Introduction: While attempting to explain what I see as a revolution-taking place in the treatment of tooth decay, I will borrow from the intellectual work of the scientific method scholar Thomas Kuhn. His principal work, The Structure of Scientific Revolutions1, will serve as a template for exploring whether Dentistry is in fact in the midst of a scientific paradigm shift away from surgery and toward chemotherapeutics. I will begin with a brief recap of the development of the scientific method, then move on to use Kuhn’s general outline to identify key current events that may be evidence of a shift underway.
The scientific world was irreversibly altered when Thomas Kuhn published The Structure of Scientific Revolutions in 1962. In this landmark text, Kuhn drew examples from the Copernican revolution in the 16th century, the Newtonian revolution of the 17th century, and the Einsteinian revolution of the 20th century. These pivotal events, together with Darwin’s introduction of evolution by natural selection in 1865, rebuilt the entire worldview held by both academics and the general public of the time. Today the foundations of these discoveries are taken for granted; in fact it is hard to imagine that alternative perspectives dominated prior belief systems. The scientific method first described by Francis Bacon in the 17th century provided a framework for organizing observations and developing a standardized process for describing and predicting events in the natural world. This method of thinking has proven to be immensely powerful. Collectively, these events may be regarded as the vehicle that moved the world from a superstitious dark age and into the era of The Enlightenment. Kuhn identified very distinct sequential events that define these revolutions in scientific thinking, and he also provides a roadmap for predicting future scientific revolutions, and what paths they may take. Kuhn coined a term to describe these events, the “Paradigm Shift.” Since the introduction of the term, a great controversy has arisen about its proper usage, and in some ways, it has been appropriated by many human endeavors and has become a dictum of common language. Nonetheless, it remains a very powerful tool for examining the processes, which Kuhn labels normal science or puzzle solving, versus true scientific revolutions, paradigm shifts and game changing events in science. Today, enormous resources are dedicated to refining existing paradigms to ever-greater decimal points of accuracy. The archetypal model for a scientific endeavor leads to greater and greater storehouses of data regarding ever-decreasing realms of knowledge. Perhaps one day we will discover that we know everything about nothing. The reason that this is not a realistic threat is because the classic path through inquiry leads to a crisis when the growing body of knowledge fails to explain a nontrivial anomaly. When this happens, as has been proven time and time again, the inevitable crises calls into question the core belief systems embodied within the dominant paradigm. There ensues a period of intense conflict and confrontation between the camps of the old paradigm and those of the new one. Often attempts at reconciliation are utter failures, as it is likely that both the old and new paradigms are sufficient to explain many of the phenomena encompassed by both constructs. Here is where the recognition of anomaly is crucial to opening the door for the new paradigm to emerge. Newtonian mechanics were powerful in predicting the movement of planets in the solar system, with the exception of the perihelion orbital anomaly of the planet Mercury. It was through the deep pondering of this anomaly that led Albert Einstein to begin to reformulate the entire worldview of gravity, matter, energy and space-time. Likewise it was the failure of the simplistic planetary atomic model developed by Rutherford and Bohr, to explain the observations that led to the development of the most powerful physical theory and perhaps the crowning achievement of the human mind, Quantum Mechanics. Each of these transitions encountered strong resistance from the defenders of the existing paradigm. It was only after a continuing failure of the reigning paradigm to predict and describe observed events on an experimental scale, that new paradigms did emerge and compete on the playing field of natural selection.
A medical Paradigm Shift: what causes a gastric ulcer?
Prior to 1985, the general consensus in the medical community was that gastric ulcers were caused by stress and excess acid. Treatments based on this belief ranged from simple antacids to radical gastric surgery and were routinely carried out worldwide. Then an anomaly appeared. Two Australian physicians, Barry Marshall and Robin Warren noticed that many of these patients had active infections of specific bacteria, Helicobacter Pylori. The hypothesis was introduced that these bacteria may be the cause of ulcers, and perhaps even of gastric cancer. A simple treatment using antibiotics was introduced. The dominant surgical paradigm reacted with absolute silence. For another ten years very little effort was made to try and reproduce the claims of Marshall and Warren. Twenty years later the Nobel Prize in physiology and medicine was awarded for this immense contribution to scientific knowledge and human welfare. Today surgery for gastric ulcers is uncommon.2
A brief exploration of how this process has effected and continues to effect dentistry is in order. It is my belief that dentistry is now facing a crisis of paradigm and entering into a new era of change of momentous proportions. What evidence exists for my opinion? There is a commonly held belief among dental professionals that “we know how to stop tooth decay and just need to get out and do it.”3 In the background of this widespread assertion, we see regular reports of increasing disease rates and massive access to care problems around the country. The dental care crisis in America is evident from hearings in the congress,4 to the many Mission of Mercy events taking place all across America.5 Epidemiological data shows that certain at-risk populations in America have the highest disease rates and suffer extensive morbidity and occasionally mortality.6,7 The disease is not an equal opportunity player. It preys on the poor, the aged and the disabled. In America, we experience vast inequities in both the experience of dental disease and the access to appropriate oral health care services.10 Why is this? Perhaps the usual approaches are not working. In the words of Dr. Mike Shirtcliff, CEO of Advantage Dental in Redmond, Oregon; “The Restore and Repair Paradigm Has Failed.”8,9
An elite panel of experts writing in Academic Pediatrics, September 2009, put it this way.
Strategies to overcome this chasm between science and practice will require resources and intense collaborations across many fields, not only medicine and dentistry but also in psychology, social work, nutrition, speech/language and occupational therapy.11
This was reiterated by Dr. Mark Crabtree, chair of the American Dental Association Council on Access, Prevention and Inter-professional Relations, who stated the following in the March 1, 2010 ADA News.
“We have some gaps in current knowledge to address”12
Below is an excerpt from the American Dental Association sponsored 2010 Symposium on ECC (early childhood caries) in Native American and Alaska Native Children:
Barriers to ECC control in AI/AN children . Author: Dee Robertson, MD, MPH
“Collectively we have made little if any progress over the last three decades in controlling rampant caries in the primary dentition of AI/AN children. I believe the primary barrier to progress has been, and continues to be, attitudes that are based in perception rather than fact:
• Barriers to ECC Control: Myth #1: We already know what needs to be done to control ECC among AI/AN children—we just need to do a better job with the products and strategies we currently have.
• Barriers to ECC Control: Myth #2: If there are enough dentists, we can resolve this problem.
• Barriers to ECC Control: Myth #3: We can’t control ECC until we eliminate poverty.
• Barriers to ECC Control: Myth #4: We can’t do anything to control ECC because of the parents won’t change their behavior.
• Barriers to ECC Control: Myth 5: If the mom said she followed our recommendations and her child still got ECC, the mom was probably lying.
• Barriers to ECC Control: Myth 6: ECC is self-limiting disease of the primary dentition.
• Barriers to ECC Control: Myth #7: Indian parents don’t care.
Leaving the world of mythology and coming back to the world of reality, we have eliminated polio, measles, mumps, rubella, whooping cough, Hib meningitis among AI/AN children. We did this by a combination of technology and public health infrastructure we have the public health infrastructure to control ECC, but we don’t have the technology. The reason we don’t have the technology is that unlike the other infectious diseases referenced above, rampant caries in the primary dentition is not an equal opportunity disease; it usually affects only the most disadvantaged children.“13
Where has the old paradigm failed? First, it has failed by over-emphasizing the social determinants of dental disease and not putting enough attention toward properly understanding the biological aspects. Second, active infections in teeth are treated by placing restorations, which is an engineering solution, while overlooking the basic microbiology of caries (the infection that leads to tooth cavities). This situation may be characterized as symptomatic intervention rather than definitive therapy.
Something is changing! The epidemiology of caries is changing! Many experts are introducing the acronym NCD for non-communicable disease to describe caries.14 Caries is a classic transmissible bacterial infection.15 Where is our antimicrobial disinfection agent or antibiotic that is effective against a pathogenic oral biofilm? Two systematic reviews recently produced by the American Dental Association council on scientific affairs address this topic. The reviews were on both fluoride containing and non-fluoride containing caries preventive agents.16,17 Surprisingly both of these papers omitted any mention of the use of the potent antimicrobial agent silver nitrate, which was widely used early in the 20th century, to treat caries. The recent paper by Bagramian, et. al.; “The Global Increase In Dental Caries, A Pending Public Health Crisis”,18 brings attention to the magnitude of this growing issue worldwide. A public health physician, Dr. Karen Sokal-Gutierrez, has documented the high prevalence of early childhood caries in the developing world, with characteristic malnutrition and mouth pain. This set of problems is preventing tens of millions of children from functioning in school and having normal social lives due to decaying teeth, destroyed smiles, pain, and chronic medical conditions.19 With a well-entrenched and failed belief system in place that says we know both the cause of caries and the way to eradicate it, we now find ourselves directly in the middle of what Kuhn has labeled “a crisis.” Such events foster emergence of competing paradigms and the opportunity to retool. 20
In his historic paper, Modern Management Of Dental Caries: The Cutting Edge Is Not The Dental Bur, Dr. Max Anderson challenges our expectations about traditional solutions to dental problems. “Treating the disease and not the symptoms is the change in managing caries. As researchers supply the tools, dentists can apply more efficient and realistic methods for better patient care”. 21
In the course of conducting normal science, it is inevitable that occasionally an anomaly pops up. Repeated attempts to suppress the anomaly elevate it to the status of a competing paradigm. There then proceeds a struggle between the ideologies of both worldviews, which are often championed by highly skilled scientists in both camps. Kuhn compared the process closely with Darwin’s evolution by natural selection. The best-fit paradigms with their associated observations, hypothesis, and theories duel it out until the most elegant and accurate system of observation and thought prevails. Notice that there is no inherent movement toward some ultimate truth, but a movement away from ideas that over time prove to be less satisfactory in describing the world and making way for new ones. What is the paradigm being taught today? Brushing and flossing prevents tooth decay for everyone. Going to your dentist twice a year for checkups, dental cleanings and fluoride is recommended for everyone. If the patient gets a cavity, it must be because the patient failed in one or more of these behaviors, which is little better than an ad hoc assumption. The patient gets blamed for the non-optimal outcome. The dentist injects the patient with local anesthesia, drills a hole in the tooth and places a filling. Shortly thereafter the patient gets a bill. This happens millions of times a day in dental offices all across America. Is there any chance that these practices are evidence based and that they are capable of controlling and preventing disease? Do dentists follow consistent protocols in the diagnosis of dental pathology and the development of restorative treatment plans? 22,23 No! People continue to get cavities!
When a healthy young child presents to the dentist’s office with multiple teeth needing treatment, in-office conscious sedation or general anesthesia in the hospital is routinely considered. Our current understanding of the risks of these kinds of sedations suggests that they should only be considered when no other options exist. A developing body of evidence is beginning to suggest that young developing brains are damaged by the toxic effects of general anesthetics,24 and the risk for respiratory depression and hypoxia are great with conscious sedation25. It is common practice for a dentist to act as both the surgeon and anesthesiologist during office based-sedation. This challenging work environment is ripe for catastrophe, due to the distractions involved and the limited time to intervene if a respiratory adverse event occurs in a child during treatment. How often is a comprehensive discussion held with patients and parents about the risks versus the perceived benefits to the patient, of one or more treatment options, versus no treatment at all? If dentistry is to be considered a healing profession, at the bare minimum, we owe our patients the right to full informed consent. Occasionally a new paradigm is born from the long forgotten concepts articulated in a previous paradigm that everyone thought was dead. Perhaps dentistry is in the middle of such a “paradigm shift” now. As an example of this process, I now have many little children with big smiles visiting my dental office, because they didn’t need to get a shot in order to have their cavities fixed. They only care about the pain, not necessarily the philosophies of Thomas Kuhn. A very modest examination of the dental literature since the founding of the first dental school quickly reveals the concept of treating tooth decay safely and effectively with silver nitrate. The father of modern dental practice, Dr. G.V. Black, described this process in detail in his magnum opus, The Pathologies Of The Hard Tissues Of The Teeth, published in 1908.26 Dr. Percy Howe, the American Dental Association President (1928-29) and the first research director of the Forsyth Institute, which today is the leading dental research facility in the world, used silver nitrate to arrest caries so routinely between 1917 and 1950, that it became commonly known as Howe’s Solution.27, 28 In an important paper published in 2008 and titled “A New Paradigm For Operative Dentistry,” Dr. Graham Mount posits that the operative dental paradigm from the era of G. V. Black should be set aside.
“It is suggested that it is now appropriate that the paradigm as proposed by GV Black be consigned to history and the profession should accept and apply the knowledge currently offered by science on the subject of cariology and treatment of the caries lesion.”29
Perhaps Mount overlooked the insightful suggestion by G. V. Black to treat tooth decay with medicine one hundred years earlier.
During the past eight years, this author has advocated using silver nitrate to arrest caries in combination with the re-mineralization of the lesion with fluoride varnish. This method has been labeled ”The Medical Management of Caries with silver nitrate” or MMC. 30
This technique may be considered a new paradigm in the clinical treatment of tooth decay. It borrows one ingredient, silver nitrate31, central to a dental paradigm from over 100 years ago, and combines it with the a more recent product, fluoride varnish. These two products are used in a sequential manner. The protocol is safe, simple, effective and inexpensive. Longitudinal data suggests that caries remain arrested for many years and treated individuals get fewer new cavities going forward.30 Let us explore for a moment the competing structure of the previous and then the emerging paradigms.
Current Paradigm of Dental Care:
Also known as restore and repair paradigm mentioned previously. This philosophy involves removing the diseased tissue – dentin - caused by pathogenic bacteria living in an oral biofilm and replacing it with a restorative material or filling. This can be a never-ending process, as people who receive tooth fillings for treatment of cavities often get new cavities in the future. No one has ever been cured of caries in this manner. In addition, there is a strong bio-behavioral component where the individual is expected to control the physiology of their own oral biofilm through oral hygiene practices and dietary choices.32 This paradigm focuses on the patient and the provider instead of paying attention to the pathogenic biofilm.
The Transitioning Paradigm
A transition paradigm has been in development for more than 8 years. It is called CAMBRA, an acronym for Caries Management By Risk Assessment. The term was coined by Dr. Doug Young at University of the Pacific School of Dentistry and Dr. John Featherstone, who is the dean of the University of California at San Francisco School of Dentistry. CAMBRA moves beyond the “restore and repair” paradigm to encompass risk factors for disease as a way of early identification of susceptible individuals, and the development of treatment plans based on individual needs.40 Most experts see CAMBRA as a major advance in understanding caries and the complex dynamics that lead to disease. However, the knowledge gap around the oral biofilm inhabitants and their enormously complex interactions with each other and the host, remain, a major opportunity for future investigation. 41
New Paradigm of Oral Health:
The new paradigm for treating caries is based on using medicine rather than surgery and mechanical restoration via the medical management of caries (MMC) .33
It is not the patient but rather the pathogenic bacteria living in the oral biofilm that causes the dental disease called caries. Dietary sugars play an important role.35 Yet, less than 50% of the more than 800 species of bacteria identified to date have ever been cultured 36. We know virtually nothing of their physiological contribution to the biofilm metabolism or how that dynamic process impacts the ecology of the mouth and emergence of disease. 37,38,39
Adoption of this new MMC paradigm is emerging. Dr. Moffett Burgess, the Dental Director of the King County Health Department in Seattle Washington, has successfully been using MMC to manage dental disease in her high-risk patients.42 Advantage Dental is a large Oregon Medicaid organization serving 300,00 citizens. The MMC protocol has been implemented throughout their entire provider network. They are now beginning to see population-based outcomes such as reduced hospital dental cases.43 According to Dr. Mike Shirtcliff, CEO Advantage Dental. “In its company clinics it [MMC] has reduced referrals by ov er 50%.”
Nevertheless, there has been a large increase in the number of individuals who seek care for acute dental problems in the hospital emergency department.44 This is the most expensive and the least effective setting to receive definitive dental treatment. The majority of these patients receive antibiotics, pain medications, and a referral to a dentist for definitive care. The antibiotic merely buys some time. The narcotics dull the pain for a few days, or end up on the streets for resale. Currently, few dental offices are accepting patients with public assistance dental insurance such as Medicaid.34 Inevitably, the problem returns. The reasons for this are multiple. One of the central problems is the large population of individuals in America who are uninsured for dental services and do not have the financial resources to pay for traditional restorative care in a private dental practice. Driven by the exquisite pain often associated with a dental infection, they seek palliative care in hospital emergency rooms.44 In the case where a tooth has become abscessed, it needs to be removed or receive a complex and expensive treatment of the nerve of the tooth commonly referred to as a root canal therapy. For the same reasons that drive people with no dental insurance with emergent dental problems to local hospital emergency rooms, little recourse is found in private practice dental offices. Patients are trapped in a vicious cycle of pain and infection followed by ineffective palliative care, which provides only temporary relief. Children, who experience both the pain of untreated dental disease and the trauma of invasive dental procedures, often become adult dental phobics who remain outside of an effective oral health care system. The lack of dental providers who are in a position to provide definitive care for this population is leading to programs that introduce new midlevel providers such as Dental Therapists and Expanded Function Dental Hygienists to fill the provider gap45. Even without the inevitable political turf wars that lay ahead, it will be decades before the oral health workforce is rebuilt for the America we inhabit today. If the “restore and repair” paradigm has failed, giving the tools of this paradigm to more provider groups is irrational.
A new emerging paradigm will enable medical personnel to treat dental caries in the same manner as any other bacterial infection. That is, to treat the infection known as tooth decay with medicine. That medicine is a combination therapy of silver nitrate followed by fluoride varnish. The first serves to kill the bacteria in a cavity, and the second to begin to re-mineralize the lost tooth structure. This procedure is simple, safe and effective. Many medical professionals, including physicians, nurses, physician assistants etc., could provide it. By stopping the tooth infections prior to reaching the point of severe pain, many trips to the hospital emergency department could be avoided. Of course some teeth damaged by tooth decay may eventually require a restoration of some kind. This opportunity is more likely to occur once the active infection has been stopped, severe pain is avoided and time is gained to prepare the necessary resources associated with restorative dental care. The economic savings to our healthcare system from this early intervention would be substantial.
The almost revolution of 1947
An excellent example of competing paradigms in a changing world is represented by an important dental conference that was held at the University of Michigan in 1947. The title of the event was “Dental Caries Mechanism and Present Control Technics,” and was sponsored by the W.K. Kellogg Foundation. Dr. Kenneth Easlick, the grandfather of dental public health, organized the presentations, and the proceedings were published in the Journal of Dental Research.46 The most prominent dental experts in America at the time were in attendance: Dr. Basil Bibby, director of the Eastman Dental Center; Dr. John Knutson, Chief of the dental section US Public Health Service; Dr. Robert Stephan, National Institute of Health; Dr. Helmut Zander, Tufts College of Dentistry; Dr. Phillip Jay, Professor of dentistry, University of Michigan; and Dr. Russell Bunting. Professor of Dentistry, University of Michigan. One of the central themes of this conference was focused on the pros and cons of one historical paradigm: silver nitrate to control caries,” versus an emerging paradigm “sodium fluoride.” A robust dialogue between the participants was transcribed verbatim and even today provides us with an insightful view into the process for examining scientific evidence and attempting to reach consensus
Dr. Phillip Jay: “The role of silver nitrate in caries control has been discussed for years. Among us here, Olin Hoffman of Iowa thinks it works and John Knutson of Washington thinks it doesn’t. Dr. Zander, whose job it was to render a verdict, ‘isn’t saying’ He is of the opinion that silver nitrate could be given a fairer trial.”
Dr. Hulmut Zander: “There are many public health workers here; perhaps one of them will go home with the possibilities of silver nitrate in mind as well as the actualities of sodium fluoride.”
DR. Russell Bunting: “I can see so much substantial progress as has been reported at this conference and the zeal and true scientific approach with which the investigators have been attacking the problem, I have real hope that even in my lifetime this great question may be solved and that the boon of freedom from dental caries may be vouchsafed to mankind through dental research. May I wish you Godspeed.”
Soon after this conference, Dr. Percy Howe, an ardent advocate of silver nitrate, passed away. After his death, it seemed that Howe’s solution also passed away. The opportunity to implement the effects of silver nitrate and sodium fluoride in a sequential combination therapy disappeared. Water fluoridation became the new paradigm for caries control.47 Soon fluoride even appeared in toothpaste. The success of the fluoride paradigm cannot be overstated. By the 1970’s, caries rates were plummeting in the United States. There were rumors of a new vaccine for tooth decay that would eliminate treating tooth decay with a drill. 48 As yet, there is no vaccine and none is likely in the near future. Sixty-seven years after the Ann Arbor conference, dental decay is endemic and epidemic. How different might things be today if out of that conference the possibility of using silver nitrate and sodium fluoride together in a combination therapy had emerged instead of merely comparing the two?
I propose that we do just that.
Dr. Steve Duffin has a private dental practice and is the owner of Shoreview Dental, LLC. Its focus is prevention and evidence-based clinical services, delivered primarily to patients covered for dental care services under the Oregon Health Plan. A principle component of the practice is to investigate the multifactorial contributing factors of caries and periodontal disease. In March, 2006, he retired as president, CEO and dental director of Capitol Dental Care after 12 years of service.
With a combined statewide membership of over 300,000, CDC is under contract with the state of Oregon to provide dental care services for the Oregon Health Plan. He began working with the organization in 1994 as the clinical director and grew the organization from 2 clinics to 19 clinics statewide, and 2006 revenue run rate was in excess of $30 million (2005). He was also the Regional Clinical Director for InterDent, a 500 dentist group practice with over 130 offices in eight states, and developed and co-delivered a comprehensive leadership training program for clinical and administrative leaders working throughout the InterDent organization.
References
1. Kuhn T . The Structure of Scientific Revolutions, University of Chicago Press. 1962
2. Staedter T. Medicine and Physiology Nobel Awarded to H. pylori Researchers. Scientific American October 2005
- Action for Dental Health, American Dental Association 2013. http://www.ada.org/~/media/ADA/Public%20Programs/Files/bringing-disease-prevention-to-communities_adh.ashx
- Sanders B. Dental Crisis in America. A Report from Bernard Sanders, Subcommittee on Primary Health and /aging, US Senate Committee on Health, Education, Labor and Pensions. February 29, 2012 http://www.sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf
- Mission of Mercy
- Satcher D. Oral Health In America, A Report Of The Surgeon General. http://silk.nih.gov/public/[email protected]
- Otto M. For Want Of A Dentist. Washington Post Wednesday, February 28, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/02/27/AR2007022702116.html
- Shirtcliff M. A New Paradigm In Dentistry, Membership Matters, Oregon Dental Association, March 2010
- Shirtcliff M. Dental Mythology. Membership Matters, Oregon Dental Association April 2008
- Disparities In Oral Health. Centers For Disease Control. http://www.cdc.gov/OralHealth/oral_health_disparities/
- Academic Pediatrics: Special Issue on Children’s Oral Health – December 8, 2009 http://www.elsevier.com/about/press-releases/research-and-journals/special-issue-of-academic-pediatrics-reports-on-state-of-pediatric-oral-health-in-us#sthash.6HM3cv0a.dpuf
- Crabtree M. Response to letter to the editor, A different Disease? ADA News March 2010
- Robertson D. ADA 2010 Symposium On Early Childhood Caries In American Indian and Alaska Native Children http://www.ada.org/~/media/ADA/Education%20and%20Careers/Files/2010_ecc_symposium_report.ashx
- Frazo P. Epidemiology of dental caries: when structure and context matter* Braz. oral res. vol.26 no.spe1 São Paulo 2012 http://www.scielo.br/scielo.php?pid=S1806-83242012000700016&script=sci_arttext
- Caufield P. Dental caries: an infectious and transmissible disease. Compend Contin Educ Dent. 2005 May;26(5 Suppl 1):10-6.
- Rethman MP. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011 Sep;142(9):1065-1071.
- Wyant R, et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. JADA November 2013 144(11): 1279-1291
- Bagramian RA. The global increase in dental caries. A pending public health crisis. Am J Dent. 2009 Feb;22(1):3-8.
- Sokal-Gutierrez K. Early Childhood Cries Epidemic presentation at TEDxBERKELEY. May 13, 2013 https://www.youtube.com/watch?v=YnsTvfNXPk4
- Pajares F. The Structure Of Scientific Revolutions a Synopsis. http://www.uky.edu/~eushe2/Pajares/Kuhn.html
- Anderson M. Modern Management of Dental Caries: The Cutting Edge Is Not The Dental Bur. J. Am. Dent. Assoc. 1993 June;124(6);36-44
22. Goszkowski R. Dentistry Lacks Consistency In Restoration Decision Making. May 7, 2012 Dr. Bicuspid.com http://www.nationaldentalpbrn.org/pdf/Dental%20News,%20Dental%20education,%20Dental%20Social%20networking.pdf
23. Greenhalgh T. Evidence based medicine: a movement in crisis? BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3725 (Published 13 June 2014)
Cite this as: BMJ 2014;348:g3725. http://linkis.com/www.bmj.com/content/ygyyG
24. S Velayudha Reddy. Effect of general anesthetics on the developing brain. J Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1): 6–10.
25. Lee HH1, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6. doi: 10.1111/pan.12210. Epub 2013 Jun 14.
26. Black G V . The Pathologies Of The hard Tissues Of The Teeth. 1908. Pp 235-257
27. Silver diamine fluoride: a caries "silver-fluoride bullet". J Dent Res. 2009 Feb;88(2):116-25. Rosenblatt A, Stamford TC, Niederman R.
28. Peng JJ1, Botelho MG, Matinlinna JP. Silver compounds used in dentistry for caries management: a review. J Dent. 2012 Jul;40(7):531-41. doi: 10.1016/j.jdent.2012.03.009. Epub 2012 Apr 3.
29. Graham J Mount. A new paradigm for operative dentistry. J Conserv Dent. 2008 Jan-Mar; 11(1): 3–10.
30. Duffin S. The Medical Management of Caries Introduction. Journal of the California Dental Association November 2012
31. Gottlieb B. Dental Caries It’s etiology, Pathology, Clinical Aspects and Prophylaxis Lea & Febiger 1947 p.p. 222-235
32. Axelsson P. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after 6 years. J Clin Periodontol. 1981 Jun;8(3):239-48.
33. Llena P., Forner Navarro L. Evidence concerning the medical management of caries. Med Oral Patol Oral Cir Bucal. 2008 May 1;13(5):E325-30.
34 Aved B. Without Change it is the same old drill, Improving access for DentiCal children through dentist participation. Barbara Aved and Associates report October 1012
35. Yabao RN1, Duante CA, Velandria FV, Lucas M, Kassu A, Nakamori M, Yamamoto S. Prevalence of dental caries and sugar consumption among 6-12-y-old schoolchildren in La Trinidad, Benguet, Philippines. Eur J Clin Nutr. 2005 Dec;59(12):1429-38.
35. Marsh P, BMC Oral Health 2006, 6(Suppl 1):S14 Dental plaque as a biofilm and a microbial community – implications for health and disease
36. Wade W. Unculturable bacteria—the uncharacterized organisms that cause oral infections. J R Soc Med. Feb 2002; 95(2): 81–83.
37. Seymour, G., Cullinan, M., Heng, N.. “Oral Biology: Molecular Techniques and Applications.” Chapter 5, p56
38. Costerton JW, The Biofilm Primer, Chapter 4 page 144-145 Springer-Verlag Berlin 2007
39. Costerton W. How Bacteria Stick. Scientific American. Jan. 1978
40. Young D. Caries Management By Risk Assessment . Journal Of The California Dental Association October 2007
41. Siqueria J. As-yet-uncultivated oral bacteria:
breadth and association with oral and
extra-oral diseases Journal of Oral Microbiology 2013, 5: 21077 - http://dx.doi.org/10.3402/jom.v5i0.21077
42. Duffin S., Burgess M. The Medical Management of Caries. NNOHA national meeting Denver, November 2013. Burgess M, Duffin S, The Medical Management of Caries, NNOHA conference November12 2013, Denver Colorado, http://www.nnoha.org/events/npohc/presentation-archives/2013-2/
43. Shirtcliff M. Testimony given 3-11-2013 at the Oregon state legislature. https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/7702
44. Allareddy V1, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization.
J Am Dent Assoc. 2014 Apr;145(4):331-7. doi: 10.14219/jada.2014.7.
45. Nash, D. A. et al. A Review of the Global Literature on Dental Therapists. Community Dentistry and Oral Epidemiology. 2014 February; 42 (1:1-10)
46. Dental Caries Mechanism and Present Control Technics, Symposium at Ann Arbor University of Michigan School of Dentistry Kenneth Easlick 1947 CV Mosby
47. Centers For Disease Control. Community Water Fluoridation. http://www.cdc.gov/fluoridation/
48. Taubman MA1, Nash DA. The scientific and public-health imperative for a vaccine
