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Detection and
Assessment
of Dental Caries

A Clinical Guide
Andrea Ferreira Zandona
Christopher Longbottom
Editors

123
Detection and Assessment of Dental Caries
Andrea Ferreira Zandona
Christopher Longbottom
Editors

Detection and Assessment

of Dental Caries
A Clinical Guide
Editors
Andrea Ferreira Zandona Christopher Longbottom
Department of Comprehensive Care King’s College London Dental Institute
Tufts University School of Dental Medicine London, UK
Boston, MA
USA

ISBN 978-3-030-16965-7    ISBN 978-3-030-16967-1 (eBook)

https://doi.org/10.1007/978-3-030-16967-1

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword I

A Clinical Guide to Dental Caries Detection and Assessment has been constructed
carefully by two authors who are deeply skilled in the art and science of caries
detection and assessment and who have worked for years to build the often-fragile
link bridging best evidence to best clinical practice. Together, they have assembled
a formidable array of international talent to provide a much needed, comprehensive,
accessible, well-illustrated, and authoritative guide for clinicians.
The Guide’s structure provides a logical flow from the essential background
required to understand the preparation for, conduct of, and limitations associated
with clinical visual assessment of caries. This is followed by descriptions of a range
of available visual detection criteria which are distinguished by some important dif-
ferences. Intriguingly, many criteria systems also share very substantial commonali-
ties. Detection during caries excavation is also addressed.
There follows a comprehensive series of chapters addressing additional detection
methods as aid to caries lesion diagnosis. These range through radiographic film
based and digital methods in both 2D and 3D, the use of white and near-infrared
light, followed by fluorescence, bioluminescence, and photothermal radiometry.
After considerations of what’s in the pipeline (which often remains a frustratingly
long one), important chapters cover making treatment decisions after caries detec-
tion and an essential appendix on the thorny but important topic of definitions.
The authors and contributors are to be congratulated on producing a focused and
very useful Clinical Guide. I share the hope of the Editors that “this book will give
the reader additional confidence to manage dental caries in the early stages with
non-surgical approaches by using more precise and objective methods of assess-
ment” and trust that this will help clinicians provide better care for their patients.

Nigel
London, UK Pitts

v
Foreword II

Following the characterization of the initial phases of the dental caries process and
the repeated demonstration that subsurface demineralization could be reversed by
remineralization, many dental scientists focused their research on the identification
and development of strategies and technologies for the very early detection of the
caries process. For the past 40 years, numerous international dental scientists have
meticulously and successfully investigated a wide variety of clinical methodologies
and instrumental technologies for early caries detection resulting in a remarkable
number of scientific publications in the dental literature.
A Clinical Guide to Dental Caries Detection and Assessment has been developed
by two of these scientists who have been intimately involved in this research for
more than 20 years and they have enlisted additional renowned scientists with simi-
lar experiences. The knowledge and experiences of this team of investigators has
resulted in the compilation of this unique state-of-the-art review of research in this
area. In developing this Guide, the authors have carefully included both clinical and
instrumental technologies noting both the technical abilities of the strategies and
their limitations. This material will be quite useful for the clinical control and man-
agement of dental caries by dental practitioners using non-surgical procedures.
In addition, the information presented in the Guide will be useful for the future
development of even more effective procedures for the prevention of dental caries.
Due to time and cost considerations, the development and clinical validation of
more effective caries-preventive methods has become virtually impossible using
historical procedures for clinical caries trials accepted by governmental agencies.
However, these newer technologies will permit the assessment of significant caries-­
preventive benefits in much shorter time periods in much smaller cohorts of panel-
ists. Without doubt this material will serve as a reference text for current as well as
future cariologists and the authors are collectively acknowledged for their efforts.

George
Indianapolis, IN, USA K. Stookey

vii
Contents

1 Introduction������������������������������������������������������������������������������������������������   1
Andrea Ferreira Zandona and Christopher Longbottom

Part I Background
2 Preparing Teeth for a Clinical Examination��������������������������������������������   7
Christopher Longbottom and Andrea Ferreira Zandona
3 The Visual Presentation of Dental Caries������������������������������������������������ 17
Andrea Cortes, Stefania Martignon, and Gail Douglas
4 The Concept of Hidden Caries������������������������������������������������������������������ 27
Christopher Deery

Part II Visual Detection Criteria

5 Nyvad Criteria for Assessment of Caries Lesion Activity
and Severity������������������������������������������������������������������������������������������������ 35
Vita Machiulskiene
6 Visual Detection Criteria Using the International Caries
Detection and Assessment System (ICDAS)�������������������������������������������� 45
Kim R. Ekstrand and Mariana M. M. B. Braga
7 The American Dental Association Caries Classification
System (ADA CCS)������������������������������������������������������������������������������������ 57
Gregory Zeller, Douglas A. Young, and Brian Novy
8 The Caries Assessment Spectrum and Treatment (CAST)
Instrument�������������������������������������������������������������������������������������������������� 69
Soraya Leal, Ana Paula Dias Ribeiro, and Ana Luiza de Souza Hilgert
9 Caries Detection Dyes�������������������������������������������������������������������������������� 83
Marisa Maltz, Rodrigo Alex Arthur, and Clarissa Fatturi-Parolo
10 Fluorescence-Aided Caries Excavation: FACE �������������������������������������� 99
Áine M. Lennon and Wolfgang Buchalla

ix
x Contents

Part III Additional Detection Methods as Aid to

Caries Lesion Diagnosis
11 Conventional Bitewing Radiographs�������������������������������������������������������� 109
Falk Schwendicke and Gerd Göstemeyer
12 Digital Bitewing Radiographs������������������������������������������������������������������ 119
Gerd Göstemeyer and Falk Schwendicke
13 Caries Detection with Dental Cone Beam
Computed Tomography���������������������������������������������������������������������������� 127
Jeffery B. Price
14 Fibre-Optic Transillumination: FOTI������������������������������������������������������ 139
Richard Hogan, Iain A. Pretty, and Roger P. Ellwood
15 Near-Infrared Light Transillumination �������������������������������������������������� 151
Jan Kühnisch
16 Quantitative Light-Induced Fluorescence ���������������������������������������������� 159
Baek-II Kim
17 DIAGNOdent���������������������������������������������������������������������������������������������� 171
Klaus W. Neuhaus and Adrian Lussi
18 Photothermal Radiometry and Modulated Luminescence:
The Canary System������������������������������������������������������������������������������������ 177
Bennett T. Amaechi

Part IV Caries Diagnostic Methods in the Making

19 Near-Infrared Reflectance Imaging of Caries Lesions �������������������������� 189
Daniel Fried
20 Optical Coherence Tomography for Imaging Dental Caries ���������������� 199
Daniel Fried
21 Use of Ultrasound for Caries Detection �������������������������������������������������� 209
Funda Çalışkan Yanıkoğlu and Dilek Tağtekin
22 Bioluminescence Technology to Aid Lesion Activity Assessment���������� 217
Christopher Longbottom and Bruce Vernon

Part V Treatment Decision After Detection

23 Clinical Decision-Making in Caries Management:
Role of Caries Detection and Diagnosis �������������������������������������������������� 227
Margherita Fontana and Marie-Charlotte D. N. J. M. Huysmans
24 Integrating Caries Detection Devices into Clinical Practice������������������ 235
Stephen Abrahams
Contents xi

Part VI Conclusion
25 Concluding Remarks �������������������������������������������������������������������������������� 243
Christopher Longbottom and Andrea Ferreira Zandona

Part VII Appendices
26 Definitions �������������������������������������������������������������������������������������������������� 247
Marie-Charlotte D. N. J. M. Huysmans
Introduction
1
Andrea Ferreira Zandona and Christopher Longbottom

Dental caries detection is the cornerstone of every general dental practice. However,
limited time is spent in the dental schools’ curriculum; teaching dental caries
detection and calibration of faculty is regarded as a great challenge [1–5]. Extensive
lesions are usually easy to detect due to obvious clinical or radiological signs.
Lesions in the early stages, however, are challenging. The visual signs can be sub-
tle, and there can be many confounding effects. These lesions in the early stages,
with no cavitation and no radiographic sign of demineralization, are considered
questionable caries. A recent study with 82 practitioners and 6910 patients indi-
cated that up to 34% of patients had questionable occlusal caries [6]. Clinical expe-
rience does not seem to reduce the number of surfaces deemed with questionable
caries [6–8].
Dental caries remains a prevalent disease affecting millions of people worldwide
[9]. Given the widespread use of fluoride, the burden of disease has decreased [10]
but more than 90% of all United States dentate adults and more than two thirds of
all children still experience dental caries [11]. With more adults retaining teeth later
in life, we can expect an increase in surfaces with questionable caries. Many of
these questionable caries surfaces will not progress toward cavitation [12]; there-
fore, it is paramount to both determine if there is a lesion and to assess caries activ-
ity. A paradigm shift pushing the management of dental caries from an operative/
surgical approach to a nonsurgical approach in the last decades has led to a rise in
interest on more detailed and objective caries detection methods [13].

A. Ferreira Zandona (*)

Department of Comprehensive Care, Tufts University School of Dental Medicine,
Boston, MA, USA
e-mail: [email protected]
C. Longbottom
King’s College London Dental Institute, London, UK
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

A. Ferreira Zandona, C. Longbottom (eds.), Detection and Assessment of Dental
Caries, https://doi.org/10.1007/978-3-030-16967-1_1
2 A. Ferreira Zandona and C. Longbottom

Dental explorers and air drying are the methods most commonly used for detec-
tion of caries (91%) with magnification and radiographs used on only half the
lesions [6]. Several criteria have been developed based on visual examination, aim-
ing to decrease subjectivity and improve the ability to monitor lesions (see Chaps.
3, 5–8). However, there is a myriad of detection aids available which can help den-
tists to more confidently monitor early initial lesions (see Chaps. 11–21). Once a
lesion is detected and surgical intervention is proposed, distinguishing the different
layers of carious dentin once a tooth is excavated prior to a restorative procedure
(see Chaps. 9 and 10) is another challenging area for dentists who aim to preserve
tooth structure.
For the practicing clinician, it is difficult to keep up with all the new methods and
devices available, determine when and where to use them, and compare across all
methods. This book aims to assist students and dentists on a better understanding of
the several methods and devices available for caries detection. They are grouped
based on the modality used (visual, x-rays, transillumination, fluorescence, and oth-
ers). The chapters follow a standard template which should facilitate comparison
among the methods. The chapters’ authors are experts in their fields and have pro-
vided the latest evidence-based information for each of the methods. This book is
not an all-­encompassing review of all devices available. We do not discuss caries
risk assessment, beyond discussing the role of caries detection in caries risk assess-
ment: identifying the presence of caries lesions and assessing caries lesions activity
are key procedures for an accurate diagnosis and prognosis. We also do not discuss
caries management strategies beyond discussing treatment decision-making (see
Chap. 22). We do discuss extensively the characteristics of tooth surfaces when they
are affected by dental caries and changes in enamel and dentin properties as surfaces
demineralize and remineralize. Many of the methods described rely on these
changes to distinguish between sound surfaces and surfaces affected by dental car-
ies. Some redundancy related to enamel/dentin properties and characteristics was
allowed across the chapters to facilitate the understanding of the method in discus-
sion without requiring the reader to go back to previous chapters.
Although there are clear distinctions among the methods discussed, there are
also some clear messages across all chapters: teeth must be free of plaque prior to
being examined to provide optimal conditions for the method being used; early car-
ies detection methods can support clinical decision-making and allow for monitor-
ing outcomes on nonsurgical interventions; methods should support visual
examination and not be used in place of visual examination; users should be famil-
iar with the limitations of each method and use sound judgment, especially when
considering surgical intervention. Since many of the methods discussed in this book
aim to improve detection of early lesions, we cannot overemphasize that this
improvement in sensitivity is valuable for monitoring lesion behavior, and it is not
a license to increase surgical intervention.
We hope this book will give the reader additional confidence to manage dental
caries in the early stages with nonsurgical approaches by using more precise and
objective methods of assessment.
1 Introduction 3

References
1. Fontana M, Guzmán-Armstrong S, Schenkel AB, Allen KL, Featherstone J, Goolsby
S, Kanjirath P, Kolker J, Martignon S, Pitts N, Schulte A, Slayton RL, Young D, Wolff
M. Development of a core curriculum framework in cariology for U.S. dental schools. J Dent
Educ. 2016;80(6):705–20.
2. Martignon S, Gomez J, Tellez M, Ruiz JA, Marin LM, Rangel MC. Current cariology
education in dental schools in Spanish-speaking Latin American countries. J Dent Educ.
2013;77(10):1330–7.
3. Raphael SL, Foster Page LA, Hopcraft MS, Dennison PJ, Widmer RP, Wendell Evans R. A
survey of cariology teaching in Australia and New Zealand. BMC Med Educ. 2018;18:75.
https://doi.org/10.1186/s12909-018-1176-4.
4. Schulte AG, Buchalla W, Huysmans MC, Amaechi BT, Sampaio F, Vougiouklakis G, Pitts
NB. A survey on education in cariology for undergraduate dental students in Europe. Eur J
Dent Educ. 2011;15(Suppl 1):3–8.
5. Tikhonova S, Girard F, Fontana M. Cariology education in Canadian dental schools: where
are we? Where do we need to go? J Dent Educ. 2018;82(1):39–46. https://doi.org/10.21815/
JDE.018.006.
6. Makhija SK, Gilbert GH, Funkhouser E, et al. Characteristics, detection methods, and treat-
ment of questionable occlusal carious lesions: findings from the National Dental Practice-
Based Research Network. Caries Res. 2014;48(3):200–7. https://doi.org/10.1159/000354841.
7. Ferreira Zandona AG, Al-Shiha S, Eggertsson H. Student versus faculty performance using
new visual criteria for the detection of caries on occlusal surfaces: an in vitro examination with
histological validation. J Oper Dent. 2009;34(5):598–604. PMID: 19830976.
8. Lara JS, Braga MM, Shitsuka C, Wen CL, Haddad AE. Dental students’ and lecturers’ per-
ception of the degree of difficulty of caries detection associated learning topics in Brazil. J
Educ Eval Health Prof. 2015;12:56. https://doi.org/10.3352/jeehp.2015.12.56. Published 2015
Dec 25.
9. Frencken JE, Sharma P, Stenhouse L, Green D, Laverty D, Dietrich T. Global epidemiol-
ogy of dental caries and severe periodontitis—a comprehensive review. J Clin Periodontol.
2017;44(Suppl 18):S94–S105. https://doi.org/10.1111/jcpe.12677.
10. Pitts NB. Are we ready to move from operative to non-operative/preventive treatment of dental
caries in clinical practice? Caries Res. 2004;38:294–304.
11. Dye BA, Mitnik GL, Iafolla TJ, Vargas CM. Trends in dental caries in children and adoles-
cents according to poverty status in the United States from 1999 through 2004 and from 2011
through 2014. J Am Dent Assoc. 2017;148(8):550–65, e557.
12. Ferreira Zandona AG, Santiago E, Eckert GJ, Katz BP, Pereira de Oliveira S, Capin OR, Mau
M, Zero DT. The natural history of dental caries lesions—a 4 year observational study. J Dent
Res. 2012;91(9):841–6. PMID: 22821238. PMCID: PMC3420396.
13. Ferreira Zandona A, Epure E. Evolution of caries diagnosis. J Multidisc Care Decisions Dent.
2018;4(2):43–6.
 Part I
Background
Preparing Teeth for a Clinical
Examination 2
Christopher Longbottom and Andrea Ferreira Zandona

2.1 Introduction

In this chapter examination condition, including the need for prophylaxis, air
syringe, magnification and tooth separation are discussed. Additionally, susceptibil-
ity of different teeth and surfaces to caries are presented. Caries lesions can occur in
the crowns (enamel), the roots (dentin) of teeth and adjacent to restorations in either/
both of these tissues. The initial pathology of enamel or dentin is defined as primary
caries, the latter being traditionally labelled ‘secondary caries’, although in reality
this ‘secondary’ attack is generally the primary caries process adjacent to a restora-
tion or sealant, hence the new, more appropriate, term CARS (Caries Adjacent to a
Restoration or Sealant). In addition, the term ‘residual caries’ applies to aspects of
caries lesions remaining after operative interventions. The focus initially in this text
will be on the clinical examination in relation to primary caries lesions, with addi-
tional discussion of CARS and ‘residual’ caries.

2.2 Examination Conditions

Before examining teeth for visual signs of caries lesions, they should be: clean, dry
(dried), and well-illuminated.

C. Longbottom (*)
King’s College London Dental Institute, London, UK
e-mail: [email protected]
A. Ferreira Zandona
Department of Comprehensive Care, Tufts University School of Dental Medicine,
Boston, MA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 7

A. Ferreira Zandona, C. Longbottom (eds.), Detection and Assessment of Dental
Caries, https://doi.org/10.1007/978-3-030-16967-1_2
8 C. Longbottom

a b

Fig. 2.1 Cavitated caries lesion before (a) and after (b) plaque removal

2.2.1 Clean

The earliest optical changes of carious changes in enamel (and dentin) are very
subtle and are best visualized if the surface integuments—pellicle and plaque—as
well as any food debris, have been removed from that surface. Caries lesions always
occur under plaque, which is not transparent—a clinician cannot see through
plaque—hence it must be removed prior to the visual examination of the actual
surface of the tooth (Fig. 2.1a, b). This prophylaxis is best carried out using a rotat-
ing brush with a paste (or an air-polisher).
Failing this, the use of a toothbrush by the patient will remove the bulk of the plaque
and the clinician can supplement this by the careful use of a probe—using the long
edge of the probe to remove buccal and lingual surface plaque and a delicate ‘dredging’
technique with the probe tine to remove plaque from pits and fissures. The latter should
be used with no pressure, but with ‘the weight of the wing of a butterfly’, i.e. simply
‘resting’ or ‘balancing’ the probe on the tooth surface and ‘pulling’ it gently along the
fissure pattern with no pressure in the direction of the pulp. Flossing to remove inter-
proximal plaque is essential prior to the examination of the approximal surfaces.

2.2.2 Dry/Dried

Isolating the teeth in a sextant, using cotton rolls and a saliva ejector, as well as
retraction of the cheeks and tongue, prior to detailed examination of each tooth
surface will aid clarity of the field by helping to reduce the risk of contamination by
saliva (Figs. 2.2 and 2.3).
Air-drying of a tooth site will fully enhance the effect of the difference between
the refractive index of enamel (1.6) and that of air (1.0). Normally the enamel pores
are filled with water (refractive index 1.3), hence there is a smaller difference in
refractive index prior to air-drying and the subtle optical changes due to demineral-
ization are less readily distinguished by the clinician’s eye.
However, it is important to try to assess the extent of any mineral changes present—
a lesion which can only be visualized AFTER air-drying has generally produced less
2 Preparing Teeth for a Clinical Examination 9

a b

Fig. 2.2 Sound occlusal surface before (a) and after (b) drying

a b

Fig. 2.3 (a, b) Occlusal surface with a caries lesion before and after drying

demineralization than one which is visible PRIOR to air-drying (since the amount of
back-scattered light must be much greater to overcome the diminished refractive index
difference brought about by the ingress of water into the enamel pores) (Fig. 2.4). In
addition, for some lesions where dentin caries is present, the grey shadowing which
results from such changes is often best visualized when the teeth are wet.
Hence in order to help assess the stage of progress (in terms of depth) of any
lesion present, it is useful to visualize the tooth surface:

• prior to air-drying (i.e. a moistened tooth, not one covered in a thick layer of
saliva)
• and
• then again after air-drying. Studies have indicated that 5 s of air-drying per sur-
face will highlight the optical changes described above. This technique is used
when using the visual ICDAS method—see below for details.
10 C. Longbottom

a b

Fig. 2.4 (a, b) Occlusal surface with a caries lesion before and after drying. Note the white lesion
only visible after drying

2.2.3 Well-Illuminated

The dental operating light can be used optimally by moving/tilting it and/or the
patient’s head to maximally illuminate the teeth in different regions of the mouth
and in the two separate arches. The dental mirror should also be used to best effect
by moving it in the three orthogonal planes, thereby reflecting the operating light on
to the different surfaces of the tooth being examined in order to enhance any optical
changes which have been produced by the caries process. Observing whether shad-
ows within a tooth move or are stationary when a bright light is shone through a
tooth from different angles can inform the operator about the likely source of these
shadows—this is the fundamental process behind the use of transillumination,
which enhances optical effects within a tooth—see below and in the Chap. 14.
Viewing the teeth both directly and in the dental mirror will maximize the visual
information gathered. If the operator also moves his/her head in the three planes,
this will help provide 3D information about specific aspects of tooth morphology,
particularly in relation to fissures, and aid lesion detection. The judicious use of a
mirror when examining adjacent approximal surfaces will allow the operator to
visually access the embrasure region and facilitate identification of caries lesions
around and under approximal contact area/points.

2.3 Where to Look for Caries Lesions

2.3.1 Likely Teeth

During the last 70 years or so, a large amount of epidemiological data on permanent
teeth has been collected worldwide. Analysis of this data has revealed patterns of
susceptibility of teeth and specific surfaces of teeth.
2 Preparing Teeth for a Clinical Examination 11

The pattern of susceptibility in teeth and their surfaces occurs in groups, but by
individual teeth is as follows, in order, decreasing from the highest to the lowest
susceptibility to caries, as a child grows from the age of 5–6 years onwards:

• Lower first molar

• Lower second molar
• Upper first molar
• Upper second molar
• Upper and lower second premolars
• Upper first premolar
• Upper lateral and central incisors
• Lower first premolars
• Upper canine
• Lower incisors
• Lower canine

The overall epidemiological picture is nowadays confounded by the widespread

use of pit and fissure sealants and topical fluorides, which help to prevent caries
lesions, thus modulating the sites at which caries lesions occur. However, this fun-
damental underlying ‘core’ order of susceptibility of the teeth/sites appears to
remain the same, probably due to the general eruption sequence of teeth, as well as
their morphology and position/arrangement in the mouth.
There appears to be a considerable left-right symmetry of occurrence of caries
lesions—hence, if a lesion appears in the occlusal fissure of the lower right first
permanent molar of a patient, there is a high probability that the same site in the
contra-lateral tooth, i.e. the lower left first permanent molar, will succumb or be
highly susceptible to the development of a caries lesion.
From the above information, it is possible to derive general clinical implications in
relation to examinations for caries lesions and the assessment of a patient’s caries risk.
By way of example, if a patient over the age of 15 years has no signs of caries lesions
or restorations in any of the pits and fissures of the molar teeth, it is highly unlikely that
there will be signs of caries lesions in the teeth below these molars on the above list.
An exception to this would be where a patient has had successful pit and fissure seal-
ants placed earlier in life which have prevented the development of lesions at these
sites—if sealants have not also been placed on the premolars and incisor palatal pits of
these patients, these sites should be very carefully monitored for the initial signs of
disease, since the sealants have effectively skewed the caries-­risk pattern in this patient.
By contrast, if a child patient aged 9 years has caries lesions present in the upper
incisors the probability of caries lesions developing in the occlusal pits and fissures of
ALL the as yet unerupted molars and premolars, after they erupt, is extremely high. It
is virtually certain that by the age of 9 this child will have had caries lesions in the pits
and fissures of the first permanent molars, although, as above, this may have been pre-
vented by the timely and efficient placement and maintenance of pit and fissure sealants
on these teeth. However, if the second primary molar is still present, the mesial (approx-
imal) sites on these first permanent molar teeth will be highly susceptible to caries
lesion development and should be examined extremely carefully for signs of disease.
12 C. Longbottom

Generally speaking, most individuals will lie somewhere between the two
extremes of the above examples, but the same ‘rough indications’ apply—for exam-
ple, if there are no signs of caries lesions in the fissures of any of the second premo-
lars, in the absence of fissure sealants on these teeth, the probability is that the
fissures of the first premolars and the upper lateral incisor pits will not be suscepti-
ble to caries lesion development.
These ‘rough indications’ are exactly that—approximate guides to what will
occur—and the clinician must use his/her experience and knowledge of the disease
process generally and in that patient in particular (especially with respect to the
level of caries risk) to decide which teeth and sites are likely to be susceptible to
caries lesion development. There are always exceptions to rules and the clinician
should be ever-conscious of the potentially unexpected.

2.3.2 Likely Sites

As a general guideline, pits and fissures are more susceptible initially to caries
lesion development than approximal sites, which in turn are more susceptible than
free smooth (buccal and lingual/palatal) sites. This stems from tooth morphology
and the relative difficulty (in that sequence order) for the patient in efficiently
removing plaque from each of these sites.
The detailed morphology of occlusal fissure patterns varies enormously but the
frequency of the different types of fissure morphology has been reported by several
authors. In summary, there are effectively four different fissure types, each with
their own prevalence and caries susceptibility. The name (letter) given to each type
of morphology is based on its physical shape, e.g. the I-type is a narrow deep
fissure.
The prevalence figures relate to how often each fissure type occurs when large
numbers of teeth are sectioned and examined under a microscope—the prevalence
does NOT relate to individual teeth but to the frequency across ALL fissure sites,
e.g. teeth surfaces can have all these different fissure types within a single occlusal
surface.
The least caries-susceptible fissure type is the U-type (14%) which is readily
cleansable, thus plaque can be brushed off before it instigates the caries process.
The V-type pattern (39%) is narrower than the U-type at its base so it presents a
slightly more challenging fissure pattern to clean and is therefore more susceptible
to caries. The I-type pattern (46%) is even narrower and because of its length and
narrowness the base of it is virtually impossible to clean with a toothbrush, so is at
considerable risk of developing caries lesions. Finally, the least prevalent (1%)
bottle-­type fissure, whose base is wider than its walls at the fissure entrance, is the
most susceptible to caries since its base is inaccessible to toothbrush bristles.
One or more of these fissure types can occur on the same fissure pattern, so it is
vital that the clinician uses the knowledge about these different types and their dif-
ferent susceptibilities when examining a tooth for signs of caries lesions. The
2 Preparing Teeth for a Clinical Examination 13

different visual signs corresponding approximately to the stages of the progress of

a caries lesion at a tooth site are incorporated in the visual ICDAS codes listed
below.
The more difficult a fissure pattern is to clean the more likely it is to be an I-type
or bottle-type fissure and is therefore more susceptible to caries lesion development.
The plaque will sit on the enamel at the entrance to the fissure, hence this is where
the first stage of the disease appears in the enamel. The clinician should therefore
concentrate his visual attention initially on the enamel at the entrances to the fis-
sures. Demineralization in enamel eventually produces an increase in the back-­
scattering of incident light to produce a white spot lesion—this will generally, but
not always, appear at the fissure entrance, not in the depths of a fissure.
The more complex and convoluted the fissure pattern, the more difficult it will be
to keep clean and the higher its susceptibility to caries lesion development. Thus,
narrow steep-walled deep fissures (I-type), intersections (of different parts) of the
fissure patterns and narrow pits will all present difficulties for the patient in keeping
them free from plaque. These will be generally more susceptible sites than broader
flatter fissure patterns (U-type). Examination and assessment of each patient’s
detailed pit and fissure morphology will highlight which specific sites within a fis-
sure pattern are likely to be more vulnerable than others.
The use of an explorer/probe to ‘catch’ a fissure pattern to detect primary caries
lesions has been shown to be of no diagnostic value, i.e. it adds no valid extra infor-
mation on caries lesion presence or extent to what can be gleaned by a careful
detailed visual assessment. This has been reported by several different authors over
the last 60 years. It has also been shown that for non-cavitated lesions probing can
irreversibly damage the tooth surface, effectively creating a micro-cavity within a
lesion where none previously existed, making the lesion more prone to disease
progression.
On older patients exposed root surfaces are at higher risk for developing caries
lesions. Crown margins, especially those ending in dentin will be particularly at risk
as well (see below).

2.4 Temporary Elective Tooth Separation

A number of authors have reported the use of elastomeric separating modules (com-
monly used in orthodontic treatment) to create, temporarily, a small space between
contacting teeth which allows direct visual access of the two adjacent approximal
surfaces. This process involves the placement of a small elastomeric band between
these teeth (around the contact areas/points) and leaving it in place for 2–7 days.
Hence a second visit, to remove the band and visually identify the presence or
absence of any approximal lesions and assess their surface integrity for signs of
micro- or macro-cavitation. This latter assessment can be aided by the use of FOTI,
as well as by the taking of a small impression of the expanded embrasure area, to
identify any breaks in the enamel surface morphology (Fig. 2.5).
14 C. Longbottom

a b

Fig. 2.5 (a–c) A lesion was observed on the distal surface of the first premolar and the mesial
surface of the second premolar. An ortho separator was left in place for 48 h. Both lesions were
non-cavitated

2.5 Magnification

The wearing of magnification aids can help clinicians to identify changes in the
surface characteristics of enamel. The extent of the literature on the effectiveness of
using magnification aids in caries lesion detection and diagnosis is surprisingly lim-
ited and has produced some mixed results.
The latter may be the result of limitations in research methods, since the very
process of magnification of an image increases the level of detail available com-
pared to the naked eye view. This should facilitate and enhance the identification of
the various visual changes which occur during the caries process.

2.6 Caries Lesions in Primary Teeth

The morphology of primary molars and permanent posterior teeth is significantly dif-
ferent—primary molars have broader contact areas than permanent posterior teeth,
which makes it more difficult to visualize into the embrasures to assess the enamel
beneath the contact points and also leads to a greater potential for plaque retention.
2 Preparing Teeth for a Clinical Examination 15

The shapes of the fissures on the occlusal surfaces of primary molars are gener-
ally less pronounced than for permanent teeth, hence they tend to be less caries-­
susceptible than in their permanent tooth equivalents.
Separators can be used in children, from as young as 4 or 5 years upwards to
adulthood, to aid visual caries lesion detection—they are well tolerated as their use
by orthodontists for over 5 decades attests.

2.7 Root Caries Lesions

See the ICDAS criteria (Chap. 6)—although visual indicators such as colour (dark-
ening) and glossiness seem to be helpful in differentiating between active and inac-
tive root caries lesions, essentially the texture (softness) of a lesion using a ball-ended
probe appears to be the best detection aid for the presence of an active root caries
lesion and the increased hardness of a lesion over time is a good indicator that the
lesion is arresting.

2.8 CARS

See the ICDAS criteria (Chap. 6). CARS lesions are primary caries lesions adjacent
to restorations or sealants, hence the same visual signs for primary caries lesions are
appropriate for CARS lesions. The specific ‘added’ factor to be taken into account
is the potential presence of a ‘plaque-trap’ caused by the presence of a restoration
or sealant, e.g. a ledge (restoration), or a breakdown of the marginal integrity of the
restoration or sealant (fracture and/or loss of seal between the enamel and the resto-
ration/sealant). The routine use of floss can aid the identification of ledges on
approximal restorations.

2.9 Concluding Remarks

The detection of dental caries lesions is not a simple task and requires careful and
systematic visual techniques to identify the subtle changes in the various character-
istics of tooth tissues brought about by the pathological processes involved. Each
tooth site being examined should be clean, dry (dried), and well-illuminated for
optimum visual assessment. Even then, meticulous visual examination is not suffi-
cient to detect totally accurately all lesions and assess the stage of each lesion at the
different sites at which they occur. There are well-recognized patterns of suscepti-
bility of tooth sites to caries attack in both the permanent and primary dentitions.
Knowledge of these site-risk patterns will aid the clinician in the optimization of the
visual assessment method of caries lesion detection.
Caries lesion detection is the first step in a three-stage process, which then
involves lesion characterization and subsequent assimilation of the lesion informa-
tion, together with patient data, to lead the clinician to a diagnosis relating to the
16 C. Longbottom

activity (or otherwise) of any detected lesion(s) and his/her subsequent treatment-­
decision with regard to each lesion.

References
1. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet. 2007;369:51–9.
2. Longbottom C, Huysmans M-C, Pitts NB, Fontana M. Glossary of key terms. In: Pitts NB,
editor. Detection, assessment, diagnosis and monitoring of caries, Monographs in oral science,
vol. 21. Basel: Karger; 2009. p. 207–15.
3. Pitts NB, Stamm J. International Consensus Workshop on Caries Clinical Trials (ICW-CCT)—
final consensus statements: agreeing where the evidence leads. J Dent Res. 2004;83(spec iss
C):125–8.
4. Neuhaus KW, Ellwood R, Lussi A, Pitts NB. Traditional lesion detection aids. In: Pitts NB, edi-
tor. Detection, assessment, diagnosis and monitoring of caries. Basel: Karger; 2009. p. 42–3.
5. Bader JD, Shugars DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and
management methods. J Dent Educ. 2001;65(10):960–8.
6. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device
for detecting caries. J Am Dent Assoc. 2004;135(10):1413–26. Review.
7. Batchelor PA, Sheiham A. Grouping of tooth surfaces by susceptibility to caries: a study in
5–16 year-old children. BMC Oral Health. 2004;4:2.
8. Pitts NB, Longbottom C. Preventive care advised (PCA)/operative care advised (OCA)—cat-
egorizing caries by the management option. Community Dent Oral Epidemiol. 1995;23:55–9.
The Visual Presentation of Dental Caries
3
Andrea Cortés, Stefania Martignon, and Gail Douglas

3.1 Introduction

A caries lesion is the result of diverse local metabolic events that lead to pH fluctua-
tions at the interface between the biofilm and the tooth structure [1]. The production
of organic acids resulting from bacterial metabolism generates H+ and a decrease in
the pH. The H+ react with the PO4−3 and –OH− ions from the enamel to form phos-
phates (HPO4−2 and H2PO4−1), phosphoric acid, and water, thus generating a sub-
saturation environment that favors mineral loss [2]. The study of the histopathology
of dental caries has contributed to the understanding of the behavior of the enamel,
the dentin, and the cementum in the demineralization process [3–5] and has pro-
vided an essential understanding of its visual appearance [6]. When the ion loss in
the surface is higher than the ion gain, over a period of time [1], a visible caries
lesion may be detected during the clinical examination. If the metabolic events in
the biofilm continue without being disturbed over a long period of time, the caries
lesion progresses, manifesting different visual characteristics as severity worsens.
Current understanding of the tooth structure recognizes the enamel structure as a
nanocomposite bioceramic which helps to protect the tooth from the assaults which is
constantly exposed to in the oral environment. The enamel is formed by thickly packed

A. Cortés (*)
UNICA Caries Research Unit, Research Vice-Rectory, Universidad El Bosque,
Bogotá, Colombia
e-mail: [email protected]
S. Martignon
UNICA Caries Research Unit, Research Vice-Rectory, Universidad El Bosque,
Bogotá, Colombia
King’s College London Dental Institute, Dental Innovation and Translation Centre, Guy’s
Hospital, London, UK
G. Douglas
School of Dentistry, University of Leeds, Leeds, UK

© Springer Nature Switzerland AG 2019 17

A. Ferreira Zandona, C. Longbottom (eds.), Detection and Assessment of Dental
Caries, https://doi.org/10.1007/978-3-030-16967-1_3
18 A. Cortés et al.

crystals made up of calcium, phosphate, hydroxyl groups (Ca10[PO4]6[OH]2), and other

ions such as fluoride, magnesium, sodium, chlorine, potassium, and carbonate [2].
Careful visual and tactile examination to search for enamel changes related to
caries lesions, after careful cleaning of the teeth (see Chap. 2), can be combined
with other diagnostic methods to make the evaluation more accurate [7, 8] (see Part
III, Chaps. 11–18).
A good visual-tactile detection and assessment system for caries should include a
clinical assessment which: (1) is useable for both the primary and permanent dentition;
(2) records the status of all surfaces; and (3) includes the assessment of caries from the
early stages. These are important characteristics to assist clinicians in proposing patient
care focused upon preventing new caries lesions, arresting any active caries lesions and
to support the patient achievement of good oral health. Additionally, caries detection and
assessment systems should be compatible for use by clinicians, researchers, educators,
and epidemiologists to facilitate communication about caries between these fields.
Based upon this understanding of the dental caries process, different classifica-
tions systems such as Nyvad [9] (see Chap. 5), ICDAS [10] (see Chap. 6), ADA
CCS [11] (see Chap. 7), and CAST [12] (see Chap. 8) have been devised to detect
caries lesion at all stages, especially in early caries phases when the lesions are dif-
ficult to be detected by traditional systems.
The appearance of normal enamel and early caries to the naked eye is influenced
by how light interacts with the tooth surface. Sound enamel is translucent and has a
refractive index of 1.6.

3.2 Initial Caries Lesions (A)

As net mineral loss occurs during the caries process, the first mineral which is lost is
from dissolution of the crystals located at the prismatic surface and from the interpris-
matic space. This results in an increase in enamel pore-volume. These gaps between the
crystals in the very initial stage of caries however do not change the visual appearance of
the enamel as the small gaps between crystals are filled with fluid with a similar refrac-
tive index to the enamel itself (1.33) and light passes through the lesion in a similar way
to the surrounding normal enamel. These lesions can be visualized by driving off the
moisture from the enamel by prolonged air drying for around 5 s with the three-in-one air
syringe. If the caries lesion continues to progress, and the loss of mineral from the lesion
causes the gaps between the prisms to become large enough to be air filled (refractive
index = 1.0), then the lesion becomes visible clinically as a whitish area. Light hitting the
surface of the porous caries lesion is refracted differently from that hitting sound enamel
[3]. If the lesion’s progression is arrested or significantly slowed down, then lesions may
take up color from the oral environment and become more brownish [13].

3.3 Moderate Caries Lesions (B)

If demineralization continues, the caries progresses further until the gaps between
the crystals become so large and the structure becomes fragile and vulnerable to
mechanical forces. The enamel surface starts to break down causing microcavitation
Another random document with
no related content on Scribd:
 XX
CHRISTMAS EVE
Tabby Green was alone in the snowy street. The wind which blew
with gusts of the finest snow had nearly taken Tabby off her feet as
she crept around the corner, and she was so cold and tired that she
could hardly take another step. Just as she was preparing to make a
final jump for the shelter of a flight of steps, a great white dog came
trotting through the snow and, to her great alarm, they ran into each
other.
"I beg your pardon," said the dog, in the politest way.
"My fault, I'm sure," said Tabby Green, for she was such a well-bred
kitty that no dog, even if he had the finest manners in the world,
could be more courteous than she.
Then, "Why, bless me!" she exclaimed. "Can it be you, dear Bobby
Gordon? How glad I am to see you once again!"
And to show how pleased she was, poor Tabby rubbed her thin sides
against the good dog's legs.
Together they crouched under the arch of the high stone steps,
where, from a grating in the sidewalk, came a breath of good warm
air. It was close to somebody's furnace room, and only such poor
wandering creatures as the hungry cat and the dog who had known
better days can appreciate the air from a warm cellar.
They sat close together and Tabby tried to purr, but she was nearly
dead and purr she could not.
"There, there!" soothed Bobby Gordon, as he licked the snow from
poor kitty's back in the gentlest way. "I wouldn't purr. It's very kind of
you to try, but it's a bad thing to do in the open air. They say it hurts
the voice."
"And I have no voice left these days," admitted Tabby sadly. "Really,
if it were not for these warm cellar-ways and the few stray scraps of
food that one finds in such shocking places, I wouldn't be alive."
"But," said Bob, "you're just a poor tramp cat, and no one's bound to
kill you. I'm a dog without a collar, all alone and afraid to be seen. I
can't let any one come near for fear they'll tell the officers about me.
Once I had a collar—such a beauty, too! But it came off within a
week of my great misfortune. You know my master went away, and
the wicked people in the house were going to get rid of me. I knew it.
I wasn't wanted any more. I had to go."
Great tears stood in Bobby Gordon's eyes but he brushed them
away with his paw.
Tabby was overcome. In all her wanderings she had never met a
case so sad.
"Poor Mr. Gordon!" was all she could say. "My poor, hunted friend!"
Then she thought of her own fireside, the cozy home that she had
known. And simply to think of the saucers of cream, and the plates of
dainty pieces from her mistress' table, made Tabby Green's poor
mouth water.
"Ah, me!" she sighed, and was pretty near to crying when a thought
flashed to her mind. "There's one more chance!" she suddenly
exclaimed. "You have a fine strong voice, and you can make folks
hear. Now just below this house, where that shoemaker's sign hangs
out, is a little girl, and a boy whom I know to be her brother. They
stopped and spoke to me but this very day. I felt that they were kind
and understood my case. But, although I followed to their door, they
didn't see me. And, call out as loudly as I could, my poor voice has
grown so weak I know they didn't hear me."
"It's little use," was all the weary dog could say. "I've barked at a
hundred doors."
Kitty waited and yielded to his discouragement. Of course it was no
use, she thought. They must simply wait and wait until the cold and
hunger did its work.
The wind howled, and the snow, which was piling higher and higher
on the steps, was drifting around them.
"We Scotchmen die hard," said Bob at last. "The Gordons are a
brave lot. I have to remember that."
"My mother purred away her life in song," cried Tabby Green. "She
was mindful of her kittens to the last. She said almost in her dying
breath: 'Remember, children! Never scratch, and always dry your
tails when you come in out of the rain.'"
Suddenly a voice came through the cold night air. It was a child's
voice, as sweet and clear as a bell.
"Kitty! Kitty! Come, Kitty, come!"
In an instant the poor, starved cat and the lame, hungry dog looked
out and leaped into the drifting snow.
A shaft of lamp-light lay wide across the street. The door at the
shoemaker's house was open. There stood a woman, and, with her,
two little children, all wrapped in shawls and blankets. Their little feet
were tucked in bed slippers and their eager faces peered into the
night.
"It's no use, your calling," said the woman. "You were only dreaming.
Any cat out in this storm is a dead cat now."
"Oh, but I know I heard a kitty."
"And I heard it, too," cried the little boy.
"Yes, and you made me get you out of bed to stand here and catch
your death o' cold. I hope you are satisfied."
Scarcely had she spoken, and just as she was about to close the
door, Bobby Gordon and Tabby Green came bounding past her feet
into the hall.
"'Twas naught but the Christmas angels brought them here!" the
woman said, when they had all seated themselves in the little parlor,
which was the poor shoemaker's shop and kitchen too.
The Christmas night was turning into morning. Tabby and Bobby
Gordon were sleeping by the stove, and in the bedroom, tucked
deep and warm under their blankets, were the two children who had
called the wanderers in.
Santa Claus was near, and thousands of lovely angels, drifting like
the snowflakes, whispered to him and beckoned as they flew over
the housetops.
"This way, this way," they kept singing. And Santa Claus came to the
shoemaker's chimney with such a pack of toys as he takes only to
the sweetest, kindest children in the world. For Santa Claus and all
the good, sweet spirits know the children who love to keep the kitty
warm and happy, and who would never let the poor, deserted dog go
friendless.
"And tell me," whispered Santa Claus to Tabby Green, "tell me every
child that so much as said, 'Poor Kitty!' to you in your wanderings. I
shall take them what they want the most for Christmas."
So Tabby Green, as fast as she could think, and the dog with the fine
manners told all they knew of the children. And when they had
finished, Santa told them that before another year was out they must
have news of other good children, like the shoemaker's little boy and
girl.
So there are many Tabby Greens and Bobby Gordons, forsaken and
driven and chased by the cruel people of the world. But sometimes a
little girl or boy stops to pet the straying animal, or even calls it
home. And you may be very sure that Santa Claus hears of it.
 XXI
MOTHER RABBIT'S ADVICE TO HER BABIES
Mother Rabbit and her five babies lived among the sand-hills down
by the sea. Their cozy home was a small cave in the side of the hill,
and it had two separate entrances, one at each end. These assured
her escape in case a dog or a weasel should enter her home.
One evening, just as the moon was showing itself, big and round and
yellow, over the tops of the pine trees, Mother Rabbit led her children
out of their cozy home to the big out-of-doors, which they had only
begun to know. Their education must begin, she felt, for they were
nearly one month old and already able to jump and skip around as
nimbly as Mrs. Fox's young sons. She feared that, if left in ignorance
longer, they were likely to become overbold.
"It is, first of all, my dears, necessary to be cautious in life," she said.
"You must follow me now very quietly to the edge of the wheat-field,
where we will sit down to talk. There are things you must know."
So they bounded along behind their mother, so lightly that they made
not a sound on the driest leaves of the woodland, and when they
came to the edge of the field they took the first high jump of their
lives, for the mother selected a place between the bars of the fence
and leaped through it swift and clean.
"Do it that way," she said. "You must never run under anything in the
dark if you can jump over it."
Once within the pleasant field, where there was so much green
wheat that the little rabbits wondered how in the world all of it ever
could be eaten, Mrs. Rabbit seated her family around her and began
by telling the babies all about their noble father.
"Ah, my dears, your father was such a rabbit as one seldom sees.
Such stout legs, and short, too, just as they ought to be! Such a long,
graceful body—and what magnificent ears! They were like flowers,
and stood up in such a taking fashion! Could you but see him,
dancing in the moonlight, hitting his heels together in the air, and
wagging those wonderful ears at the stars, his tail as white and fluffy
as a full-blown rose, why, my children, you would burst with pride. I
shall never see his like again."
"But where is Daddy Rabbit now?" the babies cried in one voice,
fearing that their mother spoke with sadness. "He isn't dead, is he?"
"Dead? No, no, my dears," she replied. "He's traveling; you'll see him
yet, I'm sure. He has a way of coming back.
"But in case he doesn't return, you must know how brave he is, and
what he can do. For you must grow up to be as like him as you can.
"Any of the neighbors can tell you of his clever ways, and his
bravery. He rid this field of a dreadful dog, once, and the history of
these parts will always relate that exploit. It made him famous."
At this the little rabbits cocked their ears in wonder.
"You see," Mother Rabbit went on, "it was this way: Once he
returned to his burrow below the hill over there and discovered, by
means of his keen sense of smell, that a terrier dog was in the
burrow. He immediately called for a friend, and together they closed
up the entrance to the burrow and smothered the dog to death.
That's what I call bravery. And that's the kind of father you had. The
world will expect much of children of your parentage.
"Your father and I first met on the hillside one evening, and we liked
each other at once. Every evening after, we would meet out there to
play hide-and-seek in the grass and sand. Perhaps he will come to
see you some day, and I want you to be smart and handsome, so
that he will be proud of you.
"But I have said enough, dear Jacks, and now I must teach you
some of the wise things he knew. He learned at an early age that
each rabbit must procure his own food, and has many foes to shun.
To do these things one must have a sharp wit.
"Always sleep during the day while other animals are prowling about,
and come out only evenings when it is cool, to seek your food.
Young wheat, fresh onions, lettuce and cabbages make splendid
food for rabbits. Of course, it is rather dangerous to cultivate such
expensive tastes, for lettuce and onions usually grow only in gardens
and people are apt to set traps to catch you. So be careful never to
go near a trap, or bite at anything that looks as though man had
placed it there for you. It is said that your father prided himself on
destroying traps.
"Our family is blessed by being both watchful and swift. Just watch
me how I can run."
Mother Rabbit sprang to her feet, and over the field she sped like
lightning. The children stared in wonderment, and then shouted for
glee at their mother's rapidity. Finally Mrs. Rabbit returned as quickly
as she had departed.
"Now, that is the way you must learn to run. And the next most
necessary thing for you to acquire is the ability to stand on your hind
legs like this."
To their amusement, Mother Rabbit stood up like a walking dog or a
bear.
"An enemy can be seen at a long distance from such a position," she
explained; "and it is well never to run until you have taken in the
situation. Many rabbits have lost their lives by failing to observe that
simple precaution. Once your Uncle Cotton heard a dog coming, and
turned to run in the opposite direction without having stood up to
survey the land. As a result, we found only his bones on the hillside
the next day. It is supposed that he ran right into the jaws of another
dog. Dogs are clever and often hunt together.
"But that's enough for the first lesson," she concluded. "Some
evening we'll come again and I'll teach you to dance, and we'll play
till the moon goes down in the West."
They jumped up, skimmed through the fence, and ran after their
mother, who had them home and tucked them in bed almost before
they knew it.
 XXII
THE MICE AND BABY STORK
"I find it very hard," said the learned watchdog, "to speak well of the
rats and the mice."
He was talking with his visitor, Professor Screech Owl, who perched
on the peak of the kitchen roof and was engaged with him in a
pleasant exchange of views and ideas. The moon was clear and
everything was very still. All the world seemed asleep but the owl
and the dog, and they were talking of many matters. For Professor
Screech Owl was a knowing bird and he had, moreover, the most
learned relatives.
"Of course, you know more than I do," Collie Dog hastened to add.
Professor Screech Owl nodded.
"And you may have heard in your travels of something which credits
the mice with being other than thieves and rogues. But for my part, I
am skeptical of all the good I hear of them."
"There are mice, and there are mice," said the Professor. For this is
one of the best ways to open a subject and draw a distinction. "I
have rarely inquired into their morals, preferring to take them as I
find them. In the matter of one's living one must not be too
squeamish. Probably I have eaten moral mice and immoral mice,
with indifference. But I have heard that the mice in Belgium are the
gentlest and sweetest of creatures. Have you heard of the Belgium
mice, Mr. Dog?"
This was the point to which Collie Dog had drawn his visitor with
intent. For no matter what subject you brought up, if you passed it
over to Professor Screech Owl and showed him the respect and
patience which is due to scholarly persons, he would refresh your
mind with wonderful facts and you would be vastly improved and
informed when he finished. So Collie Dog admitted that he was no
book dog, and knew precious little about anything. This was not so,
for he knew a great deal about sheep, the pasturing of cows, and the
time for getting the mail, and he knew that the buggy meant
business, and the surrey meant church, and he knew where his
mistress kept the chocolate creams. Also he knew why the cook left,
but he never told. But he pretended that blankness of mind which is
a humility pleasing to superior students.
Screech Owl stared at the moon as though to recall what he could
from his vast store of learning.
"The dates have escaped me," he began, "but it is the nature of the
event, not the time which is important.
"Once long ago, as I was told by the great Arctic Owl, who is a sort
of cousin of mine, the mice in the city of Ghent entered into a sort of
league with the storks. Ghent, as you know, is in Belgium."
This was news to Collie Dog, but he wagged his tail as if to approve.
He was glad to know that Ghent was in Belgium, and he wished to
seem pleased.
"Don't wag your tail!" Screech Owl spat out at him. "I'm telling you
history; I'm not asking you to have a bone. That's no way to act when
I'm lecturing!"
Poor Collie Dog wished to laugh, but he only sat still and looked
humbly at the conceited little owl on the peak of the barn.
Professor Screech Owl suddenly grew quite himself again,
apologized for his agitation, and resumed:
"The storks are a noble lot, and have been renowned in Egypt and
on the Continent. They dwell on the chimney-pots, I'm told, or build
on the edges of steeples and such. Very proud they are, and given to
the practise of medicine. The cranes in the country make great
pretense of being cousins of the stork. But we all know the
difference,—we who have traveled. Ha! Ha!"
Screech Owl screamed a terrible laugh. Collie Dog, to be polite,
joined in; but he stopped short when Screech Owl's feathers began
to ruffle up.
"In Ghent, long ago," the Professor went on, "the mice that lived in
the barn of the mayor's place were many. They overran it and lived
under the very eaves as well as in the cellars. And those nearest the
roof became great friends of the storks who dwelt on the gables and
chimneys.
"Now, so the story runs, the mayor's barn caught fire. The good lady
stork had but just left her nest. The storks, you know, go far out into
the country to get their food. I think it very foolish of them to live in
the cities. But Mrs. Stork took her chances, as all mothers do when
they leave their young ones for any length of time.
"Dr. Stork, the father of this particular family, was away on medical
matters, and so the baby was alone. You can imagine what Mrs.
Stork felt when she came flying toward the city and saw smoke
pouring from the roof of the mayor's barn."
Collie Dog scented the drift of the story, and grew suddenly impatient
for the slow Professor to reach the point.
"And was the baby stork burned to death?" he interrupted.
Professor Screech Owl only looked down and cleared his throat.
"The mice," he said, "are credited with singular humanity. They
scrambled all around and in and out of the nest, and at last they
grabbed the baby stork and dragged him down to the edge of the
roof."
"They Grabbed the Baby Stork and Dragged Him Down to the
Edge of the Roof"

"And then?" exclaimed Collie Dog, now really excited. "What then?
Did he fall off and get killed after all?"
"The roofs of the houses in Ghent are not very high," came from
Professor Screech Owl, in the deepest of tones, "but they are very
steep. A plank was leaning against the wall and they slid him down
on that, so that he reached the ground in safety.
"Since then the storks give all the feathers they can spare to the
mice; and now these frisky creatures sleep on down. That is, the
mice in Belgium do."
Professor Screech Owl came to a sudden stop and watched Collie
Dog. Seeing his audience was profoundly impressed, he then went
on:
"Those who were witnesses to this rescue say that Mrs. Stork's
excitement was terrible. She went to Egypt for a year to recover her
nerves—"
An unearthly screech pierced the night. The Professor and Collie
Dog jumped in surprise. Old Tom Cat, who had listened to all this as
he sat on the door-step in the dark, was trying to laugh. He was also
making remarks about owls and mice in general. But just then the
master of the house threw open the window and expressed his
views.
Collie Dog retired quickly to his kennel to think over this wonderful
chapter of history; and wise Professor Screech Owl flew silently from
the peak of the barn to his nest in the hickory woods.
 XXIII
MRS. BOB-WHITE AND THE HUNTING DOG
At the very peep of day Collie Dog and Setter Pup started out on a
hunting trip of their own. Collie Dog called the place "my farm" and
he had told his friend of all the wonderful sights there were to be
seen on the place by a dog who could travel alone and do as he
wanted. It was his habit, he said, to be abroad very early;
sometimes, indeed, he would run over the fields and along the
shore, or back into the woodland, for miles and miles before
breakfast.
"And what do you do that for?" Setter Pup asked. For this youngster
was just from the city, and he was not used to these country ways.
"We never get up until long after the man with the milk cans has
gone by the door, and the postman has come and gone," he
yawned. "That's the proper thing in town."
Collie Dog laughed in a courteous way.
"And we get up before the milk cans start for town," he said. "That is,
some of us do. But they'll take you out early enough when the
hunting begins. And you'll be pointing birds all day in the fields and
the swamps."
Setter Pup waved his tail proudly, for he meant to be a great hunter.
That was why they had him in the country now—to teach him all
sorts of things about guns and what to do when he smelt a covey of
birds.
But Collie Dog was no hunter, being more of a scholar and a poet.
His master, at any rate, had read him a great deal of poetry. And
much of the poetry had been of a nature to discourage hunting;
which was just what the doggie's master liked to do. He was
thoroughly in sympathy with his pet, who couldn't endure a gun,
either the sight or the sound of it. But, much as the gentleman knew
about the fields and the woods, he would have known more could he
have understood what Collie Dog would have loved to tell him. For
that gentle dog was on the best of terms with every living creature for
miles around. His early morning expeditions were always but so
many rounds of visits.
Consequently, the newcomer, this eager and noisy young setter, was
to make many new acquaintances on this daybreak excursion with
Collie Dog.
Down the lane from the barn to the pasture they romped, the dew
drenching their flanks as they brushed the tall weeds and bushes.
Setter Pup, with his ears flapping in excitement, was plunging
heedlessly ahead when Collie Dog called him back.
"Go easy here! We are sure to hear something," Collie Dog
whispered.
And suddenly, while they walked almost on tip-toe, there came from
the very edge of the field, a clear, ringing call:
"Bob! Bob! Bob!"
"Why, who can be down here in the hayfield at this time of the
morning?" Setter Pup asked in surprise.
"Just wait!" laughed Collie Dog, delighted.
"Bob, Bob, Bob-White!"
The voice was as clear as a boy's.
"That's my best friend out here," Collie Dog explained. "It's little Mr.
Partridge."
Then very quickly the beautiful, trim little Mr. Partridge hopped clear
of the tangled grass and stood gaily on the fence-rail. He was
speckled and shapely and his eyes were full of wonderful humor. But
he caught sight of the strange dog, and was gone in a second. Then,
to Setter Pup's great astonishment, there were many little voices,
and wild scuttlings in the very path ahead of him. And two beautiful
partridges, their wings apparently broken, were hobbling along
almost before his very nose. They were dying, as it seemed.
Setter Pup was all for seizing them. Two such crippled creatures
were easy prey. But his instincts were, after all, of another sort; for,
although he had never done it before, he stood stock still and
pointed his nose straight at the birds, his tail stretched out like a long
plume behind him.
Collie Dog shook with laughter.
"Well, that gun shooting master of yours would be proud of you if he
could see you now," he said. "You're pointing straight as a weather
vane. But we're not out hunting birds this morning. Come here, and
I'll show you something."
Setter Pup dropped his tail and stepped back. Then Collie Dog came
softly up to the little birds that were cowering in the path. They knew
him well enough. Even if he was a dog, he was a friend; and if there
is a creature who knows a friend and would be on terms of friendship
with the whole world it is Mr. Bob-White.
They were even pleased to meet young Setter Pup, when they found
out that he was staying at the farm. They could not believe that a
personal friend of their wonderful Collie Dog could be ill-disposed to
such as the partridge family.
And Mr. Bob-White talked about "our farm" exactly as though it were
his own. He said that he and his family could surely keep down the
potato bugs that year; and that if it could only be known what his
intentions were in this matter of eating up the pests that canker and
destroy, he was sure no one would want to kill him.
"You always say that, poor Mr. Bob-White, and how I pity you," the
gentle Collie Dog replied. For he was as quick to weep as to laugh,
being so refined a dog. "And it's a shame. My master reads to me all
about you. And we get very indignant when we think of how you are
the one thing that these farmers can depend upon to eat up more
bugs than anybody else could ever devour. You're so much better
than poison and all the rest of the truck they sprinkle around."
"Yes; the poison just washes off in the rain. My family, if only we
could be let alone, would do it all. Didn't you tell me that my cousin
down in Texas ate up all the boll weevils in a county full of cotton?"
"That's the truth," answered Collie Dog. "Master read it to me. But
you're safe enough on this farm anyway. You know that. My friend
Setter Pup is not going to hunt here at all."
"And I shall never hunt partridges—never!" declared Setter Pup, who
was sadly distressed. "I wish I had never been born"—he was crying
now—"if I have to hunt down such folks as Mr. Partridge." For poor
Setter Pup had found that he possessed a heart; and that discovery
is the most distressing one in the world.
"Oh, you'll get over that," Collie Dog comforted him. "You'll have to.
Your master will attend to you. But I'm sorry for you. And just look at
these baby partridges."
One by one, as Mrs. Partridge had clucked to them, in a little voice
like the ticking of a tiny clock, they had crept up to her. Ten little
chicks there were, of a light brown, and nothing but fluffy down and
beady eyes. One of them hopped right out from in front of Setter
Pup, where it had hidden under a leaf.
"Good gracious!" he exclaimed. "There was that chicken, and I never
saw it at all!"
"No," Collie Dog replied; "you would never guess where they go to
when their mother gives the alarm. And then she runs off and tempts
you to kill her. She hobbles and cries and lies down to die right at
your feet. My own mother, who was a Scottish noblewoman, being
an Argyle, used to say that she never saw such a wonderfully
devoted mother as Mrs. Bob-White."
With a gay farewell to Mr. Partridge, the sprightly dog was off. And
Setter Pup went racing after him. For there was much to see, and
the sun was already clear and golden. The grass shone in waves of
green, and as the dew dried there came the loveliest odors of wild
honeysuckle and clover. It was a time to be gay, and Collie Dog did
not want to have his young friend depressed. There were some
wonderful mud-holes to visit, where they could get just as cool and
as dirty as they pleased.
"And when the mud dries off," Collie Dog explained, as they plunged
through the bushes, "your coat will shine as though it had been
brushed."
It was a wonderful romp that they had in the mud-hole, deep in the
swampy meadow, under the blackberry vines. And when they came
out, disgracefully dirty, to dry themselves under a China-berry tree,
they were rolling over and over on the grass, when a funny little
voice called out from the branches overhead:
"Hello, Mr. Dog!"
Setter Pup jumped to his feet; but Collie Dog only looked up into the
tree.
"'Morning, friend 'Possum; and how's your family to-day?"
"Oh, they're doing fine. Twelve of them and all getting plump. We like
your turnip patch very much."
Then he laughed; a squeaky little laugh it was; and Collie Dog
seemed to enjoy the joke too, for he sat up with a smile.
"Come on down and let's see you die," he requested. "My friend has
never seen a 'possum play dead."
"No, indeed, Mr. Collie. I don't know your friend—and I don't think I
care to. He's a hunting dog. But I'll die right here on this branch, if
that will amuse you."
So Mr. 'Possum threw himself into a wonderful attitude and looked
as dead as dead could be. His head hung over the branch and his
mouth lolled open, and his little paws were all curled up.
"How queer!" Setter Pup exclaimed. "I suppose he's satisfied that
nobody but a buzzard would touch him now. What a dandy trick!"
"It fools 'em, all right," said Collie Dog, who always delighted in this
performance.
Then Mr. 'Possum winked a sly wink and slid like a big rat along the
branch to a hollow place in the tree.
"He's gone in. Probably his wife wanted him."
And then Collie Dog was off again, bounding and racing across the
field, with Setter Pup keeping beside him.
Miles they went, through the country. Young Setter Pup saw more
than he ever had guessed could be seen. There was Mr.
Blacksnake, who raced like mad over the leaves, making an
astonishing noise. He carried his head very high and went such a
zigzag course that the dogs lost sight of him.
"He's an ugly fellow, too, but he can't hurt you. He makes a funny
noise with his tail, rattling it on the leaves if you corner him. He wants
you to think he's a rattlesnake. But it's only a clever trick," said Collie
Dog. "Sometimes on that sandy piece of road we've just passed,
we'll come across Mr. Hognose. He's a queer little snake. He can
scare you terribly by puffing and blowing, so that you would think he
was very dangerous. But he can't bite at all, nor hurt you as much as
a cat. He plays off at being dead too, just like Mr. 'Possum. But he
never crawls out till the sun is high. He likes the heat. I've met him a
great many times, but always when it was hot."
By this time it was a glorious morning, and as the two dogs trotted
down the wood road and along the river bank, the birds were calling
from every side.
"I like to come this way," Collie Dog went on. "There's a redbird, a
very aristocratic cardinal, who flies ahead of me every time. He's had
a whole story written about himself. Master's read it aloud to me.
Does your master read aloud to you?"
Setter Pup was somewhat embarrassed.
"We read about guns and cartridges and Canadian guides, and
fishing tackle," he admitted.
"H'm!" mused his companion. "Destructive, of course. Right in your
line. But not my style. We prefer the other kind, my master and I. But
not everybody can be a poet, of course."
Just then the cardinal-bird darted out of the honeysuckle and flew
ahead of them, and in an instant a brilliant bluebird followed him.
"They fly together just that way. Master says they must like each
other's color. Aren't they beautiful?"
And then, before they knew it, the birds were gone; and Setter Pup
was surprised to see that this river path had been the way home, for
they were almost at the farm door.
"If I could only go hunting with you instead of with those guides and
guns," Setter Pup began; for evidently there was something on his
mind and he wanted to talk.
But Collie Dog just wagged his tail. He understood. There was
nothing to be said, for a dog owes everything to his master, and
there are many kinds of masters. Besides, the door was open and
there were voices upstairs. Setter Pup's owner was calling across
the hall to his host.
"He ought to make a fine pointer. His mother was a prize bird dog,
you know."
Poor Setter Pup looked wistfully at Collie Dog as they flopped down
on the floor.
And Collie was truly distressed. But, then, as he often asked himself:
"What could a poor dog do?"