Management of Gross Caries Flashcards
D1
caries limited to enamel
D3
caries into dentine
- after ADJ not go to point of triangle - goes wide
describe the iceberg of caries experience from peak to base
Clinically decantable lesions in dentine D3
- Most epidemiological data dependent on
PLUS clinically detectable ‘cavities’ limited to enamel D2
- Since most used fluoridated toothpaste, less seen now
PLUS clinically detectable enamel lesions with intact surfaces D1
PLUS lesions detectable only with additional diagnostic aids (e.g. FOTI and BWs)
PLUS sub-clinical initial lesions in a dynamic state of progression and regression
- Never caries free
- Constant de and re mineralisation
what infected dentine
the irreversible demineralized and denatured layer with bacterial invasion
what is affected dentine
dentin is partially demineralized (leathery\softer than normal), collagen is not denatured and contains minimal to no bacteria
what has the stronger bond strength affected or infected dentine
Bond isn’t so good to affected dentine
Ensure on caries removal good solid bond so restoration doesn’t leak
describe key ethos behind dealing with caries
preserve healthy and remineralisable tissue
like helter skelter
- Top: healthy tooth
- Slide down - bucket: tooth extracted
Aim to keep tooth high - As soon as restore tooth - need replaced inevitably - Bigger Need replaced quicker - Need another – bigger Hit pulp - Non vital RCT, Then crown Fractured post and tooth
describe the 5 points in the ethos behind dealing with caaries
preserve healthy and remineralisable tissue
achieve a restorative seal
- Caries is bacteriological process, Seal in the caries and bacteria so no way of them surviving. Bacteria will die as no food (kill germs)
maintaining pulpal health
- keep tooth alive
maximise restoration success
- best possible shape for retention
- not extension for prevention technique
- Material bonds so less need
carious tissue is removed to create conditions for long lasting restorations
- dont remove means tooth will fall out and caries progress
appearance of gross caries
Apple cores
- Older patients on lower incisors and uppers
Radiotherapy pt
- Caries at gingival margin on smooth surface - concerning should be easy to clean
More seen now Underneath canine 13
why is achieving a restorative seal key to dealing with caries
Caries is bacteriological process, Seal in the caries and bacteria so no way of them surviving. Bacteria will die as no food (kill germs)
why is maintaining pulpal health key to dealing with caries
keep tooth alive
as soon as non-vital more complex Tx and poorer prognosis
what are the 3 stages of dealing with caries
Assess reason for caries
Address oral environment
Restore if necessary
- Tissue removal
- Restoration placement
why do you need to assess the reason for caries
Need numerous fillings
- By the end find more to do, Never ending treadmill of restoring
Need to assess reason
- Poor cleaning OH
- Sugar diet
- High risk of caries
- Radiotherapy/medications - dry mouth
assess and address before restorations
why do you need to address the reason for caries prior to restorations
Reduce amount of restorations needed in future
Poor saliva or high sugar intake need to change balance in mouth to promote remineralisation
Teach good technique for brushing rather than just prescribing high Fluoride
4 reasons for caries
- Poor cleaning OH
- Sugar diet
- High risk of caries
- Radiotherapy/medications - dry mouth
what is the optimal choice for caries removal
self cleansing
root caries
caries (type V)
- Around root on smooth buccal/labial surface
- Oral hygiene not satisfactory
- On medication etc
Need to teach OH to be successful
- Teach to brush teeth
- Stop progression of disease
- To hard and arrested caries
what do damaged/worn lesions look like but aren’t active carious lesions
Hard
Shiny
no pain
tertiary dentine laid down
4 stage theory of partial caries removal
access cavity
- you need to see
- straight line access like endo
remove caries at periphery and ADJ soft
- unsupported enamel
remove infected dentine soft
- if you can, too deep may not want to remove all to protect pulp
maximise cavity for longevity
- saucer shape = not retentive
- shape well for material of use
3 issues encountered with partial caries removal in real life
Saliva
- Harder to see and restore
Patients
- Poor OH, not compliant, not doing ideal practices for restoration
Different materials
5 stages in stepwise caries removal
Access cavity (you need to see)
Remove caries at periphery and ADJ
Remove infected dentine (if you can)
Maximise cavity for longevity
Difference
- Few months later go back into cavity and restore with more permanent material
extra stage in stepwise caries removal
Few months later go back into cavity and restore with more permanent material
3 ways to encounter the pulp if you expose it
Vital
Not hyperaemic
No pain or transient
when can you directly pulp cap
small amount of bleeding but not profuse and
no pain/intermittent pain
3 materials used in direct pulp cap
MTA
RMGI (less optimal)
CaOH
Not ledermix/ odotopaste
- Designed to kill pulp
But aim is to maintain pulpal vitality
pulpotomy
Take pulp out of pulp chamber and leave in base of RCT
Less optimistic for permanent teeth (closed apices)
Sometimes used on wisdom
when can you use partial caries removal technique
not exposed the pulp, no pulp cap needed
take away all decay
RMGI lining for partial caries removal
can lead to less irritation
- over caries/deepest point
GI/Composite/Amalgam
Less likely to have difference in success over RMGI lining, depends on clinical situation
when wouldn’t amalgam be used in a clinical situation
Smooth surface deep lesion
material for Upper left central
Supragingival and Deep lesions
composite
material for Deep restoration on molar tooth
Box is subgingival
amalgam or gold inlay
how are partial caries removals reviewed
radiographically
used of RMGI
liner
- vitrebond
extra step in stepwise caries removal
6 months later re-enter
Remove hardened dentine and restore
- Good seal, remineralise, restore properly
what is better stepwise caries removal or Partial caries removal
PCR is better – higher vitality and similar failure rates
Pick the easier option
comparison of PCR over stepwise
PCR: 1 visit
stepwise: 2 visits
vitality (3 years)
- PCR: 96%
- stepwise: 83%
failure rate
- similar
