L15. Methods of Caries Management - The Biological Approach Flashcards
What are the 4 main factors involved with the development and progression of caries?
- Tooth tissue;
- Bacteria;
- Sugar;
- Time.
What is the ultimate aim of all caries treatment?
Promoting an environment that favours remineralisation
What is the difference between detection and diagnosis of caries?
- Detection is determining the presence of disease;
- Diagnoses confirm the activity of the disease (i.e. is it active or arrested).
What is the process of examination for caries?
- Plaque chart;
- Clean teeth (can’t see caries under plaque);
- Inspect without drying for dentinal shadowing;
- Dry tooth;
- Inspect for caries.
What can be used to help confirm the presence of caries?
- Use of CPITN probe to see if any catching occurs;
- Bitewing radiographs;
- Temporary elective tooth separation (TETS);
- Transillumination;
- FOTI;
- Plaque pH;
- Salivary flow rate.
What are the stages of visual detection of coronal caries?
- Normal enamel translucency after drying;
- Enamel opacity after drying;
- Enamel opacity without drying;
- Enamel opacity with local surface destruction;
- Enamel discolouration +/- surface destruction;
- Surface breakdown opaque enamel;
- Surface breakdown discoloured/ opaque enamel;
- Enamel cavity into dentine.
Why should tactile assessment (use of a probe), never be used for enamel caries?
This can cause cavitation, cavitation is the point of no return (i.e. requires operative tx and prevents potential remineralisation)
What type of caries are bitewing radiographs typically used to confirm?
Interproximal (sometimes pick up unexpected occlusal caries)
Sometimes dark staining in fissures can look like caries, what is usually present if this is caries?
A white periphery - without this it is typically exogenous staining
When may you decide to use TETS?
Suspected interproximal caries
How is TETS carried out?
- Orthodontic separator between teeth;
- As band contracts, teeth pushed apart;
- Leave for 2-5 days;
- Review;
- Inspect surface for cavitation;
- Can use probe and or silicone impression on surface in question.
What is included in a diagnosis of root caries?
- Primary or secondary;
- According to tooth surface (e.g. buccal, proximal etc.);
- Active, arrested or remineralised.
What are two important factors to assess when examining root caries?
- Position relative to gingival margin (+/- 1mm?);
- Dimension of lesion (small or large);
- Colour (light or dark).
In terms of bacterial load, how does this typically correlate to texture and colour of a root caries lesion?
- Soft lesions have higher bacterial load (probably the best indicator);
- Lighter lesions have higher bacterial load.
What are the indications for non-operative intervention of root caries?
- Hard, dark-coloured lesion;
- > 1mm from gingival margin;
- Does not trap plaque;
- Not rapidly progressing;
- Pt able to participate in non-operative management.
In terms of a secondary caries lesion, what is the order of progression surrounding the restoration?
Outer to inner (an outer lesion does not always mean there are secondary caries under the restoration)
Criteria for tx of secondary caries is quite uncertain, what indications suggest intervention?
- Wide ditches (which admit a probe);
- Very carious outer lesions;
- Colour changes alone are not a good predictor.
What is ‘non-operative management’ of caries?
The intervention of caries progression/ risk by means of modification to the factors required for caries development (tooth, host, bacteria, [time])
What might be involved in non-operative management of caries?
- Dietary analysis (sweet episodes: how many and how much?);
- OHI;
- Increased fluoride exposure.
How has high fluoride toothpaste been seen to act on root caries?
- Significantly harder;
- Significantly further from gingival margin;
- Significantly fewer bacteria.
What is the issue surrounding evidence to support use of fluoride varnish application?
- Where the benefit in caries reduction comes from;
- Is this from the education on OH, increased/ correct brushing or from the varnish itself?
When might the use of silver diamine fluoride (SDF) be ideal?
Good for patients with littler cooperation but high caries risk
What is the main issue with SDF treatment?
The effected tooth tissue turns black
How does ICON work?
- Resin infiltration of the lesion;
- Etch lesion;
- Dry off with ethanol (withdraws moisture);
- Apply resin;
- This is ‘absorbed’ and infiltrates the demineralised lesion;
- Improves appearance.
What is the main criteria for assessing patients for caries intervention?
- What risk is the patient?;
- Low: no intervention;
- Mod-high: intervention to address and change their caries risk.
What are the aims of restorative treatment?
- Restore significant loss of dental tissue;
- Eliminate plaque retention;
- Restore masticatory function;
- Minimise the risk of recurrent disease;
- Restore aesthetics where appropriate.
What indicators are there for operative intervention of primary coronal caries?
- Cavitated lesions (probe catches on tactile assessment);
- Enamel discolouration +/- localised surface destruction;
- Plaque trap area;
- Can’t be cleansed.
What indicators are there for operative intervention of secondary caries?
- Frankly carious;
- Plaque trap area;
- Ditches wide enough to admit a periodontal probe.
What indicators are there for operative intervention of root surface caries?
- Pale coloured or black lesion, < 1mm from gingival margin;
- Plaque trap;
- Pt unable to participate in non-operative management;
- Feel soft with sharp probe.
How do fissure sealants work to treat caries?
- Acid etch decreases the viable bacteria;
- Sealant seals and starves them.
What are the options for treating deep, carious lesions?
- Non-selective removal of carious tissue to hard dentine;
- Selective removal to firm dentine (SRFD);
- Stepwise excavation treatment (SW);
- Selective removal to soft dentine.
What is the main risk with SRFD?
- Pulp exposure;
- Poor prognosis for tooth vitality in long term, even with pulp cap.
Does the risk of pulp exposure increase or decrease with stepwise excavation, from SRFD?
Decreases (less tissue removal at first step so less chance of exposing pulp)
Does the risk of pulp exposure increase or decrease with SRSD, from SW?
Decreases (however, study shows a high number of patients who didn’t go back for second SW tx so tx incomplete)
What are the non-operative options for treatment of caries?
- Non-operative;
- Non-operative management;
- Topical application.
What is involved with non-operative management of caries?
- Patient education (of caries/ their caries risk);
- Dietary modification (3-day diet diary and assessment to reduce sugar intake);
- OHI (brushing and interdental cleaning);
- Professional prophylaxis (the more they’re seen, the more the risk of caries decreases).
What topical application options are there for treatment of caries?
- Topical fluoride (twice a day: 1450, 2800 or 5000ppm);
- Fluoride varnish;
- CPP-APC;
- Chlorhexidine (for root caries);
- Silver diamine fluoride (SDF).
What other non-operative options are there for treatment of caries?
- Active management;
- Sealing in occlusal caries;
- Resin infiltration;
- Ensuring areas are self-cleansing.
What are the general principles to consider when restoring a tooth?
- Minimally invasive (remove as little tooth structure as possible);
- Prevent iatrogenic damage;
- Establish a contact point;
- Correct margin fittings;
- Justifying replacing existing restorations (new caries or a technical failure);
- Always consider repairing rather than replacing.
