Management of Deep Caries Flashcards
Outline the basic treatment plan for a patient with deep caries
- Provide emergency relief of pain
- Establish a healthy oral environment by doing a diet diary, giving OHI do some scaling. Basically trying to stabilise the caries
- Corrective therapy to repair the effects of the disease
- Replace any missing teeth
What is caries?
A disease of the hard tissues of the teeth characterised by the demineralisation and proteolytic destruction of the tissues by acids produced by bacteria in dental plaque feeding on dietary carbohydrates
How would you establish a healthy oral environment
- Diet diary
- Plaque free score
- OHI
- Scaling
- Caries stabilisation
What treatments are part of corrective therapy
- Permanent restoartions
- RSD
- endodontic treatment
- Crowns
Name the 4 basic parts of a tooth
- Enamel
- Dentine
- Pup
- Cementum
What can you find within the pulp
- Odontoblast
- Blood vessels
- Nerves
- Lymphatic system
- Stem cells
- Connective tissue
What do odontoblasts do?
They produce dentine
Name the 2 main nerves found in the pulp
- A alpha
2. C fibres
Describe a alpha nerves
- Are Myelinated
- Give a short sharp pain
- Fast response
Describe C fibres
- Unmyelinated
- Have a slow response time
- Dull throbbing ache
What type of tooth pain are alpha fibres responsible for?
Tooth sensitivity
What can a build up bacteria cause?
- Gingivitis
- Periodontitis
- Caries
Which type of bacteria cause caries?
Cariogenic bacteria
What lactic acid cause on the tooth?
Demineralisation
Name the first stage of caries formation
White spot lesion
Are white spot lesions treatable?
Yes they are the first sign of demineralisation
It is reversible with good oral hygiene
IF white spot lesions aren’t treated what can happen?
Brown spot lesions can form
When do brown spot lesions from
Repeated demineralisation and remineralisation can lead to pigments from blood / food being incorporated into the enamel
What changes are going through the pulp when white or brown spot lesions form?
- Arterial flow in the pulp increases
- Peritubular dentine gets laid down
- Affected odontoblasts produce tertiary dentine
What effect does increased arterial flow in the pulp have?
Causes an increase in the rate of flow of dentinal tubular fluid
The fluid acts to flu out bacterial toxins
Also caries anti-bacterial components (IgG, lactoferrin etc)
What effect does peritubular dentine getting laid down have on the tooth?
aMake the tubules narrower reducing the flow of fluid and also creating a barrier to bacteria
What happens if a white spot lesion isn’t treated?
- Further dentine is laid down to protect the pulp
- Cavitation may occur due to undermined enamel
- Caries start to spread lateral at the ADJ
What is affected dentine?
Demineralised dentine
What is infected dentine?
Irreversible proteolytic destruction, invasion of bacteria
What happens once bacteria has reached the dentine?
You get affected and infected dentine
When removing dentine which type of dentine do you want to remove?
Infected dentine affected can stay to protect the pulp
What happens to the pulp as caries gets closer to it?
The pulp gets inflamed and blood flow increases
A alpha fibres are also triggered
What condition does the pulp develop if caries gets too close to it?
Reversible pulpits
How can you treat reversible pulpit its?
Remove the caries to allow the pulp to heal
What happens if bacteria reaches the pulp?
Irreversibel pulpitits
What is irreversible pulpitis?
When the inflammation level of the pulp becomes irreversible
Removing caries will not preserve the vitality of the pulp but can treat painful toothache
What is pulpal necrosis?
Pulp death
Name the last cell that dies in the pulp
C fibres
What happens when the pulp dies?
A the pulp is dead theres no defence so the bacteria thrive on the dead tissue so the pulp becomes infected
How would you manage deep caries if you knew the pulp was alive vital
Treat the caries but try to keep the tooth alive
If someone has deep caries and their pulp is dead how would you treat them?
Either carry out a root canal treatment or extract their tooth
How do we check if pulp is alive or dead?
- Check symptoms
- Clinical appearance
- Special tests
- Radiographs
Which special tests do we carry out to check pulp vitality?
We do sensitivity tests
Name some sensitivity tests
- Electric pulp test
2. Ethyl chloride
What are the problems associated with Sensitivity tests
- They are not 100% reliable
- Can get many false positives and false negatives
- For EPT the numbers given doesn’t really mean anything as anything below 80 means pulp is probably alive
Describe the clinical appearance of a tooth that may be suffering from pulpal necrosis
- May have an abscess
2. Sometimes dead teeth appear darker
Which radiograph gives the best view for caries?
Bitewings
What do you need to remember when looking at a radiograph for caries?
- Caries on a radiographie image may only show 60-80% of the actual caries present
- Caries will always be deeper, and more extensive than you think
- Deep caries is at least 3/4 of the way to the pulp from the ADJ so high risk of pulp exposure
Name the 2 most common causes of pulp death
- Bacteria
2. Dentists
How can we reduce the risk of bacteria entering the pulp wet n we are carrying out treatment
- Use rubber dam
- Remove caries from the walls of the cavity first
- Never use high speed for removing caries
- On the floor of the cavity only use excavators, gently scare away anything sot
- Leave affected dentine over the pulp
- Use RMGIC liner to seal the affected dentine
Describe dental tubules if caries has extended near to the pulp
They will be wide open dentinal tubules
What cam we place on the base of the cavity to protect the pulp
Create a seal before placing restoration with RMGIC liner (Fuji-liner)
Can we place RMGIC liner on enamel?
NO only on dentine
Name the three types of pulpal exposure
1, Iatrogenic- Dentist exposes the pulp during caries removal
2, Carious- Caries has reached the pulp
3, Traumatic- trauma causes fracture of the tooth involving the pulp
How do we manage iatrogenic pulpal exposure
- Wash the cavity and dry with cotton pledget
- GET THE TUTOR
- Assess whether the dentine around the exposure is carious or not
- Assess the size of exposure
What should you do if the size of you pulpal exposure is more than 2mm ?
Will have to do RCT
What should you do if the size of you pulpal exposure is less than 2mm ?
Place Ca(OH)2 over the exposure and dress the tooth with GIC MONITOR
What does calcium hydroxide do to the mouth>
- It creates an allkaline environment i.e. bactericidal which is highly toxic to bacteria
- Stimulates odontoblasts to lay down new reparative dentine in the dentinal tubules
- Stimulates stem cells in the pulp tissue to create new odontoblast-like cells to create dentine bridges across pulpal exposures
When is direct pulp cap most successful?
- Absence of signs or clinical symptoms of pulpitis before you start opening the tooth
2, Normal response to vitality tests by the tooth - In Younger patients without previous history of restorative work on the tooth in question
- If the tooth is isolated
- If the exposure is small
- If the exposure if not probed or blown dry
Gives some clinical procedures to avoid exposure
Use a step wise excavator
Leave some affected dentine if you are close to the pulp
Talk through the stepwise excavation technique
- Establish sound enamel margins & caries free ADJ
- Remove “infected” dentine and leave a layer of “affected” dentine
- Place layer of calcium hydroxide liner over very deep affected dentine
- If cavity cannot be restored in a single visit then:
Restore the whole cavity with RMGIC (RMGIC marginal seal is critical
to prevent any micro-leakage at the & review 6 months later) - If cavity can be restored in 1 visit, then use RMGIC to restore the
“dentine depth, leaving 2-3 mm coronally for your definitive composite
or amalgam restoration
