ORIGINAL CONTRIBUTIONS
Approximal and occlusal caries
lesions
Restorative treatment decisions by California dentists
Peter Rechmann, DMD, PhD; Sophie Doméjean, DDS, PhD;
Beate M. T. Rechmann; Richard Kinsel, DDS; John D. B.
Featherstone, MSc, PhD
C
linicians increasingly have accepted minimally
invasive treatment concepts.1-3 Decisions for
restorative treatment have been delayed toward
a more advanced caries lesion stage.4
Caries preventive measures are more successful when
frequently applied.5,6 Assessing the patient’s caries risk
and assigning individualized preventive, nonoperative
care measures based on that risk have led to less need for
invasive operative treatments.7,8
Classifying caries lesions at a noncavitated stage9
could allow dentists to evaluate whether noninvasive
measures would be successful.10 Noncavitated caries le-
sions in enamel and dentin can be managed by means of
remineralization without restorative intervention.11,12
Monitoring topical fluoride application and pit-and-
fissure sealants is considered the best practice according
to the literature and should become the standard treat-
ment modality for noncavitated caries lesions.13-15 The
International Caries Classification and Management
System and Caries Management by Risk Assessment
recommend minimal intervention treatment according
to the patient’s caries risk level.10,16
Surveys in which investigators have evaluated the
restorative treatment thresholds of dentists and man-
agement strategies have been performed in many coun-
tries and reveal wide variations. Those management
differences exist among countries and among dentists
within each country.17-25
With the background of the success of preventive and
noninvasive measures in caries management, we
designed this study to determine California (CA) den-
tists’ restorative threshold for approximal and occlusal
lesions by using a Web-based survey. To our knowledge,
this is the first time such a study has been performed
in CA.
Copyright ª 2016 American Dental Association. All rights reserved.
ABSTRACT
Background. Investigators use questionnaire surveys to
evaluate treatment philosophies in dental practices. The
aim of this study was to evaluate the management strategies
California dentists use for approximal and occlusal caries
lesions.
Methods. In May 2013, the authors e-mailed a ques-
tionnaire that addressed approximal and occlusal caries
lesion management (detection and restorative threshold,
preferred preparation type, and restorative materials) to
16,960 dentists in California. The authors performed a
c2 statistical analysis to investigate the relationship
between management strategies and respondent
demographic characteristics.
Results. The authors received responses from 1,922
(11.3%) dentists; 42.6% of the respondents would restore
approximal lesions at the dentinoenamel junction, and
33.4% would wait until the lesion reached the outer one-
third of dentin. The preferred preparation type was the
traditional Class II preparation. Dentists who graduated
more recently (20 years or less) were more likely to delay
approximal restorations (P < .0001); 49.9% of the more
recent graduates would wait to restore an occlusal lesion
until the outer one-third of dentin was involved, and 42.6%
would restore a lesion confined to enamel.
Conclusions. There is wide variety among California
dentists regarding their restorative treatment decisions,
with most dentists restoring a tooth earlier than the liter-
ature would advise. More recent dental graduates were
more likely to place their restorative threshold at deeper
lesions for approximal caries lesions.
Practical Implications. Clinical evidence shows that
noncavitated caries lesions can be remineralized; therefore,
early restorative treatment may no longer be necessary or
appropriate. Noninvasive and minimally invasive mea-
sures should be taken into consideration.
Key Words. Caries lesions; approximal caries; occlusal
lesions; diagnosis; decision making; restorative treatment
threshold; California dentists.
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http://dx.doi.org/10.1016/j.adaj.2015.10.006
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 ORIGINAL CONTRIBUTIONS

TABLE 1 BOX

Demographic characteristics of Survey*

contacted California dentists and APPROXIMAL LESION (FIGURE 1)19

respondents. - Question 1: “The picture illustrates different radiographic stages of

caries progression (approximal lesion, grade 1 to 6). Starting with which
CHARACTERISTIC DENTISTS RESPONDENTS lesion size do you think an immediate restorative treatment is required?
CONTACTED (n [ 1,842) In other words—pick the Figure number with the smallest lesion size for
(N [ 16,960) which you would not postpone restorative treatment under any
circumstances even if the patient has low caries activity and good oral
Sex, % n ¼ 1,786* hygiene.”
Male 68.2 68.4 - Question 2: “Which type of preparation would you prefer for the
Female 31.8 31.6 smallest lesion you decided to drill and fill? (Imagine that the approximal
lesion is situated distally on the second premolar in the upper jaw.)”
Age, y† n ¼ 1,756*
- Question 3: “Which restorative material would you choose for the
Mean (standard 49.2 (18.0) 50.4 (12.2)‡ smallest approximal lesion you would restore?”
deviation)
OCCLUSAL LESION (FIGURE 2)19
Years Since n ¼ 1,816*
Graduation† Mean (standard deviation): - Question 1: “The picture 2 illustrates different clinical appearances of
22.8 (13)§ occlusal caries in a lower second molar (grade 1 to 5). Starting at which
lesion do you think immediate restorative (operative) treatment is
More than 20 y ago Not applicable 753 (41.5%) required? Please, pick the smallest lesion size you think requires immediate
20 y ago or less Not applicable 1,063 (58.5%) restorative treatment. In other words, that is the lesion for which you would
Type of Practice n ¼ 1,829* not postpone restorative treatment under any circumstances. The patient is
20 years old, has low caries activity and good oral hygiene.”
General 14,182 (78.4%) 1,600 (87.5%)
practitioners
- Question 2: “Which type of preparation would you prefer for the
smallest of the lesions you decided to drill and fill?”
Specialists 3,896 (21.6%) 229 (12.5%)
- Question 3: “Which restorative material would you choose for the
Pediatric dentists 703 (3.9%) 108 (5.9%) smallest approximal lesion you would restore?”
* Total number of respondents to this question. CLINICAL CASE 1 (FIGURE 3)19
† At the time of the survey (2013).
‡ Minimum: 25. Maximum: 73.
- Question 1: “Do you think that, from its clinical and radiographic
§ Minimum: 1. Maximum: 53. appearance, the tooth has occlusal (enamel or dentin) caries?”
- Question 2: “How would you treat this occlusal surface? You have not
seen the patient before, and 2 years have elapsed since his last dental
examination. The patient uses fluoride toothpaste on a daily basis and
METHODS dietary and oral hygiene habits are considered satisfactory.”
We obtained approval for the survey study from the CLINICAL CASE 2 (FIGURE 4)19
Committee on Human Research at University of Cali- - Question 1: “Do you think that, from its clinical and radiographic
appearance, the tooth has occlusal (enamel or dentin) caries?”
fornia, San Francisco (institutional review board
Question 2: “How would you treat this occlusal surface? You have not
approval 12-10135). We sent a Web-based questionnaire -

electronically (May 2013; including an online consent
form) to 16,960 CA-licensed dentists by using Survey-
Monkey (SurveyMonkey). We sent an electronic
reminder 15 days later. Table 1 provides the demographic
characteristics of the dentists contacted.
Espelid and colleagues17 and Tveit and colleagues18
designed the questionnaire used in our study, and we
used it with their permission (materials reproduced here
permission of the publisher). After users provided elec-
tronic consent, the Web-based questionnaire assessed the
stage of lesion progression at which the respondents
considered restorative strategies appropriate by using
diagrams of different stages of approximal and occlusal
caries lesions. The survey recorded preferred restorative
technique and restorative material of choice for treat-
ment of these hypothetical lesions, along with the sex,
age, year of graduation, and type of practice (general
practitioner [GP] or specialist and the specialty).
For all questions, an imaginary 20-year-old patient
was described. This patient visits a dentist annually, has
low caries activity and good oral hygiene, and uses a
fluoridated toothpaste. The items of the questionnaire
are shown in the box and Figures 1-4.19
seen the patient before, and 2 years have elapsed since his last dental
examination. The patient uses fluoride toothpaste on a daily basis and
dietary and oral hygiene habits are considered satisfactory.”
* Adapted with permission of the publisher from Espelid and colle-
ages17 and Tveit and colleagues.18
We performed descriptive analyses to characterize
the respondent population and the responses to the
different questions related to the management strategies
for approximal and occlusal caries lesions. We used a
c2 test to assess the relationship between the management
strategies and some demographic characteristics (sex,
years since graduation, and the respondents’ type of
practice). We used subgroups for further analyses. The
first set of subgroups was years since graduation (20
years or less versus more than 20 years ago). For the
second set of subgroups, we merged grades for both
approximal and occlusal thresholds with regard to clinical
relevance. Merging occurred with regard to potential
treatment options and likelihood of successful lesion
remineralization. The approximal caries lesion restorative
ABBREVIATION KEY. CA: California. DEJ: Dentinoenamel
junction. GP: General practitioner.

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 ORIGINAL CONTRIBUTIONS

threshold subgroup was

caries lesions grades 1 and 45 42.6
2 (merged) versus lesions
grade 3 versus lesions 40
grade 4 versus lesions 35 33.4
grades 5 and 6 (merged).

PERCENTAGE
30
The occlusal restorative
threshold subgroup was 25
caries lesion grades 1 and 20
2 (merged) versus lesions 15.1
15
grade 3 versus lesions
grades 4 and 5 (merged). 10
We performed the sta- 2.9 4
5 2
tistical analyses by using
0
SPSS 19 (IBM). We set the
level of significance at 5%.

RESULTS
Respondents. A total 1 2 3 4 5 6
of 1,922 dentists (11.3%) GRADE
replied to the Web-based
questionnaire survey.
Of these, we excluded Figure 1. Approximal lesion restorative threshold. The figure illustrates different radiographic stages of caries
progression. The example refers to the distal surface of a maxillary second premolar and answers the question
80 respondents because “Starting with which lesion size do you think an immediate restorative treatment is required?” (See the Methods
they only answered section for more details.) Stages of caries progression: grade 1, lesion in the outer one-half of enamel; grade 2,
questions related to their lesion in the inner one-half of enamel; grade 3, lesion at the dentinoenamel junction; grade 4, lesion involving the
outer one-third of dentin; grade 5, lesion involving the middle one-third of dentin; and grade 6, lesion involving the
demographic characteris- inner one-third of dentin. There were 1,833 respondents. Adapted with permission of the publisher from Mejare
tics. Of the remaining and colleagues.19
1,842 respondents, 87.5%
were GPs, and 12.5% were specialists that included amalgam, and 1% proposed other kinds of materials
5.9% pediatric dentists. Most of the remaining specialists (for example, gold). The preferred preparation type
were prosthodontists and orthodontists plus a few others and the suggested restorative materials were reported
who appeared to feel competent to answer caries-related independently from the reported treatment threshold
questions. Table 1 summarizes the demographic char- level.
acteristics of the CA dentists contacted and the re- Restorative management of occlusal caries
spondents. Sex distribution and average age were similar lesions. Almost 41% of the respondents would restore
for both groups; 9% more GPs and 9% fewer specialists and would not delay treatment under any circumstances
were among the respondents. In addition, 50% more for a lesion confined to enamel (grades 1 and 2). One-half
pediatric dentists participated than were accounted for of the respondents (49.9%) would restore an occlusal
in the group of contacted dentists. lesion that involved the outer one-third of dentin
Restorative management of approximal caries (grade 3), and 9.4% considered a lesion in the middle
lesions. Eighteen percent of the respondents suggested one-third of dentin or deeper (grades 4 and 5) as the
restorative treatment and would not delay treatment smallest lesion requiring immediate restoration place-
under any circumstances for a lesion confined to ment (Figure 2).
enamel (grades 1 and 2), 42.6% would not delay When asked about the extension of their restorative
treatment for a lesion at the dentinoenamel junction treatment, 64.6% of the respondents would limit their
(DEJ) (grade 3), and 33.4% would restore when the cavity preparation to the carious area, 31.5% preferred a
lesion reached the outer one-third of dentin (grade 4) preparation including the whole occlusal fissure system,
(Figure 1). The preferred preparation type (54.1%) and 3.9% chose other types of preparation (for example,
was the traditional Class II preparation, and 45.9% preparation for an inlay). Regarding the recommended
of respondents preferred a minimally invasive cavity restorative material, most (94.6%) chose tooth-colored
preparation (tunnel or saucer shaped). Most of the materials, 4.7% chose amalgam, and 0.7% would use
respondents (92.6%) recommended tooth-colored ma- other types of material (for example, gold, ceramic).
terial (resin-based composite, glass ionomer cement, Again, the preferred preparation type and the suggested
resin-modified glass ionomer cement, and sandwich- restorative materials were independent from the reported
technique glass ionomer cement), 6.4% recommended treatment threshold level.

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 ORIGINAL CONTRIBUTIONS

likely to suggest invasive

60 restorative treatment for
lesions at a later stage
49.9
50
(outer one-third of
dentin involved) than
were those who gradu-
38.9 ated more than 20 years
40
PERCENTAGE

ago (lesion confined to

enamel) (P < .0001)
30 (Table 3). We also found
a significant relationship
20
between the restorative
threshold for approximal
lesions and the type of
10 7.7 practice: pediatric den-
1.8
tists would suggest a
1.7
restoration at later
0 stages of approximal
lesions than would GPs
(P < .0001).
We found no signifi-
cant relationship between
sex and restorative de-
1 2 3 4 5
cisions. The management
GRADE decisions for occlusal
caries lesions were not
Figure 2. Occlusal lesion restorative threshold. The figure illustrates different clinical appearances of caries.
influenced by any of the
The example refers to a mandibular second molar and answers the question “Starting at which lesion do you think recorded demographic
immediate restorative (operative) treatment is required?” (See the Methods section for more details.) Stages of characteristics.
caries progression: grade 1, white or brownish discoloration in the enamel, no cavitation, no radiographic signs of
caries; grade 2, minor loss of tooth substance with a break in the enamel surface or discolored surface or dis-
colored fissures with gray or opaque enamel or caries confined to the enamel, no radiographic signs of caries; DISCUSSION
grade 3, moderate loss of tooth substance or caries in the outer one-third of the dentin according to the Investigators have stud-
radiograph; grade 4, considerable loss of tooth substance or caries in the middle one-third of the dentin according
ied restorative treatment
to the radiograph; and grade 5, considerable loss of tooth substance or caries in the inner one-third of the dentin
according to the radiograph. There were 1,813 respondents. Adapted with permission of the publisher from strategies by means of
Mejare and colleagues.19
questionnaire surveys
among practicing
Diagnosis and management of occlusal caries dentists in many countries (for example, Australia,26
lesions. Clinical case 1. The most common diagnosis Brazil,27 Canada,28 Croatia,23 France,20 Iran,29 Kuwait,21
(92.5%) for the occlusal surface of clinical case 1 The Netherlands,30 Scandinavia,4,17-19,31,32 Scotland,33 and
(Figure 3) was the presence of a dentin lesion, and the United States24,25). Espelid and colleagues17 and Tveit
97.2% of respondents would restore the tooth. Table 2 and colleagues18 developed the questionnaire used in our
presents the caries management alternatives for this study, and it is the most commonly used, thus allowing
lesion chosen by the respondents. comparisons.17-20,22,31,32 We formatted the questionnaire
Clinical case 2. The most common diagnosis (50.5%) for use as a Web-based survey.
for the occlusal surface of clinical case 2 (Figure 4) was The demographic characteristics of CA dentists in the
the presence of an enamel lesion. The respondents varied original database favorably compared with those of the
markedly in their diagnosis. Fewer dentists would restore respondents regarding the distribution of sex and age.
this tooth than in clinical case 1, but more than one-half When taking into account that nonrestorative specialists
of them (56.9%) still would restore this noncavitated who typically do not manage caries-related treatment
lesion. Table 2 presents the caries management alterna- decisions directly did not reply to the survey, the ratio of
tives related to this enamel lesion chosen by the GPs to specialists actually answering the survey appeared
respondents. representative. Because 50% more pediatric dentists
Influence of type of practice and number of years answered the survey, we may conclude that pediatric
since graduation on caries management strategies. For dentists were slightly overrepresented in the response.
approximal caries lesions, the c2 test showed that re- The response rate in this Web-based survey was 11.3%
spondents who graduated 20 years ago or less were more and thus much lower than response rates of similar mailed

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 ORIGINAL CONTRIBUTIONS

surveys, which generally

achieved responses
between 40% and
80%.17,19,20,25 Web-based
surveys have lower
response rates. Rosenstiel
and colleagues34 in 2004
surveyed 12,000 US den-
tists about their molar
restoration choices and
longevity with a response
rate of 6.3%. In surveys of
specialists about specifics
in their field, the response
rate is generally higher,
between 15% and 40%.35-38
A B
The response rate in
our study was similar to
the rate of dentists in
Ontario, Canada, who
were asked a detailed
question about treating
teeth with apical peri-
odontitis. When queried
about their preference of
an endodontic treatment
or extraction without C
and with replacement by
an implant, the special-
Dentin Lesion (92.5%) Uncertain (3.0%)
ists answered at a 40%
response rate on a mailed Enamel Lesion (4.1%) Sound (0.4%)
survey, and the GPs
showed a 15% response
rate to the same Web- Figure 3. Answers to the question “For clinical case 1, do you think that, from its clinical and radiographic
based survey.35 appearance, the tooth has an occlusal (enamel or dentin) caries lesion?” There were 1,808 respondents.
A. Radiographic view of the tooth. B. Clinical view of the tooth. C. Practitioners’ answers. Adapted with
Restorative thresh- permission of the publisher from Mejare and colleagues.19
old. Studies in which the
investigators have surveyed dentists’ restorative thresh- a lesion extending into the outer one-third of dentin. In
olds reveal wide variations (Table 4).4,18-21,23,25-29 In some contrast to this conservative behavior, almost 20% of the
countries, most dentists would restore approximal le- respondents would recommend restorative intervention
sions confined to enamel.20,27 In others, most dentists at much earlier stages with lesions confined to enamel.
recommended treatment only when the lesion has This practice is not consistent with the literature and
reached the outer one-third and the middle one-third of potential remineralization and reversal of these lesions.
dentin, respectively.21,25,29 For occlusal lesions, fewer data were available for
In this regard, Scandinavia appears to play a leading comparison (Table 5).19-21,25,39 More than 40% of CA
role. For more than 16 years, the restorative treatment dentists suggested an immediate restoration for an early
threshold has been high, abstaining from restorative stage of caries progression (grades 1 and 2). Almost one-
options until the lesion had progressed far into dentin.19 half of the French dentists reported their restorative
Results from studies in Norway also have shown that threshold at the same level in 2002.20 One-half of the CA
administering the same survey several years later resulted dentists decided to intervene restoratively at a more
in the treatment thresholds that moved consistently advanced dentinal lesion level (outer or middle one-third
toward deeper lesions.4,18 of dentin), and in 2012 the threshold of French dentists
In our study, most CA dentists reported their also had shifted to more progressed lesions.39 Similarly
restorative treatment threshold for lesions that had for approximal lesions, dentists in Sweden and Kuwait
reached the DEJ. One-third of the dentists would reported their restorative threshold at even more
recommend a cavity preparation and restoration for advanced occlusal lesions.19,21

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 ORIGINAL CONTRIBUTIONS

Practitioners have used

the saucer-shape prepa-
ration, a minimally
invasive slot preparation
with extensive bevels
primarily located in the
enamel, successfully in
long-term studies.42,43
Most dentists in Nor-
way and France indicated
the saucer-shape prepa-
ration as their preferred
treatment approach.4,44
In contrast, most of the
surveyed CA and Kuwait
A B dentists choose the tradi-
tional Class II approach.21
Conversely, despite this
invasive approach for
approximal lesions, most
CA respondents and
Kuwait dentists would
remove only carious tis-
sue for occlusal lesions.21
Notably, for the addi-
tional clinical cases
C
included in our study
(clinical cases 1 and 2),
Dentin Lesion (15.0%) Uncertain (15.4%) most practitioners
Enamel Lesion (50.5%) Sound (19.1%) opted for restorative in-
terventions over the
more conservative sealant
Figure 4. Answers to the question “For clinical case 2, do you think that, from its clinical and radiographic and treatment with fluo-
appearance, the tooth has an occlusal (enamel or dentin) caries lesion?” There were 1,796 respondents. rides and no treatment,
A. Radiographic view of the tooth. B. Clinical view of the tooth. C. Practitioners’ answers to the question.
Adapted with permission of the publisher from Mejare and colleagues. 19 respectively.
Although sealants are
recommended for non-
As for all dentist surveys, one should keep in mind cavitated lesions,15 other researchers2,3 have demonstrated
that showing a picture of an occlusal lesion and saying that ultraconservative sealed amalgam and resin-based
that radiographically the lesion is evident in the outer composite restorations placed directly over frank cavi-
one-third of dentin, for example, may have elicited a tated lesions extending into dentin exhibited superior
more aggressive treatment response than showing clinical performance and longevity. Also, enamel-bonded
the image alone, without a description. To be able to composite resin restorations placed over cavitated lesions
compare the results of this survey of CA dentists with arrested the clinical progress of these lesions for 10
results of surveys performed earlier and more recently in years.2,3 The restorative material of choice in all countries
other countries, we decided to use an unchanged version was tooth-colored restorations.
of the survey. This survey is more than 10 years old, so Today, dentists should know that operative dental
survey terms such as noncavitated were yet not treatment alone does not ensure oral health.45 In a 2012
integrated. caries clinical trial,7 the investigators demonstrated that
Preparation type and material. When dentists decide placing restorations in the control group did not reduce
that a restorative approach to an approximal lesion is the mutans streptococci bacterial challenge significantly
needed, a minimally invasive removal of tooth structure nor did placing restorations significantly change the
should be the goal. Whereas the tunnel-shape prepara- caries risk status. Only targeted antibacterial and fluoride
tion was not successful because of the obliterated view of therapy based on salivary microbial and fluoride levels
the preparation field and recurrent caries lesions, the favorably altered the balance between pathologic and
saucer-shape preparation preserves tooth structure.40,41 protective caries risk factors.7

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Early restorative intervention is especially inappro- TABLE 2

priate because it starts a process known as the repeat Clinical cases 1 and 2: how would you
restoration cycle or the cycle of rerestorations, each
restoration being less prophylactic and more iatrogenic treat this occlusal surface?*
46
than the previous one, which can cause early loss of the MANAGEMENT STRATEGY CLINICAL CASE CLINICAL CASE
tooth.45 Therefore, traditional restorative dentistry pro- 1, NO. (%) 2, NO. (%)
(n [ 1,802) (n [ 1,774)
tocols may be outdated.
No Treatment 13 (0.7) 220 (12.4)
In Norway, dentists changed the clinical criteria for
intervention in the caries process.4,47 As a result, the Fluoride Treatment 8 (0.4) 101 (5.7)
Sealant 30 (1.7) 443 (25.0)
number of restored surfaces was reduced dramatically in
the 1980s because of a change in the criteria for place- Prepare Carious Part and
Restore
351 (19.5) 219 (12.3)
47
ment of restorations in the treatment of enamel lesions. Prepare Carious Part, Restore, 962 (53.4) 539 (30.4)
The number of restored surfaces decreased by 92% and Seal Whole Fissure
because clinicians treated caries lesions in the enamel Prepare Whole Fissure and 438 (24.3) 252 (14.2)
preventively instead of restoratively.48 Those lesions were Restore
approximal. Lesions reaching into the outer one-half * Not all participants responded to all questions; treatment decisions
presented are independent of suggested diagnosis.
of dentin were
treated successfully
32% less often with TABLE 3
a filling but rather Influence of type of practice and years since graduation on
with preventive restorative threshold for approximal and occlusal caries lesions.
measures.47
Dental educa- RESTORATIVE TYPE OF PRACTICE, P VALUE YEARS SINCE P
THRESHOLD % (NO.) GRADUATION, % (NO.)* VALUE
tion and treatment
criteria have evol- GP† Pediatric > 20 £ 20
Dentists
ved over time.
Approximal Lesion‡
Younger dentists
Grades 1 and 2 18.3 (291) 9.3 (10) 20.2 (213) 14.8 (111)
may be educated
Grade 3 43.6 (694) 30.6 (33) < .0001 40.3 (426) 46.2 (347) < .0001
about new princi-
Grade 4 32.3 (515) 49.1 (53) 32.3 (341) 34.8 (261)
ples such as mini-
Grades 5 and 6 5.8 (92) 11.1 (12) 7.3 (77) 4.3 (32)
mal intervention
Occlusal Lesion§
dentistry, Caries
Grades 1 and 2 41.7 (660) 35.2 (37) Not 39.3 (409) 42.6 (317)
Management by significant
.05
Grade 3 49.2 (778) 57.1 (60) 50.0 (521) 49.9 (372)
Risk Assessment,
Grades 4 and 5 9.1 (144) 7.6 (8) 10.7 (112) 7.5 (56)
and minimally
* At the time of the survey (2013).
invasive dentistry. † GP: General practitioner.
This difference was ‡ Cross-tabulations related to approximal lesions: Restorative threshold per type of practice: 1,700 respondents.
demonstrated in Restorative threshold per years since graduation: 1,808 respondents.
§ Cross-tabulations related to occlusal lesions: Restorative threshold per type of practice: 1,687 respondents. Restorative
a French study in threshold per years since graduation: 1,787 respondents.
which older den-
tists favored open-
ing the whole fissure when restoring occlusal caries These groups have accepted that demineralized but
lesions significantly more often than did younger noncavitated enamel and dentin can be remineralized;
dentists.20 therefore, the traditional operative approach of “drilling
In our study, CA dentists with 20 or fewer years since and filling” no longer may be necessary and appropriate
graduation decided to restore approximal lesions inva- for such lesions. Noncavitated lesions have lost mineral
sively at a significantly later stage in caries progression at different degrees, but there is no physical loss of
than did those who graduated more than 20 years ago. enamel prisms, nor is there localized enamel break-
Although in The Dental Practice-Based Research down.50 The philosophy of minimal intervention dictates
Network survey female dentists suggested a restorative that operative intervention should be performed only
treatment of approximal caries lesions at a further pro- when cavitation is present.51 Some enamel lesions never
gressed stage than did male respondents,49 in our study penetrate into dentin, and up to 60% of lesions in the
we did not find those sex differences. Results from our outer one-half of dentin are noncavitated and can be
study showed that pediatric dentists suggested restorative arrested.52,53 Therefore, postponement of restorative
treatment for approximal caries lesions at significantly intervention should be taken into consideration
later stages than did GPs. accordingly.54,55

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TABLE 4
Restorative threshold for approximal lesions reported in various countries, with
number of surveys sent out and percentage of respondents, lesion depth,
preferred type of preparation, and preferred restorative material.
AUTHOR, YEAR (COUNTRY) SURVEY POPULATION LESION DEPTH, %*
No. of Surveys Response Rate, Outer One-Half Inner One-Half DEJ†
Sent % Enamel Enamel
Riordan and Colleagues,26 1991 (Australia) 45 95.1 2 9 29
el-Mowafy and Lewis,28 1994 (Canada) 2,450 52.1 1 27 67§
Mejare and Colleagues,19 1999 (Sweden) 923 70.5 0 1 4
Tveit and Colleagues,18 1999 (Norway) 640 84.4 4** 15
Domejean-Orliaguet and Colleagues,20 2,000 39.1 20 36 32
2004 (France)
Traebert and Colleagues,27 2005 (Brazil) 840 89.4 32 23 25
Ghasemi and Colleagues,29 2008 (Iran) 1,033 ††
8 — 23
Baraba and Colleagues,23 2010 (Croatia) 800 38.0 10 32 39
Vidnes-Kopperud and Colleagues,4 2011 3,654 61.0 1** 6
(Norway)
Heaven and Colleagues,25 2013 (United 901 63.0 2 42¶¶ 54
States)
Khalaf and Colleagues,21 2014 (Kuwait) 200 92.5 2 8 7
Present Study (United States) 16,960 11.3 3 15 43
* Percentages are rounded for lesion depth, so they do not necessarily total 100.
† DEJ: Dentinoenamel junction.
‡ Not available.
§ Just beyond DEJ.
¶ Includes outer one-half of dentin.
# Two different surveyed areas.
** These studies only reported for the combined class and lesion depth.
†† Dentists at 2 conferences.
‡‡ Outer one-half of dentin.
§§ Inner one-half of dentin.
¶¶ The picture did not show the DEJ obviously.

In a qualitative study of private practice dentists to
assess barriers to the use of evidence-based clinical rec-
ommendations in the treatment of noncavitated occlusal
caries lesions, the investigators realized that diagnosis of
and knowledge about noncavitated lesions were limited;
despite the presented fact that the lesion was non-
cavitated, 50% would base their treatment decision on
the presence or absence of the sticking of a sharp ex-
plorer.56 Future education of dentists should emphasize
that noncavitated lesions can be remineralized easily but
that the surface of any noncavitated lesion can be
changed into a cavitated lesion by the stick of an
explorer.
For approximal lesions, in which the visibility of a
cavitation is limited, slight tooth separation by using a
wedge could be a last resort for clarification, resulting in
most correct clinical management decisions and most
correct decisions regarding the choice of treatment as
shown by a study.57 Direct application of fluoride to the
lesion or resin infiltration can be regarded as treatment
choices.58-60
Results from some studies have shown that the
treatment prescription strongly depends on which caries
risk scenario is given. When the risk is presented as high,
more dentists recommend invasive treatment than when
the risk is described as low for the same lesion depth
confined to enamel.25 The appropriate treatment sug-
gestion still would have been a remineralization tech-
nique and other caries management measures. In our
survey, the caries risk was suggested as relatively low.
Finally, determination of lesion activity by using, for
instance, the observational clinical criteria in Nyvad and
colleagues’ article61 also may influence the caries man-
agement decision. As a shortcoming of this survey, in
which participants were shown one photograph or
radiograph to make a decision, no prior lesion status was
presented.
CONCLUSIONS
There is a wide disparity between CA dentists regarding
their restorative treatment decisions. Most CA dentists
reported their restorative treatment threshold was for
lesions that had reached the DEJ. Only one-third of
the dentists would recommend a cavity preparation
and restoration for a lesion extending into the outer
one-third of dentin. In contrast, dentists in Scandinavia

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 ORIGINAL CONTRIBUTIONS

TABLE 4 (CONTINUED)

LESION DEPTH, %* PREPARATION TYPE, % RESTORATIVE MATERIAL, %

Outer One-Third Middle One-Third Inner One-Third Traditional Tunnel Saucer Tooth Amalgam Others
Dentin Dentin Dentin Class II Colored
40 11 9 —‡ — — — — —
5¶ — — 23.0/55.0# 77.0/45.0# — — — —
42 52 1 — — — — — —
62 19 1 28.3 47.4 24.3 81.5 15.5 3.0
11 1 — 12.0 33.3 54.7 76.1 20.5 3.4

18 3 — — — — — — —
58‡‡ — 11§§ — — — — — —
18 1‡‡ 0§§ 32.0 46.0 22.0 96.0 4.0 —
57 36 — 27.8 3.8 68.4 100 Banned —

3 1 — — — — — — —

40 19 24 49.2 24.9 25.9 88.6 11.4 —

33 4 2 54.1 23.5 22.4 92.6 6.4 1.0

TABLE 5
Restorative threshold for occlusal lesions reported in various countries, lesion
depth, suggested limit of preparation extension, and preferred restorative
material.
AUTHOR, YEAR SURVEY LESION DEPTH, %* PREPARATION RESTORATIVE
(COUNTRY) POPULATION EXTENSION, % MATERIAL, %
No. of Response Grade Grade Grade Grade Grade Limited to Extended Tooth Amalgam Other
Surveys Rate, % 1 2 3 4 5 Carious to Whole Colored
Sent Tissue Fissure
Mejare and 923 70.5 —† 6 67 27 — — — — — —
Colleagues,19
1999 (Sweden)
Domejean- 2,000 39.1 2 47 47 3 — 61.2 36.0 79.9 17.1 3.0
Orliaguet and
Colleagues,20
2004 (France)
Heaven and 901 63.0 1 9 34 33 2 — — — — —
Colleagues,25
2013 (United
States)
Khalaf and 200 92.5 — 4 28 43 24 78.9 21.1 88.7 9.7 1.6
Colleagues,21
2014 (Kuwait)
Domejean and 2,000 41.9 2 37 55 6 — 67.8 30.0 92.6 7.3 0.1
Colleagues,39
2015 (France)
Present Study 16,960 10.9 2 39 50 8 2 64.6 31.5 94.6 4.7 0.7
(United States)
* Percentages are rounded for lesion depth.
† Not available.

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 ORIGINAL CONTRIBUTIONS
are much more reluctant to provide invasive restorative
treatment and prefer treatment at more pronounced
stages. The same is true for restorative treatment de-
cisions for occlusal lesions, for which CA dentists
decided to intervene restoratively at a dentinal lesion
level at the outer or middle one-third of dentin.
Because clinical evidence shows that caries lesions can
be remineralized, early restorative treatment no longer
seems to be necessary or appropriate. Noninvasive or
minimally invasive measures should be taken into
consideration when judging the need for invasive
restorative treatment. In this study, we found that recent
dental graduates and pediatric dentists were more likely
to place their restorative threshold at deeper lesions for
approximal caries. These CA dentists seem to have
embraced a minimally invasive and, even more impor-
tant, the remineralization concept.
However, dentists still need to be trained in dis-
tinguishing between cavitated and noncavitated lesions
and when it is appropriate to use remineralization
therapy rather than invasive restorative methods.
Financial incentives for remineralization of noncavitated
lesions and more minimal invasive treatment would be
appropriate to change behavior. n
Dr. Rechmann is a professor and the director, Clinical Sciences Research
Group, Department of Preventive and Restorative Dental Sciences, School of
Dentistry, University of California, 707 Parnassus Ave., San Francisco,
CA 94143, e-mail Peter.Rechmann@ucsf.edu. Address correspondence to
Dr. Rechmann.
Dr. Doméjean is a professor, Department of Operative Dentistry and
Endodontics, School of Dentistry, University of Clermont-Ferrand,
Clermont-Ferrand, France.
Ms. Rechmann is a senior research associate, Department of Preventive
and Restorative Dental Sciences, School of Dentistry, University of Cali-
fornia, San Francisco, CA.
Dr. Kinsel is a health science associate clinical professor, Department of
Preventive and Restorative Dental Sciences, School of Dentistry, University
of California, San Francisco, CA.
Dr. Featherstone is a professor, Department of Preventive and Restorative
Dental Sciences, School of Dentistry, University of California, San Francisco,
and the dean, School of Dentistry, University of California, San Francisco,
CA.
Disclosure. None of the authors reported any disclosures.
The authors thank Drs. Espelid and Tveit for allowing the use of their
original questionnaire and pictures for our Web-based survey.
1. Brostek AM, Bochenek AJ, Walsh LJ. Minimally invasive dentistry: a
review and update. Shanghai Kou Qiang Yi Xue. 2006;15(3):225-249.
2. Mertz-Fairhurst EJ, Adair SM, Sams DR, et al. Cariostatic and ultra-
conservative sealed restorations: nine-year results among children and
adults. ASDC J Dent Child. 1995;62(2):97-107.
3. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM.
Ultraconservative and cariostatic sealed restorations: results at year 10.
JADA. 1998;129(1):55-66.
4. Vidnes-Kopperud S, Tveit AB, Espelid I. Changes in the treatment
concept for approximal caries from 1983 to 2009 in Norway. Caries Res.
2011;45(2):113-120.
5. Frencken JE, Peters MC, Manton DJ, et al. Minimal intervention
dentistry for managing dental caries: a review—report of a FDI task group.
Int Dent J. 2012;62(5):223-243.
6. Hausen H. How to improve the effectiveness of caries-preventive
programs based on fluoride. Caries Res. 2004;38(3):263-267.
10 JADA ( )
- - http://jada.ada.org - 2016
7. Featherstone JD, White JM, Hoover CI, et al. A randomized clinical
trial of anticaries therapies targeted according to risk assessment (caries
management by risk assessment). Caries Res. 2012;46(2):118-129.
8. Pitts NB, Ekstrand KR. The ICDAS Foundation. International Caries
Detection and Assessment System (ICDAS) and its International Caries
Classification and Management System (ICCMS): methods for staging of
the caries process and enabling dentists to manage caries. Community Dent
Oral Epidemiol. 2013;41(1):e41-e52.
9. Ismail AI, Sohn W, Tellez M, et al. The International Caries Detection
and Assessment System (ICDAS): an integrated system for measuring
dental caries. Community Dent Oral Epidemiol. 2007;35(3):170-178.
10. Deery C, Ellwood R, Gomez J, et al. ICCMS Guide for Practitioners and
Educators. Available at: http://www.icdas.org. Accessed October 23, 2015.
11. Baelum V, Machiulskiene V, Nyvad B, Richards A, Vaeth M. Appli-
cation of survival analysis to carious lesion transitions in intervention
trials. Community Dent Oral Epidemiol. 2003;31(4):252-260.
12. Sbaraini A, Evans RW. Caries risk reduction in patients attending a
caries management clinic. Aust Dent J. 2008;53(4):340-348.
13. Featherstone JD. Prevention and reversal of dental caries: role of low
level fluoride. Community Dent Oral Epidemiol. 1999;27(1):31-40.
14. Holmgren C, Gaucher C, Decerle N, Domejean S. Minimal inter-
vention dentistry II: part 3—management of non-cavitated (initial) occlusal
caries lesions, non-invasive approaches through remineralisation and
therapeutic sealants. Br Dent J. 2014;216(5):237-243.
15. Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical
recommendations for the use of pit-and-fissure sealants: a report of the
American Dental Association Council on Scientific Affairs. JADA. 2008;
139(3):257-268.
16. Chaffee BW, Cheng J, Featherstone JD. Baseline caries risk assess-
ment as a predictor of caries incidence. J Dent. 2015;43(5):518-524.
17. Espelid I, Tveit AB, Mejare I, Sundberg H, Hallonsten AL. Restorative
treatment decisions on occlusal caries in Scandinavia. Acta Odontol Scand.
2001;59(1):21-27.
18. Tveit AB, Espelid I, Skodje F. Restorative treatment decisions on
approximal caries in Norway. Int Dent J. 1999;49(3):165-172.
19. Mejare I, Sundberg H, Espelid I, Tveit B. Caries assessment and
restorative treatment thresholds reported by Swedish dentists. Acta
Odontol Scand. 1999;57(3):149-154.
20. Domejean-Orliaguet S, Tubert-Jeannin S, Riordan PJ, Espelid I,
Tveit AB. French dentists’ restorative treatment decisions. Oral Health
Prev Dent. 2004;2(2):125-131.
21. Khalaf ME, Alomari QD, Ngo H, Domejean S. Restorative treatment
thresholds: factors influencing the treatment thresholds and modalities of
general dentists in Kuwait. Med Princ Pract. 2014;23(4):357-362.
22. Baraba A, Domejean S, Juric H, et al. Restorative treatment decisions
of Croatian university teachers. Coll Antropol. 2012;36(4):1293-1299.
23. Baraba A, Domejean-Orliaguet S, Espelid I, Tveit AB, Miletic I.
Survey of Croatian dentists’ restorative treatment decisions on approximal
caries lesions. Croat Med J. 2010;51(6):509-514.
24. Gordan VV, Bader JD, Garvan CW, et al; Dental Practice-Based
Research Network Collaborative Group. Restorative treatment thresholds
for occlusal primary caries among dentists in The Dental Practice-Based
Research Network. JADA. 2010;141(2):171-184.
25. Heaven TJ, Gordan VV, Litaker MS, et al. The National Dental
Practice-Based Research Network. Agreement among dentists’ restorative
treatment planning thresholds for primary occlusal caries, primary prox-
imal caries, and existing restorations: findings from The National Dental
Practice-Based Research Network. J Dent. 2013;41(8):718-725.
26. Riordan PJ, Espelid I, Tveit AB. Radiographic interpretation and
treatment decisions among dental therapists and dentists in Western
Australia. Community Dent Oral Epidemiol. 1991;19(5):268-271.
27. Traebert J, Marcenes W, Kreutz JV, et al. Brazilian dentists’ restor-
ative treatment decisions. Oral Health Prev Dent. 2005;3(1):53-60.
28. el-Mowafy OM, Lewis DW. Restorative decision making by Ontario
dentists. J Can Dent Assoc. 1994;60(4):305-310, 313-316.
29. Ghasemi H, Murtomaa H, Torabzadeh H, Vehkalahti MM. Restor-
ative treatment threshold reported by Iranian dentists. Community Dent
Health. 2008;25(3):185-190.
30. Mileman PA, Espelid I. Decisions on restorative treatment and recall
intervals based on bitewing radiographs: a comparison between national
surveys of Dutch and Norwegian practitioners. Community Dent Health.
1988;5(3):273-284.
 ORIGINAL CONTRIBUTIONS
31. Espelid I, Tveit A, Haugejorden O, Riordan PJ. Variation in radio-
graphic interpretation and restorative treatment decisions on approximal
caries among dentists in Norway. Community Dent Oral Epidemiol. 1985;
13(1):26-29.
32. Sundberg H, Mejare I, Espelid I, Tveit AB. Swedish dentists’ decisions
on preparation techniques and restorative materials. Acta Odontol Scand.
2000;58(3):135-141.
33. Nuttall NM, Pitts NB. Restorative treatment thresholds reported to be
used by dentists in Scotland. Br Dent J. 1990;169(5):119-126.
34. Rosenstiel SF, Land MF, Rashid RG. Dentists’ molar restoration
choices and longevity: a web-based survey. J Prosthet Dent. 2004;91(4):
363-367.
35. Azarpazhooh A, Dao T, Figueiredo R, Krahn M, Friedman S.
A survey of dentists’ preferences for the treatment of teeth with apical
periodontitis. J Endod. 2013;39(10):1226-1233.
36. Kalkani M, Ashley P. The role of paediatricians in oral health of
preschool children in the United Kingdom: a national survey of paediatric
postgraduate specialty trainees. Eur Arch Paediatr Dent. 2013;14(5):319-324.
37. Banzai R, Derby DC, Long CR, Hondras MA. International web
survey of chiropractic students about evidence-based practice: a pilot
study. Chiropr Man Therap. 2011;19(1):6.
38. Creasy JE, Mines P, Sweet M. Surgical trends among endodontists:
the results of a web-based survey. J Endod. 2009;35(1):30-34.
39. Domejean S, Leger S, Maltrait M, et al. Changes in occlusal caries
lesion management in France from 2002 to 2012: a persistent gap between
evidence and clinical practice. Caries Res. 2015;49(4):408-416.
40. Ratledge DK, Kidd EA, Treasure ET. The tunnel restoration. Br Dent
J. 2002;193(9):501-506.
41. Wiegand A, Attin T. Treatment of proximal caries lesions by tunnel
restorations. Dent Mater. 2007;23(12):1461-1467.
42. Nordbo H, Leirskar J, von der Fehr FR. Saucer-shaped cavity prep-
aration for composite resin restorations in class II carious lesions: three-
year results. J Prosthet Dent. 1993;69(2):155-159.
43. Nordbo H, Leirskar J, von der Fehr FR. Saucer-shaped cavity prep-
arations for posterior approximal resin composite restorations: observa-
tions up to 10 years. Quintessence Int. 1998;29(1):5-11.
44. Domejean S, White JM, Featherstone JD. Validation of the CDA
CAMBRA caries risk assessment: a six-year retrospective study. J Calif
Dent Assoc. 2011;39(10):709-715.
45. Elderton RJ. Preventive (evidence-based) approach to quality general
dental care. Med Princ Pract. 2003;12(suppl 1):12-21.
46. Brantley CF, Bader JD, Shugars DA, Nesbit SP. Does the cycle of
rerestoration lead to larger restorations? JADA. 1995;126(10):1407-1413.
47. Gimmestad AL, Holst D, Fylkesnes K. Changes in restorative caries
treatment in 15-year-olds in Oslo, Norway, 1979-1996. Community Dent
Oral Epidemiol. 2003;31(4):246-251.
48. Mjor IA, Holst D, Eriksen HM. Caries and restoration prevention.
JADA. 2008;139(5):565-570.
49. Riley JL 3rd, Gordan VV, Rouisse KM, McClelland J, Gilbert GH;
Dental Practice-Based Research Network Collaborative Group. Differences
in male and female dentists’ practice patterns regarding diagnosis and
treatment of dental caries: findings from The Dental Practice-Based
Research Network. JADA. 2011;142(4):429-440.
50. ICDAS Foundation website. Available at: http://www.icdas.org.
Accessed October 23, 2015.
51. Mount GJ, Ngo H. Minimal intervention: a new concept for operative
dentistry. Quintessence Int. 2000;31(8):527-533.
52. Bille J, Thylstrup A. Radiographic diagnosis and clinical tissue
changes in relation to treatment of approximal carious lesions. Caries Res.
1982;16(1):1-6.
53. Pitts NB, Rimmer PA. An in vivo comparison of radiographic and
directly assessed clinical caries status of posterior approximal surfaces in
primary and permanent teeth. Caries Res. 1992;26(2):146-152.
54. Anusavice KJ. Efficacy of nonsurgical management of the initial
caries lesion. J Dent Educ. 1997;61(11):895-905.
55. Elderton RJ. Overtreatment with restorative dentistry: when to
intervene? Int Dent J. 1993;43(1):17-24.
56. O’Donnell JA, Modesto A, Oakley M, et al. Sealants and dental caries:
insight into dentists’ behaviors regarding implementation of clinical
practice recommendations. JADA. 2013;144(4):e24-e30.
57. Baelum V, Hintze H, Wenzel A, Danielsen B, Nyvad B. Implications
of caries diagnostic strategies for clinical management decisions. Com-
munity Dent Oral Epidemiol. 2012;40(3):257-266.
58. Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of proximal
superficial caries lesions on primary molar teeth with resin infiltration and
fluoride varnish versus fluoride varnish only: efficacy after 1 year. Caries
Res. 2010;44(1):41-46.
59. Lippert F, Hara AT, Martinez-Mier EA, Zero DT. In vitro caries
lesion rehardening and enamel fluoride uptake from fluoride varnishes as a
function of application mode. Am J Dent. 2013;26(2):81-85.
60. Meyer-Lueckel H, Chatzidakis A, Naumann M, Dorfer CE, Paris S.
Influence of application time on penetration of an infiltrant into natural
enamel caries. J Dent. 2011;39(7):465-469.
61. Nyvad B, Machiulskiene V, Baelum V. Construct and predictive
validity of clinical caries diagnostic criteria assessing lesion activity. J Dent
Res. 2003;82(2):117-122.
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- - http://jada.ada.org - 2016 11