Periodontology 2000, Vol.
55, 2011, 231–249
Printed in Singapore. All rights reserved
Prevention of crown and root
caries in adults
J O N A S A. R O D R I G U E S , A D R I A N L U S S I , R A I N E R S E E M A N N &
K L A U S W. N E U H A U S
Dental caries remains a significant challenge in oral
health care. This review discusses current evidence
regarding methods for the prevention of caries in
adults, with particular emphasis on the control and
reduction of dietary carbohydrates, the modification
and reduction of cariogenic dental biofilm, the in-
hibition of de-mineralization and promotion of
re-mineralization, and micro-invasive ⁄ minimally
invasive technologies. In order to assess the efficacy
of various caries preventive strategies, the caries
increment, i.e. the number of new lesions per year,
was the outcome parameter of choice when available.
Relevant literature was identified by searching the
Cochrane Library and PubMed using the MeSH terms
Ôdental cariesÕ or Ôroot cariesÕ in combination with one
ore more of the following terms: ÔdiagnosticsÕ, Ôlaser
fluorescenceÕ, ÔradiographyÕ, Ôlesion activityÕ, ÔsugarÕ,
ÔxylitolÕ, ÔsorbitolÕ, Ô(sonic) toothbrushingÕ, Ôfluoride ⁄
fluoridationÕ, ÔchlorhexidineÕ, ÔStreptococcus mutansÕ,
ÔtriclosanÕ, ÔprobioticsÕ, ÔACPÕ, ÔozoneÕ, ÔlaserÕ, Ôinfiltra-
tionÕ, ÔsealingÕ, ÔpatchÕ, ÔglutaraldehydeÕ and Ôcaries
risk (assessment)Õ. In addition, issues of the following
clinical journals in English and German published
since 2000 were hand-searched: Journal of Dental
Research, Clinical Oral Investigations, Caries
Research, Journal of Dentistry, Journal of the Ameri-
can Dental Association, Oral Health and Preventive
Dentistry, Deutsche Zahnärztliche Zeitschrift,
Schweizerische Monatsschrift für Zahnmedizin.
Additional literature was identified in the reference
lists of the relevant articles. The highest level of
external evidence was considered, and 176 articles
were included.
 2011 John Wiley & Sons A/S
PERIODONTOLOGY 2000
Diagnostic aspects of coronal and
root caries in adults
Visual ⁄ tactile caries detection and
assessment
Crown caries in adults mainly occurs at interproximal
sites and restoration margins (108). Visual inspection,
together with use of a sharp-ended probe, has tradi-
tionally been recommended for detection of crown
caries. However, in a landmark study in which 26
dentists inspected 100 non-cavitated molars, Lussi
(87) showed that, in clean teeth, the use of a sharp
explorer plus visual inspection did not yield higher
sensitivities or specificities than visual inspection
alone. The specificities of these methods were equally
high (0.93), and the sensitivities were equally low
(0.12 and 0.14, respectively). These findings were
corroborated in a recent review, which concluded
that use of a sharp-ended explorer or a ÔstickinessÕ
test is of little value for the detection of crown caries
(111).
Visual inspection may be augmented by use of
systematic visual caries detection methods such as
the International Caries Detection and Assessment
System (ICDAS II) (www.icdasfoundation.dk) and the
Nyvad criteria (118). ICDAS II integrates the results of
several international consensus meetings on clinical
caries trials, and was established in 2003 (74) as a
system to assess the tooth surface texture (155).
Twofold inspection of the tooth in the moist and dry
states allows good differentiation between outer and
inner enamel caries (likelihood ratio 6.5) (155). In a
231
Rodrigues et al.
recent study, the ICDAS II system produced sensi-
tivity and specificity values of 0.99 and 1, respectively,
for deep occlusal enamel caries, and values of 1 and
0.69, respectively, for early dentin caries (38). The
intra-examiner reliability of the ICDAS II system was
generally high (j values of 0.74–0.88) (75); however,
lower values were found for an untrained examiner
(j value of 0.5).
The second major caries detection system is
referred to as the ÔNyvad criteriaÕ, and assesses the
cavitation status and lesion activity status of a tooth
(118). This system has been shown to have good
predictive and construct validity (119). According to
the Nyvad criteria, active enamel caries appears
whitish, matte and chalky (Fig. 1A), and feels rough
upon gentle probing with an explorer (118). Inactive
enamel caries, on the other hand, is rather shiny,
glossy (Fig. 1B) and smooth upon probing, and is
often stained brown or black. As determination of
lesion activity depends on the presence of plaque, the
visual inspection according to Nyvad is performed
without prior professional plaque removal. This is a
A
B is given in Table 1. The severity of root caries lesions
Fig. 1. (A) Active white spot lesions are located in plaque
stagnation areas and are often covered with plaque. They
are chalky white in appearance and feel slightly rough
upon gentle probing. (B) Inactive white spot lesions are
clean and glossy, and can remain stable over decades if
cleaned properly.
232
conceptual difference from the ICDAS II system,
which is performed on clean teeth.
Little diagnostic gain with respect to cavitation
formation on interproximal surfaces can be expected
from temporarily separating teeth in adults (70). The
sensitivity values for detection of interproximal cav-
itation after temporary tooth separation were 0.342
for visual inspection compared to 0.041 for fibre-
optic trans-illumination and 0.631 for bite-wing
radiography (70). The positive predictive values were
highest for visual inspection (0.565) compared to
fibre-optic trans-illumination (0.333) and bite-wing
radiography (0.364). There is limited evidence sup-
porting the reliability of visual detection of secondary
caries, as the interpretation of discolorations at
amalgam restoration margins varies widely (155).
Early detection of root caries is more difficult than
that of coronal caries, for which initial de-minerali-
zation can readily be made visible by drying the tooth
surface. There is general agreement that use of a
combination of visual and tactile criteria (i.e. gentle-
to-moderate probe pressure) is more indicative of
root caries than use of visual criteria alone (47, 111).
Several studies have been performed to assess the
reliability of visual ⁄ tactile diagnosis of root caries
(see (18) for review). High inter- and intra-examiner
reliability was achieved in these studies. However,
these studies also included restorations of root sur-
faces. When detection of root caries lesions without
restorations was investigated, the degree of agree-
ment was low (j values ranging from 0.29 to 0.61)
(140). With regard to tactile criteria in particular,
there seems to be frequent disagreement among
examiners with regard to the softness or hardness of a
lesion, due to different sensory perceptions (18).
The prevalence of root caries in different countries
may be assessed using the Ôroot caries severity indexÕ
(23) or Ôroot caries stages 1–4Õ (55). In the latter index,
the severity of root caries lesions is correlated with
their extent around the circumference of the root.
The dynamic nature of root caries has lead to the
requirement to differentiate between active and
inactive lesions (117). Active lesions are often covered
with microorganisms, and the surface looks yellowish
or light brown (Fig. 2A), and, more importantly, feels
soft and leathery upon tactile inspection. Inactive
lesions, however, are dark brown or black (Fig. 2B,C),
and the surface does not feel softer than the sur-
rounding healthy dentin. (74). In an ex vivo study
comparing secondary caries at crown margins
extending into the root, lesions that were clinically
scored as moderate to advanced showed better
 Prevention of crown and root caries in adults

Table 1. Prevalence of root caries (carious and filled) and the root caries index in elderly patients from selected
countries

Publication date Patient age Percentage of Root caries index* Reference

in years patients with root
caries (prevalence)
Australia 1997 >65 – 11.9 147
Germany 2006 65–74 45 17 108
UK 1990 >55 88.4 16.3 33
Ireland 1990 >65 – 18.5 33
Canada 1993 >50 70.9 – 33
Netherlands 1991 >60 – 28.0 82
Norway 1988 >60 24.7 82
Sweden 1990 55–75 89.0 16.0 33
USA 1987 >65 56.9 – 33
USA 1994 >75 52.4 – 33
Brazil 2001 50–59 78.1 13.4 ⁄ 18.6 167
Switzerland 2001 >70 48 12 90
Japan 2006 >60 53 – 73

*The root caries index, as suggested by Katz (80, 81), is defined as the ratio of carious and filled root surfaces to all exposed root surfaces:
RCI = (RD + RF) · 100 ⁄ (RD + RF + RN), where RD are diseased root surfaces, RF are filled root surfaces, and RN are caries-free root surfaces.

correlation with histological findings than early
lesions (177). Another ex vivo study comparing
bite-wing radiography with visual ⁄ tactile criteria for
sub-gingival secondary caries detection at crown
margins found a higher accuracy for mesial root
surfaces for both methods (170). However, both
methods showed equally low positive predictive
values for lesions without cavitation (values of 0.43
for both bite-wing radiographs and visual ⁄ tactile
criteria) and even lower positive predictive values for
lesions with cavitation (values of 0.12–0.31 for bite-
wing radiographs, and of 0.09–0.29 for visual ⁄ tactile
criteria) (170). Although early detection of root caries
lesions may be important, diagnosis of these lesions
using only visual ⁄ tactile criteria is fraught with
problems, and is less indicative than in coronal caries
(18).
Bite-wing radiography for lesion
detection
For primary interproximal coronal caries, use of bite-
wing radiography considerably enhances sensitivity
at the dentin level (0.5–0.7) compared to visual
inspection alone (169). In interproximal lesions of the
inner enamel or beginning dentin lesions, bite-wing
radiography rarely provides sufficient information on
whether or not a cavity has formed, and therefore
does not aid in the decision of when to start operative
treatment (70). However, bite-wing radiography does
allow earlier detection of interproximal caries than
visual inspection alone (26). In populations with a
generally low prevalence of caries, specificities
ranging from 0.03 to 0.3 indicate a high frequency of
false-positive diagnoses, and thus may promote over-
treatment (16). A clinical study in 872 12-year-old
children compared the diagnostic yields of visual
inspection and bite-wing radiography (97). Forty-five
per cent of the lesions were detected by clinical
inspection alone and 25% by radiographs alone, with
the methods giving matching results in 30% of cases.
Dentin lesions were detected by clinical inspection in
only 13% of the cases, and by radiographic assessment
in 44% of the cases. Thus, the combination of visual ⁄
tactile criteria and bite-wing radiography appears
superior to either detection method alone (44).
Bite-wing radiography aids in the detection of root
caries because interproximal cavitated root caries
lesions can be imaged as radiolucency (116). How-
ever, smaller or incipient lesions are likely to be
overlooked on radiographs (18). In addition, the
cervical burn-out effect and parallax phenomena
may impair correct diagnosis. An axial-eccentric
angulation of only 10 or more is sufficient to impair
the diagnosis of cervical root caries (156). Radio-
graphic detection of secondary caries in class II

233
Rodrigues et al.
A percentage of false-positive results decreased to 3%
B
C
Fig. 2. (A) Active root caries lesions are covered with
plaque, are brownish in appearance, and are soft on
probing with a sharp explorer. (B) An inactive ⁄ inactivated
root caries lesion after removal of the superficial soft
layer. Due to constant cleaning and fluoridation, such
lesions can remain stable for years. (C) Active and inactive
root caries lesions can develop independently on root
surfaces in close proximity.
amalgam restorations has been shown in an in vitro
study to yield false-positive results in 12% of cases
(42). When visual ⁄ tactile diagnosis was included, the
234
(42).
Laser fluorescence for lesion detection
There is ample evidence to support the diagnostic
value of laser fluorescence in the detection of occlu-
sal crown caries (89, 112). Sensitivity for occlusal
surfaces is generally higher for laser fluorescence
than for visual inspection (15). In a clinical study in
which 240 patients were enrolled, laser fluorescence
showed a specificity of 0.86 for lesions extending into
dentin, compared with 0.99 for bite-wing radiography
(91). For enamel caries, the sensitivities in that study
were 0.96 for laser fluorescence and 0.63 for visual
inspection, and for dentin caries, the sensitivities
were 0.92 (laser fluorescence), 0.31 (visual inspection)
and 0.63 (bite-wing radiography). Laser fluorescence
may also be used for detection of interproximal caries
(88). In an in vitro study, a pen-type laser fluores-
cence device yielded a sensitivity of 0.89 at the dentin
level (vs. 0.45 for bite-wing radiographs) and a spec-
ificity of 0.82 (vs. 0.89 for bite-wing radiographs) (88).
There are some limitations with regard to the acces-
sibility of the interproximal space. However, when
used for the detection of interproximal secondary
caries lesions at the sites of composite (139) and
amalgam restorations (114), laser fluorescence may
provide valuable information because more space is
available for the tip to penetrate.
In combination with other detection methods,
laser fluorescence may have value in the detection of
root caries (175). In a study in which 717 patients
aged 60 years or older were enrolled, a significant
positive correlation between visual ⁄ tactile and laser
fluorescence assessments were found (175). The dif-
ference between carious and healthy tissue was
highly significant, as was the difference between
active and inactive lesions (175). In another in vitro
study, no correlation was found between lesion depth
and laser fluorescence measurements of root caries
lesions (79). The additional use of laser fluorescence
compared to ICDAS II and bite-wing radiography for
occlusal caries was tested in a recent in vitro study
(138). Post-test probabilities for single methods were
0.798 for laser fluorescence, 0.641 for ICDAS II and
0.914 for bite-wing radiography. Combination of
ICDAS II with either laser fluorescence or bite-wing
radiography increased the post-test probabilities to
0.893 and 0.957, respectively. When ICDAS II was
combined with bite-wing radiography and laser
fluorescence, the post-test probability increased to
0.99 (138). Thus, more accurate caries detection is

expected from careful combination of meticulous
visual inspection and non-invasive additional caries
detection methods (112).
Control of dietary carbohydrate
intake
The industrial revolution and the mass production
of low molecular weight carbohydrates (white flour
and white sugar) have been widely implicated in the
concomitant increase in caries prevalence observed.
Low molecular carbohydrates have been identified as
a primary metabolic source for many oral pathogens.
It is thus reasonable to argue that avoidance of
these carbohydrates would decrease the prevalence
of caries. However, sugar abstinence is an elusive
goal in most individuals (176). Sweet taste in the
absence of fat is largely responsible for withdrawal
syndrome and addictive-like behaviors (8, 9).
Another approach has been to replace low molec-
ular weight carbohydrates with non-cariogenic
sweeteners. Dietary advice should not only focus on
avoiding carbohydrates by omitting candies and
white bread, but should also suggest replacing dietary
sugars with non-cariogenic sugar alcohols. As found
in early studies, replacement of sugar with sugar
alcohols leads to a decrease in the frequency of sugar
intake, and thereby significantly minimizes caries risk
(59). Furthermore, the simple advice to consume
sugars after meals instead of snacking between meals
reduces the caries risk drastically (83).
Sugar alcohols in the prevention of caries
Streptococcus mutans and other cariogenic oral
microorganisms cannot metabolize sugar alcohols.
Use of sugar alcohols has been shown to result in a
shift of the oral microflora (126), and a decrease in
caries incidence. The cariogenicity of sorbitol has
been evaluated in numerous studies in humans,
animal experiments, and dental plaque pH mea-
surements in vivo and in vitro. Most of these studies
found that sorbitol has little or no cariogenic poten-
tial (24, 25). Although mutans streptococci can
develop alternative mechanisms to ferment sorbitol
after prolonged exposure (92), sorbitol does not seem
to increase the caries risk under normal conditions
(27, 71). No such adaptation pathways have been
found for xylitol. Thus, this compound is completely
non-acidogenic and non-cariogenic (29, 54). Intake of
xylitol has been shown to reduce the levels of mutans
streptococci in dental plaque and saliva (148) and to
Prevention of crown and root caries in adults
prevent coronal caries (94). However, with regard to
dosage and frequency, there is evidence that a min-
imum daily xylitol dose of approximately 6 g ⁄ day,
administered several times throughout the day, is
required to significantly reduce S. mutans counts
(109). A higher frequency of xylitol use is associated
with greater effectiveness (76, 93, 129). Studies have
found no incremental benefit for caries reduction at
doses >10 g ⁄ day (99). Chewing gums or candies are
the preferred mode of xylitol delivery. In a 3-year
community intervention trial in which more than 600
children were enrolled, the groups receiving xylitol or
sorbitol ⁄ carbamide gum showed no significant car-
ies increment compared to the control gum group
(98). However, all chewing gum groups showed a
significantly lower caries increment than the control
group receiving no gum, indicating that the caries
preventive effect was due primarily to the chewing
action itself rather than addition of polyols to the
gum.
Institutionalized older people have an elevated risk
for caries, in particular root caries. When the effec-
tiveness of both xylitol and sorbitol chewing gums
and candies (mean daily dose of 10.7 g) was com-
pared in a field trial (100), both test groups showed
significantly reduced root caries compared with the
control group, with the lowest incidence being found
in the xylitol group after 6–30 months. Ninety per
cent of the test subjects preferred candies to chewing
gum.
Xylitol and other polyols have been used in food
products for several decades. Adverse effects include
meteorism (bloating), flatulence, loose stools or
diarrhea when polyols are consumed in large
amounts, i.e. >40 g ⁄ day (94). To minimize the
occurrence of adverse effects, xylitol may be intro-
duced at low doses, taking the potential cumulative
effect of various polyol sweeteners from food and
dietary products into account.
An outstanding problem is identification of the
xylitol content of an individual chewing gum (94).
The xylitol content of many chewing gums is far too
low to achieve the required daily dose for caries
prevention. There is a need for a clear declaration on
product packaging in order that patients may
understand the possible benefits. Recommendations
for patients should be restricted to products with
known and sufficient xylitol content. Although dental
health may be improved through targeted adoption
of xylitol regimens, their cost-effectiveness for caries
prevention is low. In a 3-year clinical trial, a differ-
ence of 0.66 cavitated lesions per year was found
between xylitol- and non-xylitol-treated patients (98).
235
Rodrigues et al.
By extrapolation, more than 3000 xylitol chewing
gums at an estimated cost of US$300 would be nee-
ded to avoid a single caries cavity. Although xylitol
use is clinically as effective as the use of fissure
sealants (2), the costs of xylitol treatment might
exceed alternative interventions. Use of xylitol may
therefore be limited to high-risk populations such as
handicapped or frail elderly people, and patients with
a high former caries experience.
Modification and reduction of the
cariogenic biofilm
Disruption of the biofilm by
toothbrushing
A plaque-free tooth does not develop caries.
De-mineralization of such clean surfaces may occur
in the form of erosion; however, no carious insult will
occur. Regular removal of dental biofilm is regarded
as a key factor in caries prevention. Toothbrushing
has been established as the main individual method
of regular plaque removal. After toothbrushing, the
pellicle takes 2 h to re-establish, and immature pla-
que requires 8 h to fully re-establish. It was therefore
recommended that toothbrushing should be per-
formed every 8 h, i.e. three times a day. However,
epidemiological data have shown a relationship
between lower toothbrushing frequency (once per
day or less) and social class and sugar consumption
frequency (164). Additionally, the recommendation
of a higher brushing frequency might have over-
estimated the effect of brushing. With regard to the
frequency of toothbrushing, brushing the teeth twice
a day (before going to bed and once after a meal,
preferably in the morning) seems to be sufficient for
most individuals (40). Comparing manual vs. pow-
ered toothbrushing, a Cochrane review provided
evidence that oscillating round powered tooth-
brushes result in a significantly greater reduction in
plaque and gingival inflammation than manual
toothbrushes (137). Prospective clinical studies that
investigate whether the use of powered toothbrushes
also leads to reduced caries are lacking.
Most toothbrushing studies are performed using a
fluoridated toothpaste, making it difficult to quantify
the caries-preventing effect of toothbrushing alone.
For ethical reasons, a long-term prospective clinical
study comparing the caries-preventive effect of
fluoridated and non-fluoridated toothpastes is not
feasible. One of the very few clinical toothbrushing
studies in which no toothpaste at all was used
236
compared the effect of conventional twice daily
toothbrushing with chewing a dental miswak stick
five times per day (1). As only 15 adult patients were
enrolled in this 6-week trial, which assessed plaque
formation and gingival bleeding as outcome param-
eters, no conclusion can be drawn regarding the
caries preventive effects of each method.
Toothbrushing will significantly reduce the biofilm
on occlusal and facial surfaces, and, to a lesser extent
(due to limited accessibility), on lingual surfaces.
Toothbrushing does not reduce biofilm in inter-
proximal areas, even if a neighboring tooth is miss-
ing. These areas of plaque retention must be cleaned
using additional means, such as interdental brushes,
dental floss or toothpicks. A landmark study by
Axelsson et al. (10) showed that regular maintenance
of teeth, including at least four appointments per
year for re-motivation and professional tooth clean-
ing during the first 3–6 years after completing the
restorative phase of treatment, lead to caries inci-
dence rate as low as one or two new caries lesion per
30 years. The same study also showed that the
interproximal plaque accumulation of this cohort
was high, despite regular professional cleaning. Tak-
ing this observation into account, it is clear that
regular removal and disruption of the dental biofilm
on exposed tooth surfaces is an effective means of
caries prevention and control. However, surfaces
from which plaque is not removed daily are not
inevitably subject to caries (10), indicating that the
presence of an oral biofilm is necessary but not suf-
ficient for caries development (151). However, it is
unclear which proportion of the observed preventive
effects is attributable to toothbrushing, as the regi-
men included the use of dental tapes or dental sticks,
fluoridated toothpastes and professional tooth
cleaning sessions.
Chlorhexidine
Chlorhexidine is the most extensively studied agent
that targets oral biofilms. It is considered to be a gold
standard against which other antimicrobial agents
are compared (78). Chlorhexidine binds strongly to
bacterial cell walls and surfaces in the oral cavity,
such as teeth, mucosa and the pellicle. The antibac-
terial action of chlorhexidine is mediated by its action
on bacterial cell membranes. Chlorhexidine is bac-
tericidal at high concentrations, and bacteriostatic
at low concentrations. However, chlorhexidine does
have well-documented local adverse effects, includ-
ing staining of the teeth, tongue, restorations
and dentures, allergic reactions, bitter taste and

temporary taste disturbances, and increased calculus
formation. Possible means of delivering chlorhexi-
dine to the oral cavity are numerous: toothpastes,
mouth rinses, gels, varnishes, sprays and chewing
gum. Most studies investigating the effects of
chlorhexidine have dealt with its action against pla-
que and gingivitis. However, the number of clinical
trials investigating the effect of chlorhexidine on
caries prevention is limited. The effect of chlorhexi-
dine on the oral microflora is dose-dependent and
the individual treatment response may differ between
patients (134, 142). S. mutans is particularly suscep-
tible and more sensitive to chlorhexidine than most
other oral bacteria (142), and it recovers more slowly
than other oral species after exposure to chlor-
hexidine. The selective suppression of mutans
streptococci following exposure to chlorhexidine is
associated with microbial shifts (142). These shifts
involve other streptococci and Actinomyces species
taking the place of mutans streptococci in the
ecosystem. In a rat model, it has been shown that
long-term reduction in the number of mutans strep-
tococci in the biofilm leads to an appreciable reduc-
tion in caries incidence (161). According to a recent
systematic review, 40% chlorhexidine varnish has a
longer-lasting effect on the reduction of S. mutans
counts than 1% varnish (134), and more intensive
applications result in longer-lasting suppression of
S. mutans than applications with 1-month gaps (134).
However, non-mutans streptococci and other oral
species are also capable of producing acids, and may,
under favorable conditions, alter their virulence and
acidogenic potential (151).
The majority of clinical trials regarding the effect of
chlorhexidine on the development of coronal caries
have been performed in children and adolescents.
This means that large-scale clinical trials for other
patients at high caries risk, including adults, are
lacking. So far, the results have been either contra-
dictory or inconclusive, mainly due to insufficient
numbers of study participants and short follow-up
periods (157). There seems to be little additional
benefit of chlorhexidine varnish on fissure caries
when compared with fluoride varnish (157). Patients
in a population with low caries prevalence receiving
chlorhexidine varnish application every 6 months for
3 years did not experience a caries-reducing effect
(50). Another double-blind randomized controlled
trial with 68 subjects was performed in order to
evaluate the effect of a chlorhexidine ⁄ thymol varnish
on root caries (13). The chlorhexidine ⁄ thymol var-
nish was applied twice in the first week, once after
1 month, and then every 3 months until the end of
Prevention of crown and root caries in adults
the trial. The data clearly showed that this treatment
resulted in both the arrest of established root caries
lesions and the prevention of new lesion develop-
ment. However, there is no evidence to support the
long-term use of 0.12% chlorhexidine mouth rinses
to prevent caries in adults (7). In a clinical random-
ized controlled trial in which more than 1100 elderly
patients with a low income were enrolled, use of a
0.12% chlorhexidine mouth rinse was compared with
a placebo mouth rinse (containing alcohol) with
respect to the development of crown and root caries
and the need for new restorations or tooth extraction
(171). The protocol prescribed daily rinsing for
1 month and weekly rinsing for 5 months. After
6 months, the protocol was repeated up to five times.
The hazard ratios for developing coronal or root
caries in the chlorhexidine group were 0.87 and 0.91,
respectively. There was no significant difference
between groups in terms of the surfaces developing
caries or receiving fillings. It was therefore concluded
that use of 0.12% chlorhexidine mouth rinses in the
way prescribed did not preserve sound tooth struc-
ture in older adults (171). In another study in high-
risk caries patients, initial antimicrobial therapy
using 0.12% chlorhexidine mouth rinse in combina-
tion with a fluoride rinse was shown to significantly
decrease the risk of developing new lesions after a
treatment period of 3 years (45). So far, there is no
evidence that chlorhexidine treatment has a benefit
additional to fluoride application, diet modification
or improved oral hygiene with respect to the caries
increment (7).
Triclosan
Triclosan, a 2,4,4¢-trichloro-2¢-hydroxy diphenyl
ether, has been used in various formulations to sup-
press oral bacteria. It is a synthetic broad-spectrum
antimicrobial agent with antibacterial properties in
addition to some antiviral and antifungal properties.
Triclosan acts by blocking the active site of the enoyl-
acyl carrier protein reductase enzyme, an essential
enzyme in fatty acid synthesis in bacteria. By block-
ing the active site, triclosan inhibits the enzyme and
thus prevents bacteria from synthesizing cell mem-
branes. Only low concentrations of triclosan are
required to block the enzyme, which is not produced
by humans (141). There have been concerns regard-
ing the use of triclosan as an everyday agent in
toothpastes, as this may enhance antibiotic resis-
tance (172). However, the evidence that resistance
and cross-resistance of clinically important micro-
organisms is related to the use of triclosan is poor.
237
Rodrigues et al.
The Scientific Committee on Consumer Products of
the European Commission stated that, on the basis
of the available data, the use of triclosan in cosmetic
products is safe; currently, there is no evidence of
clinical resistance or cross-resistance, although the
product is banned or restricted from some markets
(145), including members of the European Union.
The use of triclosan ⁄ co-polymer as an agent in
toothpastes has been reported to reduce supragingival
plaque and gingivitis in humans (53). Randomized
controlled trials assessing the use of triclosan ⁄
co-polymer-containing fluoride toothpastes and their
effect on caries have been performed in adults.
Compared to toothpastes containing 1100 (49) and
1500 (101) fluoride, addition of triclosan ⁄ co-polymer
does not exert an additional anti-caries effect; how-
ever, it does not interfere with the efficacy of fluoride
against caries either. By contrast, a randomized
controlled trial comparing a 2430 ppm fluoride-
containing toothpaste with and without triclosan ⁄
co-polymer showed a significantly stronger anti-
caries efficacy against coronal caries in the triclosan
group, leading to a 12.2% reduction in the caries
increment score at year 1 and a 16.6% reduction at
year 2 (102). After 3 years, 1357 adult subjects were
still enrolled in this randomized controlled trial. The
analysis showed that there was a significantly lower
increment of root caries as well as in coronal caries in
the group receiving triclosan ⁄ co-polymer (163).
Specifically targeted antimicrobial
peptides
Recently, a more tailored and specific approach to
minimizing mutans streptococci counts in the oral
cavity has been described. Specifically targeted
antimicrobial peptides have been designed that are
derived from combination of a species-specific
competence-stimulating peptide (a ÔpheromoneÕ
produced by S. mutans) and a broad-spectrum anti-
microbial peptide domain (39). It has been shown
in vitro that specific eradication of S. mutans, either
in planktonic suspension or in an organized biofilm,
was achieved within seconds using this method. A
two-headed specifically targeted antimicrobial pep-
tide targeted at two species was shown to eliminate
Pseudomonas aeruginosa and S. mutans from a
mixed planktonic flora without damaging untargeted
bacteria (63). The successful incorporation of these
peptides into clinical use remains to be achieved. The
aim of reducing the number of mutans streptococci
in the biofilm is based on the paradigm that these
species are responsible for caries experience in
238
humans. However, S. mutans can be considered as
part of the indigenous microflora of the human
mouth, and dietary factors may have a far greater im-
pact on caries experience than S. mutans counts (162).
Replacement therapy and probiotics
The oral cavity is a complex ecosystem in which a
rich and diverse microbiota has evolved. There are
many examples of interactions between species of
bacteria inhabiting the same ecosystem, such as
dental plaque. The indigenous microflora can benefit
its host by inhibiting colonization and proliferation of
potential pathogens. This observation provides the
basis for an approach named Ôreplacement therapyÕ,
which is aimed at preventing microbial diseases. The
general principle of this approach is that a harmless
effector strain is permanently implanted in the hostÕs
microflora. Once established, the effector strain pre-
vents the initial colonization or outgrowth of a par-
ticular pathogen (65, 150). With regard to dental
caries, much work has been done in order to con-
struct the effector strain BCS3-L1, which is derived
from a clinical isolate of S. mutans (66). Using
recombinant DNA methodology, this strain was
made lactate dehydrogenase-deficient, resulting in a
total lack of lactic acid production. In order to com-
pensate for this metabolic imbalance, an alcohol
dehydrogenase gene from Zymomonas mobilis was
introduced (66). Animal experiments revealed the low
cariogenic potential of this strain (65). The coloni-
zation potential of this effector strain – namely
replacement of the wild strains of S. mutans in the
oral cavity – derives from its ability to produce a
natural antibiotic called mutacin 1140 that was
capable of killing virtually all other strains of mutans
streptococci against which it was tested (67). This
finding supports the suitability of the effector strain
not just in children but also in adolescence and
adults with a fully developed indigenous oral micro-
flora (65, 66). Although it has been shown that the
effector strain remains genetically stable and does
not revert to producing lactic acid (69), additional
mutations were required in order to make the strain
safe for use in clinical trials. These mutations enable
rapid elimination of the strain from the oral cavity in
the case of adverse side-effects (69). Compared to
other preventive measures, the replacement therapy
approach requires almost no patient compliance,
because a single colonization regime can lead to
persistent colonization by the effector strain
with consequent lifelong protection (65). However,
although use of this methodology is tempting,

concerns remain regarding safety and the possibility
of adverse events such as allergic reactions or cross-
reactions with host tissues or other bacteria.
In a recently published study, it was shown that
daily application of JH145, a naturally occurring lac-
tate dehydrogenase-deficient variant of Streptococcus
rattus, competed with S. mutans for its habitat on the
tooth surface when regularly applied. The authors
concluded that S. rattus JH145 has the potential for
use as a probiotic in the prevention of dental caries
(68). According to a recent review, probiotic therapy
in children appeared to have an inhibiting effect on
mutans streptococci or yeasts (158). However, further
placebo-controlled trials were strongly recom-
mended in order to assess such probiotic strains
using standardized outcomes. As no such trials have
been performed up to now with respect to the effect
of probiotic use on oral health in adults, it is too early
to draw any conlusions concerning the preventive
potential of probiotics in this age group (104).
Inhibition of de-mineralization and
promotion of re-mineralization
Fluoride
Discovery of the anti-cariogenic properties of fluo-
rides was one of the most important landmarks in the
history of dentistry. Today, fluorides play a key role in
the prevention and control of dental caries. Their use
has undeniably contributed to a significant decrease
in the decayed, missing and filled teeth ⁄ surfaces
(DMFT ⁄ S) index in children, and is also held
responsible for a significant decline in caries experi-
ence in 12-year-old adolescents (108). A key factor is
the bioavailability of fluoride in the oral cavity, i.e. the
amount of fluoride that is not bound to other ions. Its
main action is inhibition of de-mineralization (caries
prevention) and enhancement of re-mineralization
(caries control), with the latter being the stronger ef-
fect (152). Consequently, fluoride halts the progres-
sion of lesions, as has been recently shown in a large
clinical trial (119). Sources of a sufficient supply of
bioavailable fluoride include toothpastes and mouth
rinses, and, in some regions, fluoridated water, fluo-
ridated salt or fluoridated milk. There is no obvious
reason why fluorides should act differently in adults
than in children. A World Health Organization strat-
egy is to provide and establish sufficient fluoride
availability, especially fluoridated toothpastes, in
those countries with increasing sugar consumption
(127).
Prevention of crown and root caries in adults
Despite the mechanical removal of tooth surface
biofilms by toothbrushing action, fluoride may be
retained in dental plaque remnants. Fluoride that is
present in a biofilm may significantly influence the
de- and re-mineralization processes at the tooth
surface (36, 152). Fluoride ions available from
toothpastes or other sources may accumulate in both
whole plaque and plaque fluid; their concentration
remains significantly elevated even hours after
toothbrushing (31). In a recent in situ study, it was
shown that the concentrations of fluoride in biofilms
are significantly increased after brushing with fluo-
ridated toothpaste. The uptake of fluoride into the
dental biofilm that was not removed by brushing is
regarded as the main cariostatic effect of fluoride-
containing toothpastes (153). Rinsing with large
amounts of water following toothbrushing resulted in
a significant reduction in fluoride concentration in
the saliva and was associated with an increased caries
risk (146). Therefore, it has been recommended that
only a small amount of water should be used after
toothbrushing. The authors recommend use of the
amount of tap water that is retained within the
brushes of a previously washed toothbrush or use of a
fluoride-containing mouth rinse instead.
Addition of fluoride to drinking water at concen-
trations ranging from 0.6 to 1.1 ppm has been asso-
ciated with a lower prevalence of dental caries (37,
46), and is generally recommended as an effective
regimen for the prevention of caries (173). However,
public water fluoridation is not a viable method in
many countries due to political resentment and
logistical problems within small communities. Salt
fluoridation appears to be an equally effective means
of providing a substantial amount of bioavailable
fluoride in the mouth as fluoridated water (103).
Alternatively, addition at a level of 200–250 mg per kg
salt is a viable and inexpensive way to counter caries
risk, even in countries with very high caries preva-
lence or large populations of individuals in lower
socio-economic classes (56).
Other forms of fluoride application, such as gel,
foam or varnish, have been studied extensively in
children and adolescents. For adults, these additional
applications have rarely been assessed in clinical
studies with respect to primary crown caries. In a
recent meta-analysis by Griffin et al. (58), the effec-
tiveness of various forms of fluorides in preventing
caries in adults was analyzed. Twenty studies on
various forms of fluoride supplementation, including
water fluoridation and clinical applications, were
included in the systematic review. The prevented
fraction was calculated to be 34.6% for crown caries
239
Rodrigues et al.
when any form of fluoride was used, and this value
was 22% for root caries. However, many of the studies
included in the review were biased, as they had
no effective non-fluoride control group. Another
problem is that the DMFT index used in the older
studies did not consider non-cavitated coronal
caries (57). Thus, the caries prevalence may be under-
estimated in both the fluoride and non-fluoride
groups in those studies. Another study included in the
review was a double-blind clinical study on the effect
of fluoridated toothpaste on root and coronal caries in
adults (77). The authors concluded that fluoride acts
as efficiently in adults as in children with regard to
reduction of coronal caries. They also reported a root
caries reduction of 67% (77). However, inactive root
caries was counted as sound in that study, so the
overall caries experience was probably under-esti-
mated in the fluoride group, as some lesions may have
hardened and been inactivated through use of the
fluoridated toothpaste. Moreover, the calculated
preventive fractions are probably at the upper end of
the range, because of inclusion of the inactivated le-
sions in the sound cohorts. Because of these meth-
odological problems, other systematic reviews from
Sweden, which applied stricter inclusion criteria than
the Griffin study, concluded that the evidence sup-
porting the efficacy of fluoride in adults and elderly
people is incomplete for mouth rinses (157), fluoride
varnish (128) and combined preventive measures
(10). The authors emphasized that there is a need for
high-level evidence regarding the preventive action of
fluoride in adults. One obstacle to well-designed
clinical trials is the widespread use of fluoridated
toothpastes, which impedes the inclusion of negative
(non-fluoride) control groups. Ethical committees will
not give their consent to depriving patients included
in a clinical trial of the obvious benefits from fluori-
dation, as daily supplementation with fluoride is re-
garded as the standard of care. It may thus be
impossible to assess the benefit of fluoride applica-
tion on coronal caries in terms of prevention of cavi-
tation or lesion inactivation.
With regard to root caries, fluoride also appears to
act as a promoter of re-mineralization and an
inhibitor of de-mineralization, but higher concen-
trations of fluoride appear to be required for
re-mineralization of root caries compared to enamel
caries (95). In a double-blind randomized controlled
trial with 201 subjects who had at least one primary
root caries lesion, toothpastes containing 5000 and
1100 ppm fluoride were compared with respect to
hardness of the teeth, the presence of plaque and the
distance of the lesion from the gingiva (96). The
240
patients were instructed to use the toothpaste at least
once a day. After 3 months, 39% of the patients had
at least one lesion that hardened in the 5000 ppm
fluoride group, but only 11% of the patients had such
a lesion in the 1100 ppm fluoride group. After
6 months, the results were even more pronounced
and statistically significantly different, with values of
57% for the 5000 ppm fluoride group and 29% for
the control group (19). The plaque scores were also
significantly lower for the high-fluoride group. In
another double-blind randomized controlled trial in
which 466 participants were enrolled, use of a pla-
cebo mouth rinse was compared to semi-annual
topical application of acidulated phosphate fluoride
(APF) gel (1.2% fluoride) and a daily fluoride mouth
rinse (0.05% fluoride) (165). The patients in the group
rinsing daily with fluoride mouth rinses showed a
statistically significant higher reversal of root lesions
than both other groups. The incremental DMFS
(decayed, missed and filled surfaces), which com-
bines the number of new and reversed lesions, did
not different between the APF and fluoride mouth
rinse groups, but was significantly lower than in the
placebo group. A recent randomized controlled trial
comparing NaF gel (2.23%) and stannous fluoride
(8%) showed that reversal of root caries from active
to arrested lesions was achieved for 95% of the le-
sions irrespective of the fluoride compound used
(52). A recent review found that daily fluoride, either
from highly concentrated toothpastes or from daily
mouth rinses, has a preventive effect on root caries
(64). A clinical study performed in elderly people in
Sweden observed that mouth rinsing with 0.05% NaF
was significantly more effective in preventing new
root caries lesions over a 2-year interval than was
sucking fluoridated tablets (1.66 mg NaF twice a day)
or using fluoridated toothpaste (0.32% NaF), with or
without the Ôslurry rinsing techniqueÕ (51). However,
due to the limited number of well-designed clinical
trials, the evidence supporting the efficacy of fluo-
rides in preventing root caries is limited (135).
The re-mineralization-enhancing effect of fluoride-
releasing restorations was studied in a recent in situ
study with five 10% glucose solution challenges per
day (85). It was shown that enamel interfacing with a
compomer restoration that releases fluoride exhib-
ited significantly less mineral loss than enamel
interfacing with non-fluoride-releasing restoration.
De-mineralization in this study was measured by
quantitative light-induced fluorescence (DQ, %mm2),
and the values of DQ were calculated to be
)6.19%mm2 for the fluoride-releasing compomer
and )13.9%mm2 for the control compomer,

respectively. Given that interproximal caries is sel-
dom confined to a single tooth, treatment by means
of a class II restoration using a fluoride-releasing
filling material may contribute to lesion control of the
adjacent initial caries lesion (85).
Amorphous calcium phosphate (ACP)
Another strategy to re-mineralize teeth is to maintain
a high level of calcium and phosphorus ions at the
tooth surface in order to generate a chemical gradient
favoring re-mineralization of calcium- or phospho-
rous-deficient de-mineralized hard tissue. A technical
obstacle is inhibition of the formation of insoluble
calcium phosphate. Two products have been devel-
oped that avoid this problem.
Casein has an affinity to bind to enamel (133) and
possesses some caries protective capacity in itself
(159, 160). as1 casein has also been shown to have a
similar anti-caries effect (130). Further tryptic dis-
ruption of this protein produced much smaller
peptides, one of which was shown to have the same
characteristics as as1 casein and has been patented
as RecaldentTM (Cadbury, Tokyo, Japan) (131).
RecaldentTM is able to stabilize high amounts of Ca
and P (35), but is less bitter and has lower allergenic
potential than casein. The Ca and P in RecaldentTM
are stabilized as amorphous calcium phosphate
(ACP), and the casein phosphopeptide (CPP) gen-
erated is referred to as CPP-ACP. CPP-ACP is
unstable in an acidic environment, and releases Ca
and P ions at pH values below 7 (132). Furthermore,
it appears to have a synergistic effect with fluoride,
as shown in recent in vitro studies (34, 41). The
majority of the evidence concerning the re-miner-
alization potential of CPP-ACP is based on in situ
studies, i.e. studies in which prosthetic appliances
with tooth specimens are worn for a specific period
of time. Most of the studies showed an enhanced re-
mineralizing effect in 2-week trials. However, there
is insufficient clinical evidence to draw conclusions
on the long-term caries-preventive potential of CPP-
ACP (11). One major drawback of the published
in situ studies is under-estimation of the role of
saliva, which may have an even greater re-mineral-
izing effect itself (84), or the role of an increased
saliva flow rate (113). To date, two clinical ran-
domized controlled trials have been performed to
compare the action of CPP-ACP or fluoride on the
behavior of white spot lesions after removal of fixed
orthodontic appliances. Regression of white spot
lesions was greater for CPP-ACP than for fluoride
after 3 months (17) and 12 months (4).
Prevention of crown and root caries in adults
Another product is Enamelon (Church & Dwight,
Princeton, NJ, USA), a toothpaste containing high
amounts of calcium, phosphorus and fluoride. For-
mation of insoluble calcium phosphate and calcium
fluoride in the tube is hampered by the presence of
CaSO4 and NH4H2PO4 salts, which react only on the
tooth surface to produce non-stabilized ACP. A clin-
ical trial with 44 patients who had received radiation
of the head and neck region showed a significantly
lower root caries incidence within 1 year in the test
group (120). These results are in agreement with
those of a randomized controlled trial of 50 radiation
patients, in which the Enamelon toothpaste had a
significant preventive effect on root caries (121).
Ozone
The antibacterial efficacy of ozone is a well docu-
mented. However, there is no conclusive evidence
that ozone application is as effective in vivo as it is
in vitro (12). In a clinical trial with 40 children,
microbial samples from the cavity floor of operatively
treated teeth before and after application of gaseous
ozone for 30 s showed no differences in the number
of viable bacteria (62). Although some in vitro studies
reported promising results for the reversal of root
caries (20), there is a lack of well-designed prospec-
tive clinical trials with adequate sample sizes and
long-term follow-up.
Laser
Lasers that are used on hard dental substances
(CO2 or erbium-yttrium-aluminium-garnet (Er:YAG))
have been shown to exert caries preventive
effects when used with sub-ablative energies (43, 86).
In vitro studies using pH cycling demonstrated that
laser irradiation in the sub-ablative range increased
the de-mineralization resistance of enamel. Ultra-
structural changes in the enamel prisms are thought
to be responsible for this phenomenon. Melting of
the prism ends interferes with de-mineralization as
the vulnerable C-axis of the prism is protected from
dissolution. An in vitro study assessed the effect of
surface conditioning using an Er:YAG laser compared
to acid etching with 35% phosphoric acid on sec-
ondary caries of both enamel and root surfaces.
Compared to use of phosphoric acid, enamel condi-
tioning by means of a laser resulted in reduced lesion
depths, but the frequency of wall lesions was similar
(30). In another in vitro study, no caries preventive
effects of surface conditioning were found following
use of an Er:YAG or erbium-yttrium-scandium-
241
Rodrigues et al.
Fig. 3. Conditioning of enamel using an Er:YAG laser
(50 mW, 10 Hz, non-contact handpiece with water cool-
ing) may induce microcracks on the surface (indicated by
the arrow). The efficacy of this method is still debated.
gallium-garnet (ER:YSGG) laser (5). However, micro-
cracks at the irradiated surfaces were evident on
scanning electron micrographs, indicating a potential
increase in caries risk (Fig. 3). As this technique has
not been assessed clinically in adults with mature
tooth surfaces, its clinical efficacy cannot be deter-
mined.
Lesion control with micro-
invasive ⁄ minimally invasive
measures
Avoiding a continuous net loss of enamel mineral is
the mainstay of caries prevention. Use of the term
ÔpreventionÕ may be most appropriate for avoidance
of any visible change at the outer enamel surface. If
some de-mineralization has occurred (e.g. white spot
lesions), prevention of further de-mineralization may
be referred to as Ôlesion controlÕ (48). It has long been
shown that white spot lesions can remain stable for
years or even vanish over time (Fig. 1B) (14). In that
study, more than 50% of the original white spot
lesions were classified as ÔhealthyÕ after a 7-year
follow-up (14). It remains controversial whether
complete re-mineralization of a white spot lesion
actually takes place, i.e. whether restoration to the
original condition (restitutio ad integrum) occurs, or
whether white spot lesions vanish due to abrasion, or
whether both possibilities are feasible.
The cut-off point for use of preventive measures is
normally when the outer layer of a caries lesion has
lost its integrity, i.e. when a cavity has formed.
Biofilm that forms in a cavity is often not accessible
by oral hygiene measures, making it necessary to
242
restore the defective tooth. In some instances, e.g.
when a cavity is accessible to oral hygiene measures,
it may be considered appropriate to monitor inactive
cavitated lesions.
Lesion infiltration
A novel approach for lesion control is the ÔinfiltrationÕ
technique. Infiltration is applicable for white spot
lesions in enamel. Its aim is to fill the widened en-
amel pores with a low-viscosity resin (105, 110, 122,
124, 125) in order to protect the weakened enamel
structure from further acidic challenge by the cario-
genic biofilm. Following removal of the hyper-min-
eralized, less acid-soluble (72) superficial layer of
incipient enamel lesions using hydrochloric acid
(107), an adhesive with high penetration coefficient
(ÔinfiltrantÕ, Fig. 4) (124) is applied to the surface and
light-cured. Due to capillary forces, the low-viscosity
infiltrant penetrates into the white spot lesion.
In vitro experiments have demonstrated that enamel
lesions treated with low-viscosity infiltrants are more
resistant to de-mineralization than lesions treated
with conventional resins (106). As infiltrants are not
radiopaque, infiltrated lesions cannot be distin-
guished from untreated caries lesions. To date, only
one randomized controlled trial has been performed
on the efficacy of the ÔinfiltrationÕ technique, which
showed superior efficacy of additional infiltration of
interproximal lesions extending from the inner den-
tin to the outer dentin; lesion progression was found
in 7% in the test group compared to 37% of the
control group who received instruction on and self-
performed conventional oral hygiene measures (123).
Fig. 4. Lesion infiltration using Icon-Infiltrant (DMG,
Hamburg, Germany). White spot lesions are acid etched
with HCl gel for 2 min, then cleaned and dried for 1 min,
and then the infiltrant is applied in two steps over a period
of 4 min.

Interproximal patch
Another novel method of interproximal sealing is to
use a polyurethane patch that is bonded to the
interproximal surface (143). It has been shown
in vitro using a caries-simulating chamber model
that such a patch can completely inhibit de-miner-
alization of the underlying enamel. The interproxi-
mal patch was also assessed for use in sealing small
class II cavities and compared with unbeveled
class II fillings that were filled with a hybrid resin in
one increment (144). After exposure to thermo-
mechanical stress, practically no microleakage was
found in the patch-treated lesions, but dye pene-
tration into dentin was observed in 50% of the filled
lesions. In a 2-year clinical trial, a minimal increase
in progression was reported for incipient interprox-
imal enamel lesions following application of a patch
(3). These data indicate that achieving a good seal is
an integral part of lesion control ⁄ caries manage-
ment in adults.
Root caries control
Several regimens have been described for preventing
the formation of root caries. As with crown caries, an
important strategy for preventing root lesions is the
enhancement of re-mineralization by fluoride (see
above) or use of an antibacterial regimen involving
chlorhexidine varnish or triclosan (see above).
Another strategy to prevent root caries is to seal the
surfaces using glutardialdehyde-containing adhe-
sives. Glutardialdehyde has long been known as a
fixative agent (115), and is an ingredient of some
dentin adhesive systems. Glutardialdehyde is capable
of stabilizing the collagen fibers exposed after dentin
etching (21, 22, 32, 136), and thus increases dentin
bond strength in vitro. The surface cross-linking ini-
tiated by glutardialdehyde presumably stabilizes
calcium and phosphate ions and inhibits their dis-
solution during an acidic challenge of the root (6). It
was shown that sealing the root surface with two
types of dentin adhesive systems containing glutar-
dialdehyde led to a significant reduction or even
complete inhibition of root lesion formation,
depending on the way they were used (60). Another
study compared fluoride- and glutardialdehyde-
containing adhesive systems with respect to their
effect in response to acid attack in vitro (166). No
difference was found between groups, but the lesions
produced by S. mutans and Lactobacillus acidophilus
were significantly more shallow in the test groups
Prevention of crown and root caries in adults
than in the controls (which received either no surface
treatment or were etched with 37% phosphoric acid).
However, due to a lack of well-controlled clinical
trials, the comparative effectiveness of glutardialde-
hyde-containing adhesives in vivo is not known.
A novel approach for root caries prevention is to
combine antimicrobial and adhesive effects using a
composite releasing methacryloyloxydodecylpyridi-
nium bromide (MDPB). In an in vitro study, it was
shown that MDPB-containing composites inhibit the
progression of artificial secondary root caries lesions,
regardless of the adhesive system used (154).
However, the MDPB-containing composites did not
perform better than classical resin modified glass
ionomers (154).
Caries risk assessment
Various methods of preventing and controlling
dental crown and root caries have been described in
this review. To choose a preventive regimen and
treatment protocol, assessment of the individual,
patient-centered risk is required. Because dental
caries is a multi-factorial disease, it may be difficult,
if not impossible, to determine single risk factors for
the development or progression of dental caries. A
3-year clinical trial assessing 432 children, aged
9–14 years, identified former caries experience
(DMFS > 18%) as the best predictor (odds ratio 4.9)
(98). This is in agreement with the results of a recent
systematic review (44), which identified former car-
ies experience as the best predictor for future caries
in adults. For example, in a 5-year clinical trial
assessing the impact of sugar intake, dose and fre-
quency on the development of dental caries, 20% of
the patients in the group with highest sugar intake
did not show any caries increment. On the other
hand, caries continued to appear in some subjects
despite their avoidance of refined sugar and the
maximum possible restriction of natural sugars and
other carbohydrates (59). Thus, caries activity in
some subjects may not be related to carbohydrate
consumption (83). However, the large variability in
response to single caries risk factors, several caries
risk assessment strategies have been evaluated (128,
174). A risk assessment tool called Cariogram (28)
is available online (http://www.mah.se/fakulteter-och-
omraden/Odontologiska-fakulteten/Avdelning-och-
kansli/Cariologi/Cariogram) that includes information
about diet (content, frequency), bacteria (amount of
plaque, presence of mutans streptococci), suscepti-
bility (fluoride program, saliva buffer capacity, saliva
243
Rodrigues et al.
secretion) and other circumstances (past caries
experience, related diseases). The algorithm provides
probabilistic information regarding the possibility of
avoiding new lesion and suggests appropriate
treatment plans. It has been validated in an adult
population (149). Past caries experience may be a
powerful predictor of future caries, but is not a causal
factor. Preventive strategies must focus on factors
that can be modified, such as diet, bacteria and
fluoride use (61).
Conclusion
The aim of this review was to revisit certain aspects
of caries prevention and to analyze the current
evidence. In contrast to studies in pediatric popu-
lations, the body of evidence for caries preventive
measures in adults is limited. Thus, caries-reducing
or caries-controlling effects in adults, based on the
published evidence, are largely unquantified. As the
widespread use of fluoride interferes with the design
of placebo-controlled clinical trials, it is difficult, if
not impossible, to calculate the preventive effect of
fluoride in adults. There is clearly a need for well-
controlled, randomized, long-term clinical trials to
assess additional caries-inhibiting or caries-control-
ling effects of other preventive measures in adults in
order to optimize prevention strategies.
Adult patients have teeth that have been func-
tioning for decades. Meticulous visual inspection of-
ten identifies incipient caries lesions that developed
in childhood or adolescence. It is difficult to deter-
mine whether a caries lesion should be considered a
ÔscarÕ, reflecting the individualÕs oral history and
requiring no other maintenance than toothbrushing
with fluoridated toothpaste, or whether the lesion is
likely to progress and thus requires further profes-
sional care. Prevention may also be considered in
terms of Ôlesion controlÕ, i.e. preventing existing initial
caries lesions from progressing to cavitated lesions.
Despite the low level of scientific evidence, some
conclusions and recommendations for clinical
practice may be drawn. For example, the frequency
of appointments for re-evaluation and professional
mechanical tooth cleaning may be adjusted
according to the patientÕs risk profile. Recall inter-
vals of 12, 6 and 3 months, respectively, are justified
for patients at low, moderate and high caries risk
(10). In high-risk patients, the individual response to
additional combinations and frequencies of pre-
ventive agents need to be evaluated (168). Profes-
sional application of fluoride varnish at recall
244
appointments seems appropriate in these patients.
As frequent recall appointments and additional
preventive measures in high-risk patients change the
individual caries risk, caries increments comparable
to those of individuals at moderate to low caries risk
can be expected.
With regard to measures for home use by the
patient, there is little evidence to support or refute
the efficacy of any preventive measure as an adjunct
to regular mechanical tooth cleaning and the use of
fluoridated toothpaste for lesion inactivation and
lesion control. Further evidence is required to con-
firm whether long-term use of CPP-ACP- or xylitol-
containing products has a clinically relevant effect on
the prevention of caries.
No single preventive treatment can possibly be
optimal for every patient. The effective preventive
care and non-restorative treatment of crown and root
caries depends on reliable and early lesion detection
and identification of the individual caries risk, and
therefore remains a constant challenge for the
clinician.
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