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 the disease can be arrested -remineralization is possible above critical pH of 5.5
what does the clinical caries diagnosis process involve?
- Caries detection (non-cavitated or cavitated)
- Diagnosing if lesion: arrested/ active/ progressing rapidly
- Recording findings
what does early caries diagnosis allow us to do?
> successful prevent caries and manage the patient
what is the WHO classification of caries? (iceberg dental caries)
> sub-clinical initial lesions in a dynamic state of progression regression = no active care advised
> lesions detectable with only traditional diagnostic aids = preventative care advised
> D1 - clinically detectable enamel lesions with intact surfaces = preventative care advised
> D2 - clinically detectable cavities limited to the enamel = preventative care advised
> D3 - clinically detectable lesions in dentine = preventative and operative care advised
> D4 - lesions in pulp = preventative and operative care advised
what are all classifications of caries?
CLASSIFICATION BASIS
> Anatomical site = Occlusal/ smooth surface (proximal/buccal)/root
> Activity = active/ arrested
> Virginity = primary/ resurrent
> Extent = incipient/ compound/ cavitation
> Tissue = initial/superficial/moderate/deep/deep complicated OR enamel/dentine/pulp
> No. of surfaces = simple/ compound/ complex
> Chronology = early child hood/ adolescent/ adult
> Tooth surface affected = mesial/ distal/ occlusal/ buccal
> Blacks Classification = class 1,11,111, IV, V, VI
> WHO classification = D1 D2 D3 D4
> ICDAS = code 1-6
what are the conventional technique in diagnosing caries?
> simple visual = dry tooth, separator
> tactile = probe
> radiographs = digital image enhancement, digital subtraction radiography
what are novel techniques used to diagnose caries?
> electrical correct = electrical conduction measurement, electrical impedance
> fluorescence = visual (QLF), laser (diagnodent)
> enhanced visual techniques = FOTI, DiFOTI
what is required for visual diagnosis of caries?
> Dry tooth – compressed air
> Clean teeth – brush, prophy
> Good light
> Dental mirror
> Sharp eyes
> Blunt or ball ended probe (NOT sharp probe)
what does a white spot lesion indicate on a dry tooth?
> the caries penetrated 1/2 through the enamel
what does a WSL and BSL indicate on a wet tooth?
> the caries is through enamel and may be into the dentine
how do you carry out a temporary tooth separation and what is it used for?
> Elastomeric separator inserted for 30 mins-1 week
> Direct exam or indirectly via impression
> Diagnosis of interproximal lesions
> May avoid need for radiograph/ supplement radiograph
> Multiple visits
how do you carry out a tactile diagnosis of caries?
> 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)
> Stickness with probe may reflect morphology of fissure (Kidd et al 1993)
what are the % caries detection rates per examination? (lussi 1993)
> Visual inspection of cavitated occlusal lesion
= 62% caries detection
> Bitewings only
= 79% caries detected
> Visual inspection + BW’s
= 90% caries detection
why can clinical diagnosis of caries be difficult?
> Can be difficult e.g. with dentine caries there may be no break in the surface
> Adjunctive diagnostic aids are therefore often required
> Radiographs are the most commonly used.
what are the radiograph options for diagnosing caries in paediatric patients?
> bitewings
> lateral oblique jaw views (extra oral view for uncooperative children)
> OPT
what is first choice for caries diagnosis in children in the deciduous or mixed dentition?
> intra oral radiography (bitewings)
why would you take dental radiographs in children?
> important adjusts to visual diagnosis of caries for children and 4 and above
when should you take dental radiographs in children?
> should be taken after every clinical examination if indicated
what circumstance would indicate you NOT to take a radiograph in a child?
> well spaced dentition with open contacts
> If a radiograph is not expected to change diagnosis or treatment or add other useful information
what else should you record after taking a dental radiograph apart from the report in children?
> record if pre cooperative/ lacking cooperative ability for radiographs
why are lateral obliques not good for caries diagnosis?
> there is superimposition of the opposite side
> only large caries will be detected
what are the advantages of bitewings?
> Surfaces inaccessible to clinical exam can be studied
> Depth of lesion can be assessed
> Non-invasive (relatively)
> Radiographs can be re-examined and comparisons can be made
what is the factor increase on the detection of caries using bitewings compared to a clinical examination alone?
> between 2 and 8
what are the limits 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
what is the radiographic investigation frequency based off the FGDPuk 2013 selection criteria guidelines?
> high caries risk = 6 monthly
> moderate caries risk = 12 monthly
> low caries risk = 12-18 monthly primary and mixed dentition/ 2 years permanent dentition
what are some practical tips for a successful radiograph in a child?
> Use smaller films (size 0)
> Use smaller holders or adhesive tabs
> Use Child Friendly Terminology
(camera, photograph)
> Demonstrate equipment first (TSD)
> Distraction Techniques (counting, nose breathing)
why would you used a lateral oblique jaw view?
> Avoids intra oral film
> Less cooperative ability required
> Additional information on developing dentition
> Fair to good agreement with bitewings but not as clear
what are they key points of taking an OPT?
> Increased radiation dose
> Can detect occlusal dentine lesions ie. large lesions
> Lower sensitivity for caries diagnosis, especially in detection of approximal lesions.
> cervical spine superimposition
what is digital subtraction radiography (DSR)?
> Determines qualitative changes that occur between 2 digital radiographic images taken at different time
> Subtract pixel values for each coordinate of the 1st radiograph from equivalent coordinate in a 2nd radiograph= subtraction image
> If 0- no change
> Shows progression or regression.
what are then adjective methods of detection in caries diagnosis?
> Enhanced visualisation – FOTI
> Fluorescence - Laser Fluorescence (Diagnodent) and QLF (Qualitative light fluorescence)
> Electric – Electronic caries meter (Cariescan pro)
> Chemicals - Caries detector dyes
what should each treatment plan comprise of?
> Relief of pain
> Prevention
> Behaviour Management / Acclimatisation
> Operative procedures
- Logical treatment progression building on each previous visit
> Recall interval and radiograph frequency
what is part of a prevention tx plan?
> Diet advice- limit sugar to 4/5 times/day
> Drinks advice- water or milk as main drinks
> Brushing – x2 day, appropriate F toothpaste for age and caries risk, consider F mouthwash
> Dentist
- Fissure sealants- resin or GIC
- Fluoride varnish
what is the difference between primary prevention and secondary prevention?
> Primary prevention if no disease
> Secondary prevention if early disease
what are the treatment options for occlusal non cavitated caries in primary teeth?
> complete caries removal
> incomplete caries removal
> tissue seal with resin/ GIC
what are the treatment option for a proximal non cavitated caries in primary teeth?
> complete caries removal
> incomplete caries removal
> seal with hall crown
what are the tx options for occlusal cavitated caries in primary teeth?
> complete caries removal
> incomplete caries removal
> seal with hall crown
what are the tx options for proximal cavitated caries in primary teeth?
> complete caries removal
> incomplete caries removal
> seal with hall crown
what are some coexisting considerations before carrying out a treatment plan?
> 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.
wha is a common treatment planning method used ?
> Quadrant dentistry:
- Reduces number of visits
- Reduces number of episodes of LA
But:
- Care with LA dose
- Requires good compliance often beyond younger children/ those with special needs
what a possible alternative approach for a child lacking in cooperative ability but has asymptomatic decay?
> 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.
