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Occlusal caries: Pathology, diagnosis and

logical management

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David Ricketts
University of Dundee


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Occlusal Caries: Pathology, Diagnosis

and Logical Management

realize, however, that diagnosis

Abstract: Occlusal caries now accounts for most of the lesions in children aged 815 precedes treatment planning. They are
years. This paper presents a ranked visual scoring system for occlusal caries diagnosis. not the same.
It relates the clinical appearance of the lesion to its activity, the level of infection of the
As far as carious lesions are concerned,
dentine and the histopathology. The appropriate management for each score is
diagnosis implies deciding whether
demineralization is present, the depth of
Dent Update 2001; 28: 380-387 the lesion and whether it is progressing
rapidly or slowly (active caries) or whether
Clinical Relevance: Occlusal caries remains a problem for many young people. it is already arrested. Thus diagnosis is
This paper relates the chairside diagnosis of the lesion to its appropriate clinical
more than lesion detection: it should also
consider lesion activity.

Why does this Terminology


D ental caries is a dynamic process

taking place in the microbial
deposits on the tooth surface. It results
metabolic activity in the plaque.
 At the crystal level the
demineralization and
This distinction between detection and
diagnosis matters because the clinician
needs to know the activity of the lesion
in a disturbance of the equilibrium remineralizations resulting from pH in order to plan logical treatment. If the
between the tooth surface and the fluctuations within the plaque fluid lesion is active, preventive, and
surrounding plaque fluid so that, over cannot be prevented. possibly operative, treatment is
time, the net result may be a loss of  Thus the carious process itself required to arrest lesion progression. If
mineral from the tooth surface.1 This cannot be prevented; it is an the lesion is already arrested this would
definition of dental caries has some ubiquitous natural process. be unnecessary.
important implications:  The process can be active, rapidly
progressing, slowly progressing or
 Plaque formation cannot be totally arrested. EPIDEMIOLOGY
prevented even by toothbrushing.  The carious process is driven by It is often said that occlusal pits,
These deposits are always the activity of the plaque and fissures and grooves are particularly
metabolically active. Thus plaque therefore modification of the plaque susceptible to dental caries. Although
formation is a physiological will modify the process. the caries experience of children aged
phenomenon in an oral  The disease can be controlled so 815 years has apparently declined,
environment. that lesion progression to the stage studies have shown that occlusal caries
 Lesion formation reflects the of a white spot or frank cavity can now accounts for the majority of
be prevented. lesions in this age group.27
K.R. Ekstrand, DDS, PhD, Department of
Cariology and Endodontics, School of Dentistry,
Faculty of Health Sciences, University of What is Diagnosis? WHY DOES CARIES
Copenhagen, Denmark, D.N.J. Ricketts, BDS, FDS Diagnosis is a Greek-derived word APPEAR ON OCCLUSAL
RCS (Eng.), PhD, MSc, Unit of Comprehensive SURFACES?
Restorative Care, Dundee Dental School, Dundee,
meaning decision. Diagnosis is not an
and E.A.M. Kidd, BDS, FDS RCS (Eng.), PhD, end in itself; it is a mental resting place The dental tissues of the fissures and
Division of Conservative Dentistry, GKT Dental for prognostic considerations and grooves are not inherently caries-
Institute, Guys Hospital, London. therapeutic decisions. It is important to prone. The surface is susceptible

380 Dental Update October 2001



The tooth is most susceptible to
plaque stagnation during eruption.9
Molar teeth take some 1218 months
to erupt and a 6- or even 12-year-old
child may need some help from a
parent to clean an erupting tooth
effectively. In contemporary
populations it is rare to see occlusal
caries on premolars. This may be due
to their short eruption time and their
accessibility to cleaning.

Figure 1. Microradiograph of a section THE VISUAL APPEARANCE Figure 2. Microradiograph of a section

through a narrow fissure whose deeper part OF OCCLUSAL CARIES through a groove from the entrance (E) to the
would exclude a toothbrush bristle. base (B). The arrow divides the groove into
Demineralization is obvious on either side of
Since it has been shown that lesion
outer and bottom parts. The lines on the left,
the fissure wall. The dotted line on the left- formation takes place in the plaque- following the direction of the enamel prisms,
hand side indicates the depth of the fissure stagnation area at the entrance to the indicate lesion depth and show similar depths
from its entrance (E) to its base (B). The fissure, it follows that the lesion should of lesion at the entrance and bottom part. This
arrows divide the fissure into three equal be visible provided the plaque is is because grooves harbour metabolically
parts: outer, middle and bottom. The three active plaque throughout their depth.
black lines on the right-hand side show the
removed. A few years ago new visual
depth of the lesion along the direction of the criteria for the detection of occlusal
enamel prisms in the entrance, middle and caries were proposed.10 A ranked
bottom part of the fissure. The lesion is scoring system was described (Table 1
deepest at the entrance to the fissure, where and Figures 316) and a laboratory and 18 emphasize the importance of
metabolically active plaque is present.
study showed that this system was well this cleaning. The white spot lesion is
correlated with lesion depth as assessed clearly visible in Figure 18 but
histologically.10 obscured by plaque in Figure 17. Notice
This means that a dentist, using this that in Figure 17 the tooth does not
because plaque is likely to remain visual system alone, will have a good look obviously plaque-covered and this
undisturbed in this area. idea of the depth of the lesion shows why it is important to disclose
Owing to the minute dimensions of histologically. and remove all stained plaque before
the pits and fissures, a toothbrush Subsequent work extended the ranked making the diagnosis.
bristle cannot access the area to scoring system to differentiate active Table 1 illustrates the clinical criteria,
disturb the micro-organisms. However, from arrested lesions (Table 1).11 The the corresponding histological picture,
there is evidence that the micro- study was carried out on erupted the likely activity of the lesion and its
organisms in the deeper parts of the wisdom teeth destined for extraction. level of infection.
narrow fissure may not be the major This allowed the activity of the lesions A reasonable sequence for doing this
players in lesion formation.8 Micro- to be assessed both clinically and after careful visual examination is as follows:
organisms in the upper parts of the tooth extraction, thus validating the new
fissures and in the more open grooves system. 1. Disclose.
are metabolically active and lesion A further investigation was carried 2. Brush off all plaque and rinse
progression rate is thus faster at the out to relate the ranked scoring system thoroughly using the three-in-one
entrance to the fissures than the to the level of infection of the dentine as syringe.
bottom part8 (Figures 1, 2). What really assessed using microbiological 3. Place cotton-wool rolls and a saliva
matters as far as the patient is culturing techniques (Table 1).12 ejector. Leave the surface of the
concerned is that these areas can be When using this visual ranked tooth wet. Is there a white spot
reached by a toothbrush. It is thus scoring system it is absolutely (score 2) or a brown spot lesion
potentially possible to access and essential that all plaque is cleaned from (score 2a)?
clean these fissure areas in just the the occlusal surface so that the dentist 4. Does the wet tooth have a greyish
same way as a smooth surface. This is a can see the lesion clearly. This cleaning discoloration of the underlying
very important concept that has should be preceded by disclosing so dentine? If so, the score is 3.
implications for both diagnosis and that the dentist sees the plaque before 5. Dry the tooth with a three-in-one
management of occlusal caries. removing it with a brush. Figures 17 syringe.

Dental Update October 2001 381


Table 1. Lesion appearances, activity, histopathology and level of infection.

Score Clinical Figures Activity Histopathology Figures Level of

appearance infection

0 No, or slight, Fig. 3 Probably none No enamel Fig. 4 0

change in demineralization or
enamel a narrow surface
translucency after zone of opacity
prolonged air- (edge phenomenon).
drying (>5 s)

1 Opacity (white) Fig. 5 Active Fig. 6

hardly visible on
the wet surface
but distinctly
visible after air-

Enamel demineralization
limited to the outer
50% of the enamel
1a Opacity (brown) Fig. 7 Arrested Fig. 8 0
hardly visible on
the wet surface,
but distinctly
visible after air-

2 Opacity (white) Fig. 9 Active Fig. 10

distinctly visible
without air-drying

involving 50% of the
enamel and up to 1/3
of the dentine.
2a Opacity (brown) Fig.11 Arrested Fig.12 +
distinctly visible
without air-drying

3 Localized enamel Fig.13 Active Demineralization Fig.14 ++

breakdown in involving the middle
opaque or 1/3 of the dentine
enamel and/or
discoloration from
the underlying

382 Dental Update October 2001


Score Clinical Figures Activity Histopathology Figures Level of

appearance infection

4 Cavitation in Fig.15 Active Demineralization Fig.16 ++++

opaque or involving the inner
discoloured 1/3 of the dentine
enamel exposing
the dentine

6. Does the tooth surface appear and air (1.0). The pores in the area to remove the soft, infected dentine
sound (score 0)? Is there now a demineralized tissue fill with a watery (Figure 19).
white (score 1) or brown (score 1a) medium and the difference in refractive Once into dentine the lesion follows
spot lesion? index between this and sound enamel the direction of the dentinal tubules but
7. Is there an obvious cavity? If so results in the lesion looking white. If there is some discussion as to what
gently use a probe to check whether the dentist dries the tooth, the water happens at the enameldentine junction
there is exposed dentine at its base will be replaced with air. The difference (EDJ). It has been suggested that caries,
(score 4). Alternatively, can you see in refractive index between air and even in precavitated stages, spreads
localized enamel breakdown in enamel is greater than between water laterally along the EDJ owing to the
opaque or discoloured enamel? This and enamel, which means that a lesion lower resistance of the mantle dentine,
may look like a hole made by a becomes more obvious after air-drying and that this lateral spread undermines
woodworm or a slightly enlarged and a less porous lesion can be the sound enamel. Recent study seems
fissure. These appearances are detected. to show that lateral spread is associated
microcavities (score 3). with an advanced stage of the carious
Notice that the probe is used only to process where the enamel is
check there is dentine at the base of THE SHAPE OF THE LESION cavitated.13,14 At this stage the dentine
the cavity in score 4. The spread of the enamel lesion is is soft to probing and heavily infected.
guided by prism direction. Caries on On an occlusal surface these
occlusal surfaces does not involve the anatomical considerations explain why a
WHY DOES AIR-DRYING entire fissure system (groove-fossa lesion may look like a small cavity on the
HELP? system) with the same intensity but surface of the tooth but represent a
Demineralized enamel is more porous occurs as a localized phenomenon where great deal of destruction once the
than sound enamel and this is the key plaque accumulates. These are the areas dentist removes the undermined enamel.
to understanding some of the visual best protected against functional wear
changes. A white spot lesion that is the deepest part of the groove fossa
obvious on a wet tooth surface is more system (Figure 19). THE DEFENCE REACTIONS
porous and deeper than one that is It is important to remember that the OF THE DENTINEPULP
visible only after thorough air-drying. lesion is developing in three COMPLEX
This is due to the differing refractive dimensions. It is often initiated in the There are two important defence
indices of enamel (1.62) water (1.33) fossae, which are the depressions where
two or more interlobular grooves meet.
Thus several surfaces are involved in
the initial dissolution9 and the lesion,
following the enamel prisms, assumes
the shape of a cone with its base
towards the enameldentine junction
(Figure 20). The dentine reaction occurs
beneath this, and it is this anatomy
which gives the occlusal lesion its
apparently undermining character. This
explains why such a small cavity Figure 18. The same tooth as in Figure 17 after
Figure 17. Erupting first permanent molar with becomes a surprisingly large hole when cleaning the fissure with a brush. A white spot
its occlusal surface covered by plaque. the dentist accesses the demineralized lesion is now visible.

Dental Update October 2001 383


new visual system there was no hidden

a b caries. In other words, caries in dentine
that was sufficiently extensive to show
on a bitewing radiograph was not
missed in the visual examination but was
scored as 2, 3 or 4 (Table 1).
This is likely to be due to very careful
cleaning of the teeth and the new visual
criteria. However, this was a laboratory
study where the teeth were easy to see:
it does not imply that radiographs are
not useful in the diagnosis of occlusal
caries clinically. Whenever a bitewing
radiograph is available, it should always
be carefully examined for occlusal caries
in dentine. Without meticulous cleaning
c d and drying, quite advanced lesions are
still easy to miss clinically.

This article would be incomplete without
mentioning the enormous research effort
that has been put into making it easier
for the dentist to detect occlusal carious
Carious lesions can be detected on
Figure 19. (a) A molar tooth before plaque removal. The cavitation in the central the basis of their increased electrical
fossa is just visible. (b) The tooth has been cleaned with a brush and dried. Now the conductivity. The change in electrical
cavity is obvious, but it looks small. (c) The dentist has started to gain access to the
infected and demineralized dentine. (d) Further access has been gained prior to final
conductivity has been explained by the
excavation. Notice how large the cavity is in relation to (a). This is purely a factor of fact that the porosities, formed during
anatomy. demineralization, fill with saliva to form
conductive pathways. The technique
involves a digital readout and has been
shown to detect carious lesions and
reactions of the dentinepulp complex: THE CONTRIBUTION OF identify teeth that are caries-free.10,17,18
tubular sclerosis and reactionary THE RADIOGRAPH TO These machines are not commercially
dentine. These were well reviewed by DIAGNOSIS available in the UK.
Massler as early as 1967.15 He pointed It was in the early 1980s that Recently, a laser-based instrument
out that the response of the pulp to the practitioners first alerted the profession (KaVo Diagnodent) has been produced
carious process is productive, not in the UK to the problems of occlusal and marketed. This uses a technique of
degenerative, unless the pulp is actually caries diagnosis and advised colleagues illuminating the tooth with laser light
invaded by micro-organisms. The pulp to examine radiographs very carefully. (wavelength 655 nm), which is absorbed
dentine complex has a remarkable The phenomenon of hidden caries by both inorganic and organic tooth
healing potential and treatment of an (defined as an occlusal carious lesion substance. Some of this light is emitted
advanced lesion should be directed that is missed on a clinical examination as near-infra-red fluorescent light and,
towards promoting arrest of the but subsequently found as an obvious as the carious lesion progresses, an
infection and healing of the dentine by lesion in dentine on a bitewing increase in emitted fluorescent light
sclerosis and repair. Massler advocated radiograph) was described.16 occurs; this is detected by the
removing only infected dentine initially, The laboratory study that first instrument and presented to the
avoiding over-instrumentation and described the ranked visual scoring operator as a digital readout.19 This
placing temporary restorations so that system for occlusal caries took technique, like electrical conductance,
natural repair could take place. radiographs of all the teeth. Using the shows great promise. Both will detect

384 Dental Update October 2001


application will delay lesion progression

a b in this critical period.21 The use of a
chlorhexidine and thymol varnish has
also been suggested22 and its use during
the time of eruption of first and second
molar teeth has been researched.
Results appeared promising.
Some form of operative treatment is
indicated once the occlusal surface is
Figure 20. (a) An extracted tooth with a lesion slightly larger than in Figure 19. (b) A hemi- cavitated (score 3, 4). These lesions are
section of the tooth through the cavity emphasizing how much destruction is present beneath a active because now the patient cannot
relatively small hole. It shows: the cone shape of the enamel lesion as it follows prism direction; remove the cause of caries (the plaque)
lateral spread of the lesion along the EDJ; and spread of the lesion into dentine along the dentinal
with a toothbrush.
The accepted management for the
microcavity (score 3) is a sealant
restoration but the possibility of fissure
sealing alone should be borne in mind.
demineralization and provide a lesions (scores 1a, 2a) require no Approximately 40% of these teeth will
quantitative readout. treatment. Active lesions where the have no radiolucency on a bitewing
There is thus the potential to measure tooth surface is intact (scores 1, 2) may radiograph and will be minimally
lesion progression or arrest. It should be be managed by plaque control alone. infected.12 Handelman reviewed his
remembered, however, that these are The plaque that is causing the extensive work on this subject in 1991.
machines and they do not have brains! demineralization is on the tooth surface Even if the lesion is visible in dentine on
Both may be confused by areas of and accessible to a brush. It has been a bitewing radiograph,23 microbiological
hypomineralization, which they will shown that these lesions can be study showed a reduction in cultivable
interpret as caries. In addition, the laser- controlled by intensive patient bacteria 2 weeks after fissure sealing. It
based instrument is totally confused by education and professional tooth is even more important to note that the
staining, such as a stained fissure, cleaning.20 It would seem likely therefore demineralization did not progress over 4
interpreting this colour change as caries that occlusal caries can be controlled by years in these sealed teeth.
in dentine. Neither can these machines twice-daily plaque removal with a The cavitated lesion, where dentine is
assess the activity of the lesion if used fluoride toothpaste. exposed (score 4), requires operative
on a single occasion. They have the The problem with the erupting tooth is intervention so that the patient can
potential, however, to monitor lesion that it lies below the level of the other clean. In deep cavities where the dentist
progression or arrest if used on several teeth in the arch, and the brush misses fears an exposure, there is much to be
occasions. the occlusal surface unless it is said for accessing the carious dentine,
specifically brought over that tooth which will be heavily infected, soft and
surface with the brush head at right wet, and placing a temporary
LOGICAL MANAGEMENT angles to the other teeth (Figure 21). restoration, perhaps an acid-etched
It is now possible for the clinician to The parent should stand behind the composite resin24 or a glass ionomer
make a good diagnosis of occlusal child to assist. A hygienist or oral health cement.25 This allows the pulp-dentine
caries; both the degree of educator should show children and complex to mount the defence reactions
demineralization and the activity of the parents how to clean these erupting of tubular sclerosis and reactionary
lesion. This diagnosis must be set in the surfaces and see children and their
context of a complete clinical and parents monthly until the surface is
radiographic examination of all surfaces either being correctly cleaned or a failure
of all teeth. The dentist can then define to motivate is established.20 The latter is
the current caries activity of the patient an indication for administration of a
and plan appropriate preventive, non- fissure sealant.
operative treatment including oral If caries is to be prevented, good
hygiene instruction with a fluoride plaque control is also required once the
toothpaste, diet analysis and advice and tooth has erupted, but again this should
further fluoride supplementation, if be monitored. Topical application of
appropriate. This paper will now fluoride varnish or solution is an
concentrate on the management of important treatment while plaque control
occlusal surfaces. is being perfected but should only be Figure 21. The correct position of the toothbrush
Sound teeth (score 0) and arrested used if there is active caries. The on an erupting second permanent molar.

386 Dental Update October 2001


dentine and guards against unnecessary fluoride mouthrinsing program with implications for 14. Ekstrand KR, Ricketts DNJ, Kidd EAM. Do occlusal
the use of sealants. J Public Health Dent 1985; 45: carious lesions spread laterally at the enamel-dentin
exposure. Before this treatment, the
9094. junction? A histopathological study. Clin Oral Invest
dentist should check that these teeth are 5. Ripa LW, Leske GS,Varma AO. Longitudinal study of 1998; 2: 1520.
vital and without symptoms of the caries susceptibility of occlusal and proximal 15. Massler M. Pulpal reactions to dental caries. Int Dent J
irreversible pulpitis. surfaces of first permanent molars. J Public Health 1967; 17: 441460.
Dent 1988; 48: 813. 16. Ricketts DNJ, Kidd EAM, Weerheijm K, de Soet H.
Whether the dentist should 6. Dummer PMH, Oliver SJ, Hicks R, Kingdon A, Addy Hidden caries: what is it? does it exist? does it
subsequently re-enter to remove all the M, Shaw WC. Factors influencing the initiation of matter? Int Dent J 1997; 47: 259266.
soft dentine has to be under dispute. carious lesions in specific tooth surfaces over a 4- 17. Ricketts DNJ, Kidd EAM, Wilson RF. Electronic
There is now 10-year clinical data24 year period in children between the ages of 1112 diagnosis of occlusal caries: adaptation of the
years and 1516 years. J Dent 1990; 18: 190197. technique for epidemiological purposes. Community
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where soft, infected carious dentine was Dental Epidemiological Programme: initial surveys of 18. Le YL, Verdonschot EN. Performance of diagnostic
sealed in place with no apparent 5 and 12-year-olds. Br Dent J 1992; 172: 408413. systems in occlusal caries detection compared.
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paediatric dentistry from craniofacial has been included on the management

BOOK REVIEW development, anomalies of tooth form, of dental caries in the pre-school child.
Paediatric Dentistry. 2nd edn. Richard basic and advanced restorative It outlines the ways of managing
Welbury, ed. Oxford University Press, techniques, and treating the medically behaviour in this potentially difficult
Oxford, 2001 (35.00). ISBN 0-19-263186-1. compromised patient. The chapters are group of children, as well as sensible
clearly laid out with relevant clinical advice on treatment planning.
This is the second edition of an extremely pictures and tables to complement the text. In summary, this is an excellent book,
important book in paediatric dentistry, not There are key points and summary which I would thoroughly recommend
only for undergraduate and postgraduate sections, which serve as very useful not only for the newly emerging
dental students, but also general dental revision aids. Each chapter ends with up- specialists in paediatric dentistry, but for
practitioners. The first edition was to-date references and suggestions for all clinicians that see and treat children.
published in 1997, and it has subsequently further reading. I especially like the way It is a comprehensive book covering all
become very popular and I am quite sure advanced restorative procedures are aspects of paediatric dentistry. This
that it is on most Dental Schools reading clearly described in the form of an latest edition addresses the previous
lists. The editor, Richard Welbury, brings armamentarium and numbered technique omissions. I find it an easy to read book,
together a wealth of information from 16 rather like a recipe. which makes it very useful for quick
well-known authors, mainly within the In this second edition there have been reference in the surgery. I suggest it is
specialty of paediatric dentistry, some important changes and additions. well worth the money and should be on
supplemented with authors from oral The layout has been improved, with everyones bookshelf.
surgery and restorative dentistry. There clearer use of coloured print and Victoria Clark
are 17 chapters, which cover all aspects of highlighted text boxes. A new chapter Birmingham Childrens Hospital

Dental Update October 2001 387

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