Caries diagnosis and treatment planning Flashcards
What is dental caries
- Disease of mineralized dental tissues caused by action of
microorganisms on fermentable carbohydrates
In its early stages…
remineralisation is possible above a critical pH of
The disease can be arrested
5.5
Clinical caries diagnosis involves the process of what 3 things
1) Caries detection (non cavitation or cavitated)
2) Diagnosing if the lesion is arrested/active/ progressing rapidly
3) Recording findings
Early caries diagnosis allows
Successful caries prevention and management
Professor Nigel Pits created what to demonstrate caries diagnosis?
The iceberg of dental caries
The iceberg of dental caries is what
Demonstrative of the diagnostician thresholds used in epidemiology and practice
Describe the ‘Iceberg of dental caries’
In epidemiological surveys the iceberg floats at D3 threshold ie. cavity in dentine
Most lesions are stable by preventative care are hidden below the water
Patients who only present with D1 and D2 lesions are described as ‘caries free’ by epidemiologists.
No active care needed
(Under water)
Sub clinical initial lesions in a dynamic state of progression/regression
Preventative care advised
(Under water)
Lesions detectable only with traditional diagnostic aids
D1 Clinically detectable enamel lesions with ‘ion tact surfaces’
D2 Clinically detectable ‘cavities’ limited to enamel
Preventative and operative care advised
D3 Clinically detectable lesions in dentine
D4 Lesions into pulp
Caries classification
Anatomical site?
Activity?
Occlusal/ smooth surface (proximal/buccal)/root
Activity Active/arrested
Caries classification
Virginity?
Extent?
primary/ recurrent
incipient/occult/cavitation
Tissue?
No. Surfaces?
initial/superficial/moderate/deep/deep complicated OR
enamel/dentine/pulp
simple/compound/complex
Chronology?
Tooth surface affected?
early childhood/adolescent/adult
mesial/distal/occlusal/
buccal
Blacks Classification
class I,II,III, IV, V, VI
Methods of caries diagnosis in the paediatric patient-
Conventional techniques of caries diagnosis?
Simple visual
Tactile
Radiographs
Simple visual?
Dry the tooth
Separator
Tactile?
Probe
Radiographs?
Digital image enhancement
Digital subtraction radiography
Caries diagnosis-
Novel techniques?
Electrical current
Fluorescence
Enhanced visual techniques
Electrical current?
Electrical conduction measurement
Electrical impedance
Fluorescence?
Visual: QLF
Laser diagnodent
Enhanced visual techniques?
FOTI
DiFOTI
What should remain the standard practice in the clinical diagnosis of primary caries in paeds patients?
Visual inspection combined with bitewing radiographs for proximal surfaces
What is required for the visual diagnosis of caries?
- Dry tooth – compressed air
- Clean teeth – brush, prophy
- Good light
- Dental mirror
- Sharp eyes
. Blunt or ball ended probe (NOT a sharp probe)
What is the purpose of drying the tooth
To identify white spot lesion and brown spot lesion.
White spot lesion on a dry tooth?
Penetrated 1/2 way through enamel
White spot lesion and brown spot lesion on wet tooth?
Through enamel and may be into dentine
How to carry out temporary tooth separation and what is it for?
- Elastomeric separator inserted for 30 mins-1 week
- Direct exam or indirectly via impression
- Diagnosis of interproximal lesions
What is the importance of temporary tooth separation?
May avoid need for radiograph/
supplement radiograph
What must temporary tooth separation be carried out over?
Multiple visits
Tactile diagnosis of caries- how do you do it and what do you use?
- Visual is aided by ball ended explorer NOT sharp probe
- Remove any remaining plaque and debris and to check for surface contour, minor cavitation or sealants.
- Sharp probe – not increased accuracy and may damage intact enamel over a carious lesion (Lussi 93)
How may a probe reflect morphology of fissure ?
Stickiness with the probe
Tactile diagnosis of caries in extracted teeth?
Methods and percentage caries detected?
- Visual inspection of cavitated occlusal lesion
– 62% caries detection - Bitewings only
– 79% caries detected - Visual inspection + BW’s
– 90% caries detection
Clinical caries diagnosis can be .. for example..
Difficult
With dentine caries there may be no break in the surface
What is required because of the difficult caries diagnosis?
Adjunctive diagnostic aids ie radiographs are the most common used
What radiographs could we use in caries diagnosis?
Bitewings
Lateral oblique jaw views
OPT
What radiographs are the first choice for caries diagnosis in the primary and mixed dentition in kids?
Bitewings ie intra-oral radiography
What ages should radiographs be used in children as an adjunct to visual diagnosis?
4 and above
When should radiographs be taken
After clinical examination
What could be an example of when you don’t need radiographs?
Well spaced dentition with open contacts
Record why you haven’t taken bitewings
What stuff with radiographs should you record?
Why you haven’t taken them
If child is pre cooperative or lacking cooperative ability
What are the advantages of BWs?
- Surfaces inaccessible to clinical exam can be studied
- Depth of lesion can be assessed
- Non-invasive
- Radiographs can be re-examined and comparisons can be made
. Increased diagnostic yield when compared to clinical
examination alone:…
Increased diagnostic yield compared with examinations alone?… how
The number of approximal lesions detected increases by a factor of between 2 and 8 when bitewings taken when compared to clinical examination alone.
- Detection of inadequate restorations (86%) which otherwise appeared clinically sound or adequate on examination alone
Limitations of Radiographs in the diagnosis
of Caries
- Age/ cooperation limitations
- Occlusal caries may not be visible (enamel)
- May get triangular radiolucencies on mesial surface upper E’s and
6’s due to Cusp of Carabelli - Usually underestimate the extent of a lesion
- Use of ionising radiation -DNA damage
. May have overlapping
Radio graphic investigations frequency-
High caries risk status?
6 monthly
Moderate caries risk status?
12 monthly
Low caries risk status?
12-18 monthly for primary and mixed dentition
2 yearly for permanent dentition
Radiography should only be performed when
the patient history/ or objective findings and symptoms
lead to the conclusion that further useful information
might be obtained.
When should a radiograph not be taken?
When it is not expected to change diagnosis
or treatment or add other useful information
Radiographs are
Adjuncts, not replacement to a good history and clinical examination
Ensuring successful radiography in children?
Use smaller film sizes (size 0)
Use smaller holders or adhesive tabs
Use child friendly terminology
Demonstrate the equipment first
Distraction techniques (counting, nose breathing)
What is the benefit of a lateral oblique jaw view?
Avoids an intra oral film
Less cooperative ability required
Provides additional information on the developing dentition
Lateral oblique jaw view and bitewings?
Fair to good agreement with each other
Benefit of OPT
Can detect occlusal dentine lesions eg large lesions
Disadvantages of OPTs
Increased radiation dose
Lower sensitivity for caries diagnosis, especially approximally
Digital subtraction radiography- what does it do?
(DSR)
- Determines qualitative changes that occur between 2 digital radiographic images taken at different time
- Shows progression or regression
How does digital subtraction radiography work?
- Subtract pixel values for each coordinate of the 1st radiograph from equivalent coordinate in a 2nd radiograph= subtraction image
- If 0- no change
Methods of caries diagnosis in the paeds patient- novel techniques?
1) Enhanced visualisation – FOTI
2) Fluorescence - Laser Fluorescence (Diagnodent) and
QLF (Qualitative light fluorescence)
3) Electric – Electronic caries meter (Cariescan pro)
1)Chemicals- caries detector dyes
Principles of treatment planning- each treatment plan should comprise…
- Relief of pain
– Prevention
– Behaviour Management / Acclimatisation
– Operative procedures
* Logical treatment progression building on each
previous visit
- Recall interval and radiograph frequency
Preclinical phase?
Exposure
Primary prevention
Maintaining physiological equilibrium
Clinical phase- non cavitated?
Early diagnosis
Primary prevention
Maintaining physiological equilibrium
OR
Secondary prevention
Non operative treatment
Cavitated?
Late diagnosis
Secondary prevention
Non operative treatment
OR
Tertiary prevention
Operative treatment
Prevention treatment plan-
Diet drinks advisce, brushing, dentist
Limit sugar to 4/5 times/day
Water or milk as main drinks
x2 day, appropriate F toothpaste for age and caries risk, consider F mouthwash
- Dentist
– Fissure sealants- resin or GIC
– Fluoride varnish
Prevention treatment plan…
Dentist- prevention treatment plan?
Primary prevention if no
disease
* Secondary prevention if early disease
Treatment plan for non cavitated lesions in primary teeth? Occlusal?
Complete caries removal
Incomplete caries removal
Fissure seal with resin or GIC
Treatment plan for non cavitated lesions in primary teeth?
Proximal?
Complete caries removal
Incomplete caries removal
Seal with a Hall Crown
Treatment plan for cavitated lesions in primary teeth (no pulp involvement)?
Occlusal?
Complete caries removal
Incomplete caries removal
Seal with a Hall Crown
Treatment plan for cavitated lesions in primary teeth (no pulp involvement)?
Proximal?
Complete caries removal
Incomplete caries removal
Seal with a Hall Crown
What are the coexisting considerations for caries removal in children?
- Presence of absence of symptoms/ infection
- Number of visits required
- Number and extent of carious lesions, Oral Hygiene
- Distance travelled, attendance history
- Patient compliance
- Parental motivation
- Previous medical history
- Caries rate/risk
- Anaesthesia to be used
Planning- using quadrant dentistry- what’s the benefits?
Reduces number of visits
Reduces number of episodes of LA
Planning- using quadrant dentistry- what are the things to note?
Take care with LA dose
Requires good compliance often beyond younger children/ those with special needs
What are the possible alternatives to treatment?
- Preventive approach E.g.
– To obtain stabilisation until compliance
established
– If carious lesions are arrested
– If close to exfoliation and there is a permanent
successor developing
There are some example cases with questions at the end to look at
