavity preparation should be shallow to avoid pulp exposure. Depth of cavity 0.5 mm into dentine (approx. 1.5 mm in total from the cavosurface margin) Molars have a more broad and flat contact area Require wide proximal cavity preparation. Isthmus width should be 1/3rd the intercuspal distance. Enamel rods in cervical third are are directed occlusally Eliminates the need for a gingival bevel in class II preparation so the enamel at the floor of box is not undermined Marked cervical constriction Difficult matrix adaptation however it can be used to retain a stainless steel crown Pulp Larger pulp and higher pulp horns Pulp exposure of clinical technique imprecise or adequate Roots Longer and more slender More flared Associated with lots of accessory canals Pulpectomy can be difficult, so alternative treatments are often used Crown Basic Principles of Cavity Preparation in Primary Teeth § Black’s principles, with some modification, are the basic principles in the preparation of the cavities in the primary teeth. § Current views advocate that the cavity design is dictated by the site and extent of caries lesion. § There is no need to extend cavity preparation into the “caries-free” area. § The steps in the preparation of a cavity in a primary tooth are not difficult but do require precise operator skills combined with knowledge of biology, cariology, the anatomy of the primary teeth, and the requirement of the chosen restorative material. Basic Principles of Cavity Preparation in Primary Teeth § The Biological Principles: 1. Caries removal 2. Preserving the sound tooth structure 3. Maintain pulpal vitality ” The pulp lives for the dentin and the dentin lives by the grace of the pulp. Few marriages in nature are marked by a greater affinity” Alfred L. Ogilvie (Ingle et al., 2008, p. 468) Courtesy of FSL Wong and G Davis at QMUL Basic Principles of Cavity Preparation in Primary Teeth § The Mechanical Principles: 1. Outline form and initial depth 2. Resistance form 3. Retention from 4. Convenience form 5. Finishing This Photo by Unknown Author is licensed under CC BY Basic Principles of Cavity Preparation in Primary Teeth § Conventional Cavity Preparation: requires specific outline form, depth, resistance, retention, and marginal forms such as amalgam and stainless steel crowns. § Modified Cavity Preparation: less need for specific outline form, depth, resistance, retention, and marginal forms such as composite, RMGIC, GIC. Objectives of Cavity Preparation § Remove diseased tissues as necessary while protecting the vitality of the pulp. § Locate the margins of the chosen restorative material and be as conservative as possible. § Ensure the cavity form is not under the mastication forces of the tooth. § Allow easy access to place the chosen restorative material. Restorative Terminology § Cavosurface angle: the angle formed by the cavity walls and the tooth's external surface. § The actual junction is referred to as the cavosurface margin. § The cavosurface angle may differ with the location of the tooth, the direction of the enamel rods on the prepared wall, or the type of restorative material to be used Restorative Terminology § External walls: prepared surfaces that extend to the external tooth surfaces § Internal walls: Axial: tooth structure covering pulp parallel to the long axis of the tooth Pulpal: tooth structure covering pulp perpendicular to the long axis of the tooth Restorative Terminology § Line angle: The angle formed by the junction of two walls of a prepared cavity § Point angle: The angle formed by the junction of three walls of a prepared cavity Restorative Terminology § Isthmus: is the area present at the junction between the occlusal part and proximal part of the cavity (proximal box). It should be as narrow as possible (1/4 to 1/3) of ICD) to reduce the force on it and prevent fracture of the restoration Class I Cavity Preparation § Class I occlusal cavity preparations for incipient lesions in primary teeth are basically like those for permanent teeth. § Certain modifications are implemented and are dictated mainly by morphological and developmental differences. § Modification for Class I Cavity Preparations: 1. Less depth in pulpal direction, Depth of cavity 0.5 mm into dentine (approx. 1.5 mm in total from the cavosurface margin), to avoid the highly positioned pulp horns. 2. Rounded and concave pulpal floor to prevent pulp exposure at the bucco and lingo-pulpal line angles. Class I Cavity Preparation § General considerations: The outline form should include all retentive fissures and carious areas but should be as conservative as possible. The ideal pulpal floor depth is 0.5 mm into the dentin (approximately 1.5 mm from the enamel surface). The length of the cutting end of the no. 330 bur is 1.5 mm, so this becomes a good tool for gauging cavity depth. Class I Cavity Preparation § General considerations: The cavosurface margin should be placed out of stress-bearing areas and should have no bevel. To help prevent stress concentration, the outline form should be composed of smoothly flowing arcs and curves, and all internal angles should be rounded slightly. When a dovetail is placed in the second primary molars, its buccolingual width should be greater than the width of the isthmus so as to produce a locking form to provide resistance against occlusal torque, which may displace the restoration mesially or distally. Class I Cavity Preparation § General considerations: The isthmus should be one-third of the intercuspal width, and the buccolingual walls should converge slightly in an occlusal direction. The mesial and distal walls should flare at the marginal ridge so as not to undercut ridges. Oblique ridges should not be crossed unless they are undermined with caries or are deeply fissured. Primary mandibular second molars often exhibit buccal developmental pits. When carious, these should be restored with a small teardrop or ovoid-shaped restoration, including all the adjacent susceptible pits and fissures. Class I Cavity Preparation § External Occlusal Outline Gain access with a 330 bur in the deepest pit Extend to remove all caries and include susceptible pits and fissures Smooth outline Contour outline parallel to mesial and distal ridges (oblique ridge in maxilla) Width to be less than 1/3 of occlusal table Upper E Lower E Class I Cavity Preparation § Internal Outline 0.5 mm into dentine (1.5 mm deep in total) Round pulpal line angles Cavo-surface 90° Lateral wall undercuts Class I Cavity Preparation Correct Incorrect Class I Cavity Preparation Upper E Class I Cavity Preparation Common Errors with Class I Amalgam Restorations A. Preparing the cavity too deep B. Undercutting the marginal ridges C. Carving the anatomy of the amalgam too deep D. Not removing amalgam flash from cavosurface margins E. Undercarving, which leads to subsequent fracture of amalgam from hyperocclusion F. Not including all susceptible fissures Class II Cavity Preparation § General considerations: The guidelines given for the class I preparation should be followed during the preparation of the occlusal portion of the class II preparation and, additionally, there are several recommendations for the proximal box preparation. The proximal box should be broader at the cervical portion than at the occlusal portion. The buccal, lingual, and gingival walls should all break contact with the adjacent tooth, just enough to allow the tip of an explorer to pass. The buccal and lingual walls should create a 90-degree angle with the enamel. Class II Cavity Preparation § General considerations: The gingival wall should be flat, not beveled, and all unsupported enamel should be removed. Ideally, the axial wall of the proximal box should be 0.5 mm into dentine and should follow the same contour as the outer proximal contour of the tooth. The axiopulpal line angle is routinely beveled or rounded. No buccal or lingual retentive grooves should be placed in the proximal box. The mesiodistal width of the gingival seat should be 1 mm, which is approximately equal to the width of a no. 330 bur. Class II Cavity Preparation § External Occlusal Outline: Occlusal outline as in Class I The isthmus (narrowest junction between occlusal and proximal surface) must be less than 1/3 of the width of the occlusal table Proximal extension to ‘cleansable’ region and should be 90° to the axial surfaces of the tooth Class II Cavity Preparation § External Proximal Outline: Buccal and lingual surfaces parallel to the external surfaces and break contact point Buccal and lingual walls diverge towards the gingival margin of the box Gingival floor clear of contact area, and not sub-gingival Class II Cavity Preparation § Internal Outline: Occlusal as in Class I The proximal box is 1 mm deep and perpendicular to the axial wall Floor of the box is flat or slightly concave gingivally, not bevelled Width of the box from the surface of the tooth to the axial wall approx 1 mm Axial wall follows the contour of the missing tooth surface Class II Cavity Preparation Class II Cavity Preparation Class II Cavity Preparation Class II Cavity Preparation Class II Cavity Preparation Common Errors with Class II Amalgam Restorations A. Failure to extend occlusal outline into all susceptible pits and fissures. B. Failure to follow the outline of the cusps. C. Isthmus cut too wide. D. Flare of proximal walls too great. E. The angle formed by the axial, buccal, and lingual walls is too great. F. Gingival contact with adjacent tooth not broken. G. The axial wall not conforming to the proximal contour of the tooth, and the mesiodistal width of the gingival floor is greater than 1 mm Class II Cavity Preparation Class II Cavity Preparation Class II: The Saucer-shaped Cavity Design § This conservative preparation technique disregards the old principle of “extension for prevention”. § Replaced the conventional class II preparation and become the first choice for small primary approximal lesions. § The outline of the cavity should aim at preserving natural tissue. § Mainly depends on the adequate bonding of composite to enamel and dentine. (Koch et al., 2017) Class III Cavity Preparation § General considerations: Carious lesions on the proximal surfaces of anterior primary teeth sometimes occur in children whose teeth are in contact and those with evidence of arch inadequacy or crowding. If caries is not extensive, disking by sandpaper disc is performed to remove the decay, and then fluoride is applied topically (making lesions self-cleansable). If the carious lesion does not involve the incisal angle, a small Class III cavity may be prepared, and the tooth may be restored with composite or GIC. Class III Cavity Preparation § General considerations: The same basic principles for permanent anterior teeth should be considered in primary teeth, modified by the size of the pulp and the relative thinness of the enamel. Because of the narrow labiolingual width of the primary incisor teeth, the Class III preparation can be very difficult to perform and often needs a labial or lingual dovetail to gain access and aid in the retention of the restoration. Class III Cavity Preparation § External and Internal Outline: Penetrate the center of the lesion with a No. 1⁄2. round bur oriented perpendicular to the proximal surface and establish an axial depth of 0.5 mm into the dentin. Establish the triangular shape, creating a smooth, continuous curve with no sharp angles. The cavity should be away from the incisal edge for at least 1.5 mm. Converge of the labial, lingual, and gingival walls towards the cavosurface margins to produce mechanical retention of the composite. The pulpal floor should be convex. Modification of Class III Cavity Preparation § Slot preparation Modification of Class III Cavity Preparation § Dovetail Class IV Cavity Preparation § Caries in these cavities involve the anterior teeth' incisal proximal angle. § The principles in cavity preparation are the same as cavity preparation in permanent teeth. § Indicated? Class V Cavity Preparation § The principles in the cavity preparation are the same of the cavity preparation in permanent teeth, although the depth is not carried more than 1.5 mm. Cavity Preparations of Primary Teeth § Summary: Conventional preparation: Similar outline form to preparation in permanent teeth. Class I/II includes all grooves to prevent future caries. Class II boxes are designed to break contact gingivally but do necessarily break contact buccally or lingually. It cannot generally be deeper than 1.5-2mm due to the large pulp chamber, thinner enamel, and dentin. No complex preparation in Class II, Full crown coverage is better (e.g., SSC). No Class IV preparation, Full crown coverage is better (e.g., Strip Crown). Cavity Preparations of Primary Teeth § Summary: Modern preparation: Preparation surrounds caries with walls established on caries-free dentin/enamel. Some caries may or may not be left on the floor of the prep as an indirect pulp capping. Prepare areas restored with bonded restoration and remaining grooves sealed with sealant to prevent future caries (sealed restoration) References: Required: § Avery, D.R. and McDonald, R.E., (2016). McDonald and Avery dentistry for the child and adolescent, 10th Edition. Chapter 11, pages 185-205 § Casamassimo, P. S., Fields, H., McTigue, D. J., & Nowak, A. J. (2012). Pediatric dentistry: infancy through adolescence, 5th Edition. Chapter 21, pages 304-332 § American Academy of Pediatric Dentistry. (2023). Pediatric restorative dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry, 443-56. § American Academy of Pediatric Dentistry. (2023).. Policy on minimally invasive dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:97-9. Additional: § Koch, G., Poulsen, S., Espelid, I. and Haubek, D. eds., (2017). Pediatric dentistry: a clinical approach. John Wiley & Sons. Chapter 12, pages 130-160 § Welbury, R., Duggal, M.S. and Hosey, M.T. eds., (2018). Paediatric dentistry. Oxford university press Chapter 9-10, pages 129-182 § Cameron, A.C. and Widmer, R.P., (2013). Handbook of Pediatric Dentistry. Elsevier Health Sciences. Chapter 6, pages 79-102 § Leal, S. C., & Takeshita, E. M. (Eds.). (2019). Pediatric restorative dentistry. Springer International Publishing.. References: Cited references: § Global oral health status report: towards universal health coverage for oral health by 2030. Geneva: World Health Organization; 2022. License: CC BY-NC-SA 3.0 IGO. § Al Agili, D. E. (2013). A systematic review of population-based dental caries studies among children in Saudi Arabia. The Saudi dental journal, 25(1), 3-1 § Alshammari, F. R., Alamri, H., Aljohani, M., Sabbah, W., O'Malley, L., & Glenny, A. M. (2021). Dental caries in Saudi Arabia: A systematic review. Journal of Taibah University Medical Sciences, 16(5), 643-656 § Schulze, F. (2023). Global Dental Amalgam tracker. EnvMed Network. https://environmentalmedicine.eu/mercury-free-dentistry-for-planet-earth/# § de Almeida Neves, A., Coutinho, E., Cardoso, M. V., Lambrechts, P., & Van Meerbeek, B. (2011). Current concepts and techniques for caries excavation and adhesion to residual dentin. Journal of Adhesive Dentistry, 13(1). § Young, D. A., Nový, B. B., Zeller, G. G., Hale, R., Hart, T. C., Truelove, E. L.,... & Beltran-Aguilar, E. (2015). The American Dental Association caries classification system for clinical practice: a report of the American Dental Association Council on Scientific Affairs. The Journal of the American Dental Association, 146(2), 79-86 § Fejerskov, O. (1997). Concepts of dental caries and their consequences for understanding the disease. Community dentistry and oral epidemiology, 25(1), 5-12. § Kidd, E. A. M., & Fejerskov, O. (2004). What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. Journal of dental research, 83(1_suppl), 35-38 § Castellanos, J. E., Gallón, L. M. M., Vacca, M. V. Ú., Rubio, G. A. C., & Biermann, S. M. (2013). La remineralización del esmalte bajo el entendimiento actual de la caries dental/Enamel Remineralization under the Current Caries Understanding. Universitas odontologica, 32(69), 49-59. Thank you! Any questions [email protected]