Original Paper
Caries Res 2011;45:113–120
DOI: 10.1159/000324810
Changes in the Treatment Concept for
Approximal Caries from 1983 to 2009 in
Norway
S. Vidnes-Kopperud A.B. Tveit I. Espelid 
Faculty of Dentistry, University of Oslo, Oslo, Norway
Key Words
Approximal caries ⴢ Dental radiography ⴢ Dentistry ⴢ
Operative treatment ⴢ Proximal caries ⴢ Restorative
threshold
Abstract
The aim was to measure variations in threshold for operative
treatment of approximal caries in permanent teeth and the
use of restorative materials, compared with results from
studies conducted in Norway in 1983 and 1995. In 2009, a
precoded questionnaire was sent electronically to 3,654
dentists with E-mail addresses in the member register of the
Norwegian Dental Association. The questions were related
to caries, treatment strategies and choice of dental materials.
Replies were obtained from 61% of the dentists after two re-
minders. Restorative treatment of approximal lesions con-
fined to enamel, based on radiographic appearance, was
proposed by 7% of the dentists, compared with 66% in 1983
and 18% in 1995. Younger dentists, significantly more often
than older, would defer operative treatment of approximal
lesions until the lesion was visible in dentine. While tunnel
preparation most often was the preparation of choice in
1995 (47%), saucer-shaped preparation was most favoured in
2009 (69%). Tunnel preparation was only preferred by 4% of
the dentists. Resin composite was the restorative material
preferred by 95%, compared with 16% in 1995. The corre-
sponding values for conventional glass ionomer cement
© 2011 S. Karger AG, Basel
0008–6568/11/0452–0113$38.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
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Received: September 4, 2010
Accepted after revision: February 1, 2011
Published online: March 17, 2011
(GIC) were 1 versus 22%, for resin-modified GIC 1 versus 7%,
and for a combination of GIC and resin composite 2 versus
22%. Compomer was preferred by 1% of the respondents.
The authors conclude that treatment concepts for approxi-
mal caries have changed considerably during the last 26
years. In 2009, only 7% of dentists reported that they would
treat approximal caries operatively before the lesion reached
dentine. Copyright © 2011 S. Karger AG, Basel
Radiographic examination is commonly used to de-
tect and assess caries lesions on approximal surfaces [Me-
jàre, 2005; Mejàre and Kidd, 2009]. Based on the radio-
graphic outline of the approximal lesion and patient
characteristics, dentists use different criteria for initiat-
ing operative treatment [Rytömaa et al., 1979; Elderton
and Nuttall, 1983; Mileman et al., 1983; Espelid et al.,
1985; Riordan et al., 1991; Kay et al., 1992; el-Mowafy and
Lewis, 1994; Tveit et al., 1999; Espelid et al., 2001; Do-
méjean-Orliaguet et al., 2004; Ghasemi et al., 2008; Gor-
dan et al., 2009]. During recent decades, there has been a
considerable shift in criteria for the treatment of caries in
Norway. This is in accordance with studies showing that
caries is a slowly progressing disease and that lesions may
be arrested [Pitts and Wefel, 2009]. Consequently, initia-
tion of operative treatment is often deferred until the le-
sion has reached a certain severity [Tveit et al., 1999].
198.143.35.1 - 7/7/2015 2:26:38 AM
Simen Vidnes-Kopperud
Department of Paediatric Dentistry and Behavioural Science
University of Melbourne
Faculty of Dentistry, University of Oslo, P.O. Box 1109 Blindern
NO–0317 Oslo (Norway)
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Tel. +47 2285 2000, E-Mail simen.vidnes-kopperud @ odont.uio.no
 In many countries, the focus in cariology teaching to-
day is on non-operative caries care and a preventive ap-
proach rather than operative intervention, and a typical
phrase in cariology textbooks is that ‘a dentist’s aim
would be to avoid operative treatment wherever possible
and to manage those patients at risk of developing caries,
or those with early lesions, from a preventive point of
view’ [Ricketts and Pitts, 2009]. To what extent experi-
enced dentists follow these recommendations is un-
known.
It has been shown that one of the most important fac-
tors for the longevity of dental fillings is the dentist’s skill
[Opdam, 2007]. The age of the dentist may be an impor-
tant factor as the educational shift in treatment criteria
has come quite rapidly and recently. Older dentists may
swear allegiance to Black’s principles of ‘extension for
prevention’, whereas younger dentists are educated on
new principles such as ‘minimally invasive dentistry’.
This was demonstrated in a French study [Doméjean-Or-
liaguet et al., 2004], where old dentists favoured opening
the whole fissure when restoring occlusal caries lesions
significantly more often than younger dentists.
In Norway, use of amalgam was banned from January
1, 2008, and dentists have been obliged to use alternative
filling materials. It has been shown that amalgam was
becoming obsolete anyway and was only used in specific
categories of patients in the years preceding the ban
[Vidnes-Kopperud et al., 2009]. To what extent the shift
from amalgam to adhesive tooth-coloured materials in-
fluences dentists’ treatment criteria is not known. The
introduction of adhesive techniques has made cavity de-
sign less important for the retention of restorations. New
techniques, like saucer-shaped and tunnel preparation,
have been developed to allow minimal substance remov-
al [Peters and McLean, 2001]. Unfortunately, tunnel
preparations have been proven unsuccessful [Strand et
al., 1996; Hasselrot, 1998; Pilebro et al., 1999; Nicolaisen
et al., 2000; Strand et al., 2000].
Studies have shown that major changes in the threshold
for initiating operative treatment of approximal carious
lesions have taken place among Norwegian dentists from
the 1980s to the 1990s [Tveit et al., 1999]. The aim of the
present study was to examine whether this development
has continued, and to investigate which filling materials
and preparation techniques were preferred among dentists
in the time period from 1995 to 2009. Thus, the null hy-
pothesis was that no change had occurred in threshold for
initiation of operative treatment, preparation technique
and use of filling materials for approximal caries, com-
pared with identical surveys made 26 and 14 years ago.
114 Caries Res 2011;45:113–120
70
60
Restorative threshold (%)
50 1983
40 1995
30 2009
20
10
0
1 2 3 4 5 6
Stage of approximal caries
Fig. 1. Restorative threshold for approximal lesions based on dia-
grams illustrating different radiographic stages of caries progres-
sion in 1983, 1995 and 2009. The diagrams indicate stages of ap-
proximal caries (denoted 1–6) used to determine respondents’
criteria for initiation of restorative treatment. Diagram 1: not
more than half enamel depth; 2: between outer half and outer two
thirds of enamel; 3: to dentine-enamel junction; 4: in outer third
of dentine; 5: not more than two thirds of dentine depth; 6: in in-
ner two thirds of dentine.
Material and Methods
A precoded questionnaire was sent electronically to all den-
tists with an E-mail address in the member register of the Norwe-
gian Dental Association (Den norske tannlegeforening, NTF) in
March 2009, using the Internet-based software QuestBack. Of the
4,315 members of the NTF, 3,654 E-mail addresses were regis-
tered.
Information was collected on the respondents’ sex, age, home
county and type of practice, and to which extent the respondents
were occupied with caries diagnosis and treatment. Participation
was voluntary and no compensation was given to the respondents.
Questions were asked about treatment criteria for approximal
caries based on drawings illustrating different radiographic stag-
es of approximal caries, preferred type of preparation and filling
material of choice. The questions were copied from questionnaire
studies conducted in Norway in 1983 and 1995 [Espelid et al.,
1985; Tveit et al., 1999] with the exact same case scenarios and
questions. The results were compared.
• ‘Question 1: The figure shows different radiological appear-
ances of approximal carious lesions (fig. 1). Which lesion or
lesions should be restored immediately? We assume that the
patient’s caries activity is low and his/her oral hygiene is ade-
quate.’
• ‘Question 2: Which type of preparation would you prefer for
the smallest of the lesions you decided to drill and fill? You
should imagine that the approximal lesion is located distal on
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 the second premolar in the upper jaw. The patient is twenty
years of age, sees his/her dentist once a year, has adequate hy-
giene and uses fluoride toothpaste. Choose one of the follow-
ing alternatives: (1) traditional class II preparation; (2) tunnel
preparation; (3) saucer-shaped preparation.’
• ‘Question 3: Which filling material would you prefer? Choose
one of the options: (1) resin composite; (2) compomer; (3) con-
ventional glass ionomer cement (GIC); (4) resin-modified GIC;
(5) a combination of resin composite and GIC; (6) other.’
The software QuestBack was configured to automatically send
reminders to all participants who did not reply within 3 and 5
weeks, respectively. Anonymity was ensured by QuestBack. The
study was approved by the Norwegian Social Science Data Ser-
vices. To process the data, SPSS version 16.0 (Statistical Package
for the Social Sciences; SPSS Inc., Chicago, Ill., USA) was used and
statistical evaluation was carried out by means of descriptive sta-
tistics with ␹2 tests and logistic regression analyses. The regres-
sion analyses were performed with ‘restoring enamel lesions op-
eratively’ as the dependent variable, and dentist’s age, sex, type of
practice, DMFT (decayed, missing and filled teeth) in the den-
tist’s county of practice, dentist density in home county, prepara-
tion technique and filling material as independent variables. The
probability level for statistical significance was set at ␣ = 0.05.
Results
A total of 2,375 dentists responded after two remind-
ers. Respondents 69 years of age and older (n = 63) and
those who did not normally work with caries and filling
materials (n = 286) were excluded from the statistical
analyses. A response rate of 61.3% was calculated accord-
ing to Standard Definitions by the American Association
for Public Opinion Research [American Association for
Public Opinion Research, 2010]. The mean age of the in-
cluded dentists was 46.2 years (SD: 11.9 years). The mean
age of the 4,114 dentists registered !69 years of age in the
member register of the NTF was 47.0 years (SD: 12.0
years). The distribution of age of the respondents did not
differ significantly (p = 0.73) from that of all dentists in
the NTF member register (␹2 test). Of the respondents,
47.1% were female and 52.9% male. The corresponding
values for all dentists in the NTF member register were
44.5 and 55.5%. Similar data were collected from the
Norwegian Registration Authority for Health Personnel,
showing even higher representativeness between all au-
thorised dentists in Norway and our sample. The mean
age of all authorised dentists in Norway !69 years of age
was 46.2 years (n = 6,212), and the sex proportions were
45.9% female and 54.1% male. According to type of prac-
tice, 708 (30.6%) of the respondents were employed by the
Public Dental Health Service (PDHS), 1,399 (60.5%) were
private practitioners and 205 (8.9%) were employed else-
Changes in Treatment Concept for
Approximal Caries in Norway
where (e.g. 50% private practice and 50% PDHS, research,
administrative work, employed by hospitals or the army).
In the member register of the NTF, 32.9% were employed
by the PDHS and 67.1% were registered as private practi-
tioners. Corresponding values could not be extracted
from the Norwegian Registration Authority for Health
Personnel.
Treatment Criteria
As shown in figure 1, only 7.0% of the dentists would
initiate operative treatment of carious lesions confined to
the enamel in 2009, compared with 18.3% in 1995 and
65.6% in 1983. A majority of the dentists (56.5%) in 2009
would wait until the lesion was visible in dentine, where-
as 35.8% would commence operative treatment when the
radiolucency had reached the middle third of the dentine.
Comparing the treatment decisions between different
groups according to the age of the dentists, it was found
that the younger dentists more often than older dentists
would defer operative treatment until the approximal
carious lesion penetrated dentine radiographically (p !
0.01). In 1995, the situation was the same. More dentists
employed by the PDHS would defer operative treatment
until the lesion was visible in the dentine, compared with
private practitioners (96.1 vs. 91.6%; p = 0.008). This was
in accordance with corresponding results from the 1995
study.
Aggregated data for each of 20 Norwegian counties
were collected from the Public Dental Services (StatBank
Norway) on the number of DMFT in 18-year-olds, and on
the number of patients per dentist in each county. Eco-
logical associations between the treatment criteria and
these variables in the county where the dentists practised
were evaluated quantitatively by computing correlation
coefficients. There were no significant correlations (p =
0.91 and p = 0.13, respectively).
Preparation Technique
Altogether, 2,028 dentists answered the questions
about the preferred preparation technique for a class II
filling. A saucer-shaped preparation was preferred by
68.4% of the respondents, followed by traditional class II
preparation (27.8%) and tunnel preparation (3.8%). In
1995, the corresponding values were 24.3% (saucer-
shaped preparation), 28.2% (traditional class II prepara-
tion) and 47.3% (tunnel preparation). The younger den-
tists chose saucer-shaped preparation more often than
the older dentists (75.4 vs. 58.2%; p = 0.04), and likewise,
the saucer-shaped preparation was more often preferred
by dentists in the PDHS than by private practitioners
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Caries Res 2011;45:113–120 115
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 100 40

Initiation of operative treatment of

enamel lesions (% of dentists)
Combination
Use of restorative materials (%)

35 Private
95
GIC 30 PDHS

90 25
Compomer
20
85 Composite
15
10
80
5

75 0
20–29 30–39 40–49 50–59 60–69 20–29 30–39 40–49 50–59 60–69
Dentists‘ age (years) Dentists‘ age (years)

Fig. 2. Use of restorative materials in different practitioner age Fig. 3. Proportion of dentists who preferred to initiate operative
groups. treatment of enamel lesions (n = 133) shown by the two strongest
variables in the logistic regression analyses: dentist’s age and type
of practice.

(74.5 vs. 64.8%; p ! 0.01). In 1995, significantly more den-
tists in the PDHS preferred tunnel preparation compared
with private practitioners, and this preference was unre-
lated to the dentist’s age. There were no significant rela-
tions between threshold for initiation of operative treat-
ment and choice of preparation technique (p = 0.06).
Restorative Materials
Altogether, 2,033 dentists answered the questions
about the preferred material for a class II preparation.
Resin composite was preferred by the vast majority of the
respondents (94.9%). Preferences for other materials were
few and evenly distributed: 1.1% compomer, 1.1% conven-
tional GIC, 0.5% resin-modified GIC, and 1.8% a combi-
nation of resin composite and GIC. Because of the amal-
gam ban in Norway, amalgam was not an option in 2009.
In 1995, the values were 15.5% amalgam, 15.8% resin
composite, 22.3% conventional GIC, 7.2% resin-modified
GIC, and 22.4% a combination of resin composite and
GIC. Compomer was not an option in 1995.
There was a significant relationship between dentist’s
age and use of filling materials (fig. 2). Almost all dentists
aged 20–29 years (98.9%) would use resin composite as
filling material, compared with 89.5% of the dentists aged
60–69 years (p ! 0.01). The reduction in use of resin com-
posite was well correlated with rising age in all age groups
(p ! 0.01). In 1995, there was no significant difference in
the use of restorative materials by age group. There was
no significant difference in use of resin composite by type
of practice (PDHS: 94.8%; private practice: 94.9%; p =
0.11). In 1995, resin composite would have been used sig-
nificantly more often by private practitioners than by
dentists in the PDHS. Dentists who preferred saucer-
shaped preparation and traditional class II preparation
usually chose resin composite as a filling material (96.2
and 96.8%, respectively). The 45 dentists who preferred
tunnel preparation had a more evenly distributed choice
of filling material: 57.7% chose resin composite, 19.2% a
combination of GIC and resin composite, 12.8% conven-
tional GIC and 2.6% resin-modified GIC.
The results of the regression analysis are presented in
table 1. Dentist’s age, sex, type of practice and preparation
technique were all significantly related to the decision to
initiate operative treatment of lesions confined to enamel
(unadjusted analyses). In the adjusted analyses, only age
and type of practice remained significant (fig. 3). Accord-
ingly, dentist’s sex, caries prevalence (DMFT) and dentist
density in the dentist’s home county, preparation tech-
nique and filling material were not significantly related
to whether dentists would treat enamel lesions operative-
ly or defer treatment until the lesion was radiographi-
cally visible in dentine.
Discussion
The null hypothesis that treatment criteria and strat-
egy for approximal caries have not changed during the
last 14 years is rejected. The tendency to postpone opera-
tive treatment has continued since 1995, and the prefer-
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116 Caries Res 2011;45:113–120 Vidnes-Kopperud/Tveit/Espelid

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Table 1. Associations between selected variables and the risk of restoring enamel lesions operatively

Unadjusted Adjusted
OR 95% CI p OR 95% CI p

Age
50–59 years vs. 60–69 years 2.32 1.47–3.69 <0.001 2.40 1.49–3.86 <0.001
40–49 years vs. 60–69 years 2.38 1.45–3.90 0.001 2.53 1.49–4.30 0.001
30–39 years vs. 60–69 years 4.72 2.78–8.00 <0.001 4.61 2.65–8.03 <0.001
20–29 years vs. 60–69 years 4.88 2.04–11.7 <0.001 4.94 1.88–13.0 0.001
Sex
Female vs. male 1.91 1.32–2.75 0.001 1.26 0.84–1.89 0.259
Type of practice
PDHS vs. private practice 2.11 1.37–2.29 0.001 2.25 1.41–3.60 0.001
DMFT in county 1.02 0.79–1.32 0.898 0.98 0.74–1.29 0.865
Dentist density in county 1.00 0.99–1.00 0.330 1.00 0.99–1.00 0.414
Preparation technique
Traditional class II vs. tunnel preparation 1.80 0.87–3.75 0.116 1.28 0.57–2.91 0.550
Saucer-shaped vs. tunnel preparation 2.34 1.16–4.71 0.018 1.40 0.64–3.08 0.400
Filling material
Compomer and GIC vs. resin composite 0.58 0.29–1.15 0.117 0.97 0.45–2.09 0.935

Statistical analysis: the results are calculated using logistic regression analyses. Unadjusted results were obtained by performing
separate regression analyses for each selected variable. Adjusted results were obtained by including all the selected variables in one
regression analysis. Thus, in the adjusted analysis, the result for each variable is adjusted for all the other variables listed. OR = Odds
ratio.

ences for preparation technique and filling materials
have changed. In general, dentists defer treatment of ear-
ly carious lesions, use saucer-shaped preparations rather
than tunnel preparations, and choose resin composite as
filling material more often in 2009 than in 1995.
The NTF estimates that 90–95% of all practising den-
tists in Norway are registered members. The relatively
high response rate (61.3%) and the matching age distribu-
tion of the respondents are consistent with our sample
being representative of the members of the NTF and all
authorised dentists in Norway. Measures taken to ensure
a high response rate, in accordance with a systematic re-
view of questionnaires [Edwards et al., 2009], proved suc-
cessful, e.g. the questionnaire was styled in a personal
manner with a simple header, pictures were used as illus-
trations in the questionnaire and placed early to interest
the respondents, and in the reminder, respondents were
informed of the response rate so far to emphasise the im-
portance of a reply.
Only 7% of the dentists would intervene by operative
therapy while the caries lesion was still confined to enam-
el in 2009, compared with 18% in 1995 and 66% in 1983.
This is in line with new ‘minimally invasive’ principles in
dentistry, which have been adopted in dental education
in Norway during recent decades. It is reflected in the re-
plies which show that younger dentists significantly more
often than older dentists would defer operative treatment
of approximal lesions until the lesion was visible in den-
tine. Compared with results from the 1995 survey, many
older dentists in Norway also seem to have changed their
treatment philosophy, but this may be a cohort effect:
dentists in the middle-age quartiles in 1995 had pro-
gressed to the older-age quartiles in 2009.
More dentists employed by the PDHS would defer op-
erative treatment until the lesion was visible in the den-
tine, compared with private practitioners. This could in-
dicate that dentist remuneration distorts the link between
treatment need and actual treatment provided as the fee
of a private practitioner is mainly based on the unit price
of restorations. On the other hand, in many Norwegian
counties, the focus is on the number of patients treated.
Consequently, outside factors may affect treatment choic-
es differently in private practitioners and PDHS dentists.
Norwegian dentists seem reluctant to initiate opera-
tive treatment of early carious lesions compared with
dentists elsewhere [Doméjean-Orliaguet et al., 2004;
Ghasemi et al., 2008]. In a recent questionnaire study
among dentists in a practice-based research network in
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Approximal Caries in Norway
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the USA and Scandinavia, 63% (n = 319) reported they
would operatively treat an occlusal lesion confined to the
enamel in a patient with a low risk of developing caries.
Of the Scandinavian respondents only 2.6% said that they
would intervene that early [Gordan et al., 2010].
The decrease in proportion of dentists who would re-
store lesions confined to enamel from 1983 to 1995 was
greater than in the period of 1995–2009 (fig. 1). This may
indicate that a major change in views about dental caries
has taken place between 1983 and 1995. Such a change in
attitude could explain the results from a Swedish study of
two groups of teenagers [Edward, 1997] and the findings
from a Norwegian study [Gimmestad et al., 2003] that
reported that the highest decrease in numbers of filled
surfaces from 1979 to 1996 occurred during the first 10
years. Prior to 1983, caries progression from enamel to
dentine lesions might have been considered quite rapid,
and the concept of arresting caries was not well adopted.
Research published in the early 1980s indicated that, on
average, the progression was quite slow [Pitts, 1983; Grön-
dahl et al., 1984], but the continued occasional occur-
rence of deep carious lesions could have supported the
impression that caries progressed rapidly through den-
tine.
Drawings of different severity grades of approximal
caries based on radiological appearance were used in our
questionnaire. Radiographs are commonly used in Nor-
way when diagnosing caries [Swedish Council on Tech-
nology Assessment in Health Care, 2007]. The rationale
for this is mainly based on three factors: (1) early detec-
tion, (2) to monitor caries progression, and (3) to judge
lesion severity (depth). It has been found that clinical ex-
amination alone detects fewer than half of the approxi-
mal lesions present, whereas bitewing radiographs can
facilitate detection of more than 90% of the lesions [Pitts,
1996]. Dentists’ radiograph-based restorative decisions
are subject to wide variation [Downer and Kay, 1996;
Lewis et al., 1996], and some additional variation is likely
to occur between dentists due to differences in radio-
graphic diagnostic accuracy [Mileman and van der
Weele, 1990]. Judging the radiographic appearance of ap-
proximal caries is not the only factor in clinical decision
making, but it is an important indicator of dentists’ treat-
ment philosophy regarding operative and non-operative
treatment.
Changes have occurred not only in treatment criteria,
but also in preparation technique. In 1995, tunnel prepa-
ration was a favoured technique [Forsten, 1993; Tveit et
al., 1999]. Currently, saucer-shaped preparation [Nordbø
et al., 1993] is preferred by more than two thirds of the
118 Caries Res 2011;45:113–120
respondents. Less than 4% of dentists prefer tunnel prep-
aration compared with 47% in 1995. This shift is probably
due to clinicians’ experience of the short durability of
these restorations. The longevity of saucer-shaped resto-
rations compared with tunnel preparations is greater
[Horsted-Bindslev et al., 2005], but in general, the num-
ber of studies on saucer-shaped restorations is limited. It
is important to conduct clinical studies to monitor the
fate of restorations and to study factors which are impor-
tant over time for longevity [Bayne, 2007]. Because of its
small size and the use of adhesive techniques, the saucer-
shaped preparation is today considered minimally inva-
sive dentistry [Peters and McLean, 2001]. This supports
the contention that new materials and techniques have
changed dentistry in Norway. From an educational point
of view, this change is a successful adaptation to new
knowledge.
The choices of both preparation technique and filling
materials were more evenly distributed among the differ-
ent alternatives in 1995 compared with 2009. After the
Norwegian government had banned the use of amalgam
in 2008, dentists were forced to find alternative filling
materials. Our results indicate that resin composite,
which is preferred by 95% of the respondents, has re-
placed amalgam. In other countries, the use of amalgam
has also rapidly decreased [Lynch et al., 2007; Kirkevang
et al., 2009; Sunnegårdh-Grönberg et al., 2009; Lynch and
Wilson, 2010]. A study on trends in dental treatment in
the USA showed that patients received approximately
50% fewer amalgam fillings in 2007 compared with 1992,
whereas the rise in use of resin-based composite restora-
tions was equivalent [Eklund, 2010]. In our study the use
of other filling materials such as GIC and compomer was
less than 4%. This is in accordance with a recent study
showing that other materials than amalgam and resin
composite were preferred by only 5% of 229 dentists when
placing restorations in premolars [Nascimento et al.,
2010].
The dentists were supposed to imagine that the patient
was 20 years of age and had low caries risk. Dentists’
treatment decisions are shown to vary depending on pa-
tient characteristics such as age, dental status, caries risk
and regularity of attendance [Bader and Shugars, 1992;
el-Mowafy and Lewis, 1994; Bader and Shugars, 1998;
Gordan et al., 2010]. In a low-risk case, dentists may be
more liable to defer operative treatment than in patients
at high caries risk. Knowledge about the probability of le-
sion progression is important when deciding the appro-
priate time of surgical intervention. According to Mejàre
et al. [2004], the progression of enamel caries in approxi-
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mal surfaces is quite slow, and this supports the treatment
philosophy not to do any surgical intervention while the
lesion is confined to enamel. The knowledge of caries
progression and poor longevity of glass ionomer fillings
in posterior teeth [Hickel and Manhart, 2001] may ex-
plain the infrequent use of glass ionomer for this theo-
retical patient with low caries risk.
In 1983, 66% of dentists preferred to restore approxi-
mal caries before the lesion had penetrated the enamel-
dentine border. In 2009, the corresponding proportion
was 7%. These changes in treatment criteria indicate that
most dentists have taken into account that caries is a
slowly progressing disease and that lesions can be arrest-
ed. Studies on caries progression among Scandinavian
adolescents as well as analyses of treatment strategies
among dentists confirm this view [Lith, 2001; Mejàre et
al., 2004; Mjör et al., 2008]. When deferring operative
treatment of a carious lesion, it is a prerequisite that pre-
ventive measures are implemented, such as information
and motivation of the patient, dietary advice, proper
cleaning of the teeth and fluoride application, since the
rationale for deferring operative treatment is to allow le-
sions to be arrested. In the present study, the non-opera-
tive procedures most commonly used by dentists in Nor-
way were not investigated. Future research should ex-
plore the alternatives to surgical interventions which are
used by clinicians.
Acknowledgements
The study was funded by the University of Oslo. The English
language was corrected by Dr. Paul Riordan, Write2Publish
(http://correction-home.fr).
Disclosure Statement
There are no potential conflicts of interests.

References
American Association for Public Opinion Re-
search: Standard definitions. 2010. www.
aapor.org/Standard_Definitions/2687.htm.
Bader JD, Shugars DA: Understanding dentists’
restorative treatment decisions. J Public
Health Dent 1992;52:102–110.
Bader JD, Shugars DA: Descriptive models of re-
storative treatment decisions. J Public Health
Dent 1998;58:210–219.
Bayne SC: Dental restorations for oral rehabilita-
tion: testing of laboratory properties versus
clinical performance for clinical decision
making. J Oral Rehabil 2007;34:921–932.
Doméjean-Orliaguet S, Tubert-Jeannin S, Rior-
dan PJ, Espelid I, Tveit AB: French dentists’
restorative treatment decisions. Oral Health
Prev Dent 2004;2:125–131.
Downer MC, Kay EJ: Restorative treatment deci-
sions from bitewing radiographs: perfor-
mance of dental epidemiologists and general
dental practitioners. Community Dent Oral
Epidemiol 1996;24:101–105.
Edward S: Changes in caries diagnostic criteria
over time related to the insertion of fillings:
a comparative study. Acta Odontol Scand
1997;55:23–26.
Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C,
Wentz R, Kwan I, Cooper R, Felix LM, Pratap
S: Methods to increase response to postal
and electronic questionnaires. Cochrane
Database Syst Rev 2009:MR000008.
Eklund SA: Trends in dental treatment, 1992 to
2007. J Am Dent Assoc 2010;141:391–399.
Elderton RJ, Nuttall NM: Variation among den-
tists in planning treatment. Br Dent J 1983;
154:201–206.
el-Mowafy OM, Lewis DW: Restorative decision
making by Ontario dentists. J Can Dent As-
soc 1994;60:305–306.
Espelid I, Tveit A, Haugejorden O, Riordan PJ:
Variation in radiographic interpretation and
restorative treatment decisions on approxi-
mal caries among dentists in Norway. Com-
munity Dent Oral Epidemiol 1985;13:26–29.
Espelid I, Tveit AB, Mejàre I, Sundberg H, Hal-
lonsten AL: Restorative treatment decisions
on occlusal caries in Scandinavia. Acta
Odontol Scand 2001;59:21–27.
Forsten L: Clinical experience with glass iono-
mer for proximal fillings. Acta Odontol
Scand 1993;51:195–200.
Ghasemi H, Murtomaa H, Torabzadeh H, Veh-
kalahti MM: Restorative treatment thresh-
old reported by Iranian dentists. Commu-
nity Dent Health 2008;25:185–190.
Gimmestad AL, Holst D, Fylkesnes K: Changes
in restorative caries treatment in 15-year-
olds in Oslo, Norway, 1979–1996. Commu-
nity Dent Oral Epidemiol 2003;31:246–251.
Gordan VV, Bader JD, Garvan CW, Richman JS,
Qvist V, Fellows JL, Rindal DB, Gilbert GH:
Restorative treatment thresholds for occlusal
primary caries among dentists in the dental
practice-based research network. J Am Dent
Assoc 2010;141:171–184.
Gordan VV, Garvan CW, Heft MW, Fellows JL,
Qvist V, Rindal DB, Gilbert GH: Restorative
treatment thresholds for interproximal pri-
mary caries based on radiographic images:
findings from the Dental Practice-Based Re-
search Network. Gen Dent 2009;57:654–663.
Gröndahl HG, Andersson B, Torstensson T: Car-
ies increment and progression in teenagers
when using a prevention- rather than resto-
ration-oriented treatment strategy. Swed
Dent J 1984;8:237–242.
Hasselrot L: Tunnel restorations in permanent
teeth: a 7-year follow-up study. Swed Dent J
1998;22:1–7.
Hickel R, Manhart J: Longevity of restorations in
posterior teeth and reasons for failure. J Ad-
hes Dent 2001;3:45–64.
Horsted-Bindslev P, Heyde-Petersen B, Simon-
sen P, Baelum V: Tunnel or saucer-shaped
restorations: a survival analysis. Clin Oral
Investig 2005;9:233–238.
Kay EJ, Nuttall NM, Knill-Jones R: Restora-
tive treatment thresholds and agreement
in treatment decision-making. Community
Dent Oral Epidemiol 1992;20:265–268.
Kirkevang LL, Vaeth M, Wenzel A: Prevalence
and incidence of caries lesions in relation to
placement and replacement of fillings: a lon-
gitudinal observational radiographic study
of an adult Danish population. Caries Res
2009;43:286–293.
Lewis DW, Kay EJ, Main PA, Pharoah MG, Csi-
ma A: Dentists’ variability in restorative de-
cisions, microscopic and radiographic caries
depth. Community Dent Oral Epidemiol
1996;24:106–111.
198.143.35.1 - 7/7/2015 2:26:38 AM

Changes in Treatment Concept for Caries Res 2011;45:113–120 119

Approximal Caries in Norway
University of Melbourne
Downloaded by:
Lith A: Frequency of radiographic caries exami-
nations and development of dental caries.
Swed Dent J Suppl 2001; 147:1–72.
Lynch CD, McConnell RJ, Wilson NH: Trends in
the placement of posterior composites in
dental schools. J Dent Educ 2007; 71: 430–
434.
Lynch CD, Wilson NH: Teaching of direct pos-
terior resin composite restorations in UK
dental therapy training programmes. Br
Dent J 2010;208:415–421.
Mejàre I: Bitewing examination to detect caries
in children and adolescents: when and how
often? Dent Update 2005; 32: 588–590, 593–
594, 596–597.
Mejàre I, Kidd EA: Radiography for caries diag-
nosis; in Fejerskov O, Kidd E (eds): Dental
Caries. The Disease and Its Clinical Manage-
ment, ed 2. Blackwell Munksgaard, Oxford,
2008, pp 70–88.
Mejàre I, Stenlund H, Zelezny-Holmlund C:
Caries incidence and lesion progression
from adolescence to young adulthood: a pro-
spective 15-year cohort study in Sweden.
Caries Res 2004;38:130–141.
Mileman P, Purdell-Lewis D, van der Weele L:
Effect of variation in caries diagnosis and de-
gree of caries on treatment decisions by den-
tal teachers using bitewing radiographs.
Community Dent Oral Epidemiol 1983; 11:
356–362.
Mileman PA, van der Weele LT: Accuracy in ra-
diographic diagnosis: Dutch practitioners
and dental caries. J Dent 1990;18:130–136.
Mjör IA, Holst D, Eriksen HM: Caries and resto-
ration prevention. J Am Dent Assoc 2008;
139:565–570.
120 Caries Res 2011;45:113–120
Nascimento MM, Gordan VV, Qvist V, Litaker
MS, Rindal DB, Williams OD, Fellows JL,
Ritchie LK Jr, Mjör IA, McClelland J, Gilbert
GH: Reasons for placement of restorations
on previously unrestored tooth surfaces by
dentists in the Dental Practice-Based Re-
search Network. J Am Dent Assoc 2010; 141:
441–448.
Nicolaisen S, von der Fehr FR, Lunder N, Thom-
sen I: Performance of tunnel restorations at
3–6 years. J Dent 2000;28:383–387.
Nordbø H, Leirskar J, von der Fehr FR: Saucer-
shaped cavity preparation for composite res-
in restorations in class II carious lesions:
three-year results. J Prosthet Dent 1993; 69:
155–159.
Opdam NJ: A retrospective clinical study on lon-
gevity of posterior composite and amalgam
restorations. Dent Mater 2007;23:2–8.
Peters MC, McLean ME: Minimally invasive op-
erative care. 2. Contemporary techniques
and materials: an overview. J Adhes Dent
2001;3:17–31.
Pilebro CE, van Dijken JW, Stenberg R: Durabil-
ity of tunnel restorations in general practice:
a three-year multicenter study. Acta Odontol
Scand 1999;57:35–39.
Pitts NB: Monitoring of caries progression in
permanent and primary posterior approxi-
mal enamel by bitewing radiography. Com-
munity Dent Oral Epidemiol 1983; 11: 228–
235.
Pitts NB: The use of bitewing radiographs in the
management of dental caries: scientific and
practical considerations. Dentomaxillofac
Radiol 1996;25:5–16.
Pitts NB, Wefel JS: Remineralization/desensiti-
zation: what is known? What is the future?
Adv Dent Res 2009;21:83–86.
Ricketts DN, Pitts NB: Traditional operative
treatment options. Monogr Oral Sci 2009;21:
164–173.
Riordan PJ, Espelid I, Tveit AB: Radiographic in-
terpretation and treatment decisions among
dental therapists and dentists in Western
Australia. Community Dent Oral Epidemiol
1991;19:268–271.
Rytömaa I, Järvinen V, Järvinen J: Variation in
caries recording and restorative treatment
plan among university teachers. Community
Dent Oral Epidemiol 1979;7:335–339.
Strand GV, Nordbø H, Leirskar J, von der Fehr
FR, Eide GE: Tunnel restorations placed in
routine practice and observed for 24 to 54
months. Quintessence Int 2000;31:453–460.
Strand GV, Nordbø H, Tveit AB, Espelid I, Wik-
strand K, Eide GE: A 3-year clinical study of
tunnel restorations. Eur J Oral Sci 1996;104:
384–389.
Sunnegårdh-Grönberg K, van Dijken JW, Fune-
gard U, Lindberg A, Nilsson M: Selection of
dental materials and longevity of replaced
restorations in Public Dental Health clinics
in northern Sweden. J Dent 2009; 37: 673–
678.
Swedish Council on Technology Assessment in
Health Care: Caries diagnosis, risk assess-
ment and non-operative treatment of early
caries lesions. SBU Rep No 188 (in Swedish,
with English summary). 2008. http://www.
sbu.se/upload/Publikationer/Content1/1/
Caries_summary_2008.pdf.
Tveit AB, Espelid I, Skodje F: Restorative treat-
ment decisions on approximal caries in Nor-
way. Int Dent J 1999;49:165–172.
Vidnes-Kopperud S, Tveit AB, Gaarden T, Sand-
vik L, Espelid I: Factors influencing dentists’
choice of amalgam and tooth-colored restor-
ative materials for Class II preparations in
younger patients. Acta Odontol Scand 2009;
67:74–79.
198.143.35.1 - 7/7/2015 2:26:38 AM
Vidnes-Kopperud/Tveit/Espelid
University of Melbourne
Downloaded by: