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BDS3 Caries Symposium II > methods of caries management > Flashcards

methods of caries management Flashcards

1
Q

stages of tooth decay

A

iceberg

  • extensive decay
    • lesions into the pulp
    • clinically detectable lesions in dentine
  • moderate decay
    • clincally detectab;e ‘cavitites’ limited to enamel
  • initial decay
    • clinically detectable enamel lesions with ‘intact’ surfaces
  • very early stage decay
    • small lesionn dectectable only with additional diagnostic aids
    • sub-clinical intial lesions in dynamic state of progression/regression
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2
Q

aetiology risk factors for caries

A

caries needs

  • tooth
  • diet - amount, composition, frequency
  • bacteria in biofilm
  • time

influenced by (oral environmental factors)

  • plaque pH
  • microbial species
  • chewing gum
  • Fluoride
  • dental sealants
  • antibacterial agents
  • salive - buffering capacity, composition, flow rate
  • proteins
  • sugars - clearance rate, frequency
  • Ca2+ and PO43-

impacted by (personal factors)

  • sociodemographic status
  • education
  • behaviour - OH, smoking
  • OH literacy and awareness
  • attitudes
  • Dental insurance
  • income
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3
Q

detection

A

determining the presence or absence of a disease

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4
Q

diagnosis

A
  • determining the presence or absence of the disease,
  • knowing whether or not the disease is active or arrested such that, appropriate treatment can be planned
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5
Q

diagnosis of caries may require

A
  • Plaque Chart
  • Full mouth prophylaxis
  • Good lighting
  • Inspect without drying for dentinal shadowing (best seen in wet conditions)
  • Dry tooth with three in one for 5-10 seconds
  • Use of 2.5 X magnification is recommended

CPITN probe can be used gently remove debris from fissures, to conform visual impression of borderline cavitation and to determine the consistency of carious dentine.

Good quality Bitewings

Temporary elective tooth separation (TETS).

  • All lesions between the in inner half of enamel and the in outer half of dentine should have TETS performed to confirm cavitation.
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6
Q

special tests for caries Dx

A
  • transillumination
  • FOTI
  • diagnodent
  • plaque pH
  • salivary flow rate
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7
Q

what does management of caries depend on

A

its location

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8
Q

pit and fissure caries

direct visual assessment

A
  • Naked eye
    • (sharp eyes, clean, dry tooth)
  • Magnified vision
  • Transillumination
  • FOTI
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9
Q

coronal caries

visual detection

A
  • Enamel discoloration +/- surface destruction
    • correlates with caries in outer quarter of dentine
  • normal enamel translucency after 5sec drying
  • enamel opacity after 5sec drying
  • enamel opacity without drying
  • enamel opacity with local surface destruction
  • surface breakdown opaque enamel
  • surface breakdown discolored /opaque enamel
  • enamel cavity into dentine
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10
Q

caries Dx score 0=

A

no/slight change after drying

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11
Q

caries dx score 1=

A

opacity visible after drying

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12
Q

caries Dx score 2=

A

opacity visible without drying

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13
Q

caries dx score 3=

A

localised enamel breakdown in opaque/discoloured enamel +/- discolouration from underlying dentine

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14
Q

caries Dx score 4=

A

cavity in enamel exposing underlying dentine

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15
Q

tactile assessment of dental caries used when

A

not for enamel caries

excellent for dentine caries

  • residual caries in cavity
  • root caries
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16
Q

why not to probe enamel caries

A
  • breakdown of fragile surface zone preventing potential remineralisation
  • high incidence of false positives
    • i.e. probe sticks in a sound fissure
  • occlusal caries often starts at the sides of a fissure rather than at the base
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17
Q

Dx caries location

A

posterior smooth surface (proximal) caries

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18
Q

dx caries location

A

anterior smooth surface (proximal) caries

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19
Q

3 things to look for in direct visual assessment of caries

A
  • deminerlisation
  • uptake of stain
  • cavitation
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20
Q

transillumination caries detection

A
  • Carious lesions absorb light
  • Surgery light
    • Proximal, anterior lesions
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21
Q

bitewing radiographs caries detection

A

more posterior

  • approximal lesions for:
    • intervention
    • prevention
  • safety net for occlusal lesions

there but not if cavitated (reach that point of no return)

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22
Q

Temporary elective tooth separation

A
  • Interproximal caries only
  • Orthodontic separator between teeth
  • Review minimum 2 days later (can leave 1 week/5 days)
  • Inspect surface for cavitation
  • Take a silicone impression of approximal surface

ensure get below contact point, half remaining occlusally, probe will drop when dragged through

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23
Q

Study of ~1500 permanent and ~750 primary approximal surfaces

Comparison of radiographic extent of caries with presence of cavitation

radioluncency outer half enamel =

A

0% cavitation

no need to operate - but hard to see

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24
Q

Study of ~1500 permanent and ~750 primary approximal surfaces

Comparison of radiographic extent of caries with presence of cavitation

radiolucency in inner half enamel =

A

10.5% cavitation

sometimes need to operate, mainly dealt with preventatively

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25
Q

Study of ~1500 permanent and ~750 primary approximal surfaces

Comparison of radiographic extent of caries with presence of cavitation

radiolucecny in outer hald dentine =

A

40.9% cavitation

commonly need to operate but not always

  • but often always do and start the never ending restoration cycle
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26
Q

Study of ~1500 permanent and ~750 primary approximal surfaces

Comparison of radiographic extent of caries with presence of cavitation

radiolucency inner half dentine =

A

100% cavitation

always need to operate

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27
Q

descriptors for smooth suface/root caries

A
  • Primary or secondary
  • Described according to surface of tooth affected
    • E.g. Buccal, proximal etc.
  • Active, arrested or remineralised
28
Q

diagnosis for smooth surface/root caries

A
  • Clean teeth
    • can’t see caries under plaque
  • Tactile assessment
    • use a ball ended probe!
  • Visual assessment
    • position in relation to gingival margin
      • at gingival margin – more likely to be active
      • away from margin – les likely (white spots)
    • dimensions of lesion
    • colour of root caries (less reliable than tactile)
29
Q

clinical signs as indicators of caries disease activity (4)

A
  • Texture - key
    • soft lesions have higher bacterial loads and are more likely to be active - probably the best indicator.
  • Colour
    • lighter coloured lesions have higher bacterial loads - but colour alone is NOT a reliable indicator
  • Site
    • softer, lighter-colored lesions tend to be < 1mm from gingival margin whereas harder, darker-colored lesions tend to be >1mm from gingival margin
  • Size
    • larger lesions tend to be light brown or yellow
    • smaller lesions tend to be darker brown
30
Q

indication for non-operative intervention

A
  • hard, dark-colored lesion, > 1mm from gingival margin
  • does not trap plaque
  • not rapidly progressing
  • patient able to participate in non-operative management
31
Q

ADA caries classification system

sound

A
32
Q

ADA caries classification system

initial

A
33
Q

ADA Caries classification system

moderate

A
34
Q

ADA caries classification system

advanced

A
35
Q

secondary caries

A

For 94% amalgam and 24% composites the site of secondary caries is cervical.

75% operative dentistry is replacement existing restorations (2o caries most common reason for failure)

Criteria for 2o caries diagnosis uncertain

  • Wide ditches (will admit a periodontal probe) or frankly carious outer lesions should prompt restoration replacement
    • Use of colour change alone will result in unnecessary replacement of restorations
      • Residual staining within a cavity may be exogenous in nature
  • If margins in tact there is no indications of on going caries below*
  • Works from outside restoration and leaks into restoration
36
Q

non-operative caries management

A

Try to adapt the 4 factors to reduce caries

  • Dietary analysis
    • To reduce the amount of simple carbohydrates (i.e. reduce substrate)
  • Oral Hygiene Instruction inadequate for root and smooth caries
    • To remove plaque regularly (i.e. reduce bacteria on teeth)
    • Tooth brushing and interdental cleaning
  • Increase Fluoride exposure
    • To tip balance towards remineralisation
37
Q

non-op caries management

High F toothpaste

A
  • One systematic review (Walsh et al., 2010) has evaluated six studies…. Toothpastes with fluoride in the range 2400-2800ppmF were significantly more effective at reducing caries than those toothpastes with fluoride in the range 1000-1500ppmF.
  • 186 patients, double blind RCT, 6/12 5000ppmF
    • Significantly harder
    • Sig. further from gingival margin
    • Sig. Fewer bacteria

not cost effective for low risk groups

38
Q

non-op caries management

F varnish

A
  • substantially reduced the caries increment for the target population in most studies, however the size of effect varied widely between studies (range 20-82%)
  • at risk
    • full mouth
    • every 3-6 months

not cost effective for low risk groups

39
Q

non-op caries management

Silver Diamine Fluoride

A

no AGP – covid 19 pandemic increased interest

  • 20 clinical studies conducted worldwide demonstrated the success of SDF.
  • A recent review stated that applying a 38% solution of SDF to children, adolescents (with mixed dentations), and elderly (age >60 y) produced similar results
  • Compared with topical fluoride or fluoride varnishes, SDF produced caries arrest in 96.1% compared with fluoride 21.3%
    • turn teeth black – aesthetics,
40
Q

non-op caries managment

CPP-ACP

A
  • CPP - Casein Phosphopeptide stabilises
  • ACP - Amorphous Calcium Phosphate
  • Plus - contains F- in addition*
  • NB Adjunctive effect - Also seems to ‘lighten’ teeth!*
  • Remineralises subsurface enamel
  • Based on anticaries effect of cheese
  • Casein peptides dissolve into plaque and supersaturate Calcium and Phosphate ions from ACP, Thereby, promoting remineralisation

Mixed results

41
Q

non-op caries management

ICON

A
  • Etch the lesion
  • Dry the lesion
    • Ethanol
      • Gets ride of porous enamel
  • resin Infiltrate the lesion

demineralisation causes crystallites to be spaced by water,

useful for post orthodontic – as patchy teeth

42
Q

non-op caries management according to risk level

A
  • Don’t want to use everything on low risk patients*
  • Build up Tx according to risk level*
43
Q

disease type of caries

A

biological

not mechanical

44
Q

opterative treatment of caries when

A

“Dental restorations are only indicated when lesions have advanced to obvious cavitation and where remineralisation techniques have reached their limits”.

“Contemporary management of these lesions should use the least invasive solutions and preserve the maximum amount of sound tissue. All clinical stages of restorative procedures should be optimised, with prevention of disease recurrence as the ultimate goal”

45
Q

5 aims of operative treatment of caries

A
  • Restore significant loss of dental tissue
  • Eliminate plaque retention/stagnation
  • Restore physiological masticatory function
  • Minimise the risk of recurrent disease
  • Restore aesthetics where appropriate.
46
Q

assessment of primary coronal caries

A
  • Visual assessment
    • cavitated lesions
    • Enamel discolouration +/- localised surface destruction
    • plaque trap area
  • Tactile assessment
    • cavitated lesions
47
Q

assessment of secondary caries

A
  • Visual assessment
    • frankly carious lesions
    • plaque trap area
  • Tactile assessment
    • ditches wide enough to admit a periodontal probe
48
Q

assessment of root surface caries

A
  • Visual assessment
    • pale-coloured or black lesion, < 1 mm from gingival margin
    • plaque trap
    • patient unable to participate in non-operative management
  • Tactile assessment
    • soft feel with sharp probe

start with prevention and OH, F

49
Q

1st option for caries management

what would Tx be here for lower E

A

do nothing

  • Enamel fractured so lesion now self-cleansing so no need to intervene, may need to tidy to ease access
50
Q

2nd option for caries managment (when doing nothing is not viable)

A

starve them

resin fissure sealants

51
Q

fissure sealing occlusal caries

works by

A

Effect of an autopolymerising sealant on the viability of microflora in occlusal dentine caries Jensen and Handelman. Scand. J. Dent Res. 1980

  • Acid etch decreases viable bacteria by 75%
  • 99.9% decrease in dentine bacteria after 12 months compared with day 1

Slow progression rate

Some evidence of remineralization of dentine in teeth with vital pulps

“When occlusal caries is visible radiographically, the lesion extends into the middle third of dentine and is heavily infected.”

“when a fissure sealant is placed over such lesions there is a significant reduction in the number of cultivable microorganisms”

“Such lesions appear to arrest and no increase in lesion size has been found radiographically over a period of two years.”

  • No symptoms of pulpitis or loss of vitality.
52
Q

when to intervene for restoration for caries and how??

A
  • Extensive occlusal caries
  • Dull grey staining of dentine below,
  • brown peripheral staining,
  • cavity centrally
  • High risk of pulpal involvement and exposing the pulp if remove all caries
    • Remove overhanging, unsupported enamel
    • Hand excavation or slow speed to remove soft dentine
    • when reach hard sharp dentine so have periphery of sound enamel and dentine, can be left – will starve residual MO
53
Q

4 tx options for deeper carious lesions

A
  • non-selective removal of carious tissue to hard dentin – keep going to all removed, most likely to have carious exposure
  • selective removal to firm dentin - leathery
  • stepwise excavation treatment – remove and come back months later
  • selective removal to soft dentine – leave all soft dentine behind
54
Q

selective removal to firm dentine

A
  • Pulp exposure is expected to occur when SRFD is performed in deep carious lesions.
  • Direct pulp capping. A survival rate of 30% after 1 and 3 years of follow-up
  • 10 year survival rate of 13%. Barthel et al.
  • very poor prognosis for tooth vitality in long term
55
Q

stepwise excavation

A
  • Avoid pulp exposure and consequently increase tooth vitality
    • removal all firm dentine was worse then leaving some soft
  • Randomized clinical trial Bjørndal et al. [2010] showed a survival rate of 74% after 1 year of follow-up compared with 62.4% after SRFD.*
  • Leave behind soft stained dentine*
56
Q

selective removal to soft dentine

A

Few studies of SRSD with long follow-up periods.

  • Quantitative and qualitative radiographic assessment over a 10-year period of SRSD showed an increased radiopacity of the carious dentin left in the cavity floor, showing mineral deposition [Alves et al., 2010].

The survival rate of the therapy was 90% after 3 years, 82% after 5 years, and 63% at 10 years of follow-up.

  • When the failures caused by fracture were disregarded, success rates increased to 93 and 80% at the 5- and 10-year recalls [Maltz et al., 2011]
57
Q

Stepwise (SW) vs Selective Removal to Soft Dentine (SRSD)

A
  • No association between pulp necrosis and gender, age, and filling material (amalgam or resin) after 5 years.
  • The pulp vitality survival rate after 3 years was 78% for SRSD compared with 53% for SW treatment
  • The higher number of incomplete SW treatments may explain this difference between treatments.
  • The comparison of survival rates between teeth that had completed (n = 114) and incomplete SW (n = 26) indicated 88 and 5% after 5 years of follow-up
  • Completed SW presented survival rates similar to those of SRSD
  • After incomplete removal of deep caries, pulpal failure was more common than non-pulpal failure. Schwendicke et al. [2013]
    • SRSD reduces risk of pulpal failure compared to SW
    • SRSD compared with SW reduces the risk of pulpal failure (OR = 0.21, 95% CI: 0.08-0.55).
  • Having caries below a restoration does not affect restoration longevity
58
Q

biodentine used for

A

stepwise

59
Q

biodentine propertie

A

used in stepwise

  • Good pulp interaction – non toxic
  • Similar to MTA, calcium silicate cement
  • Seals dentine well and positive pulp response
60
Q

explain the treatment strategy used here

A

Lesions opened up so OH and F can cause remineralisation

Not aesthetic – need to recreate form of teeth as well as ensure biological soundness of teeth

61
Q

explain the Tx startegy used here

A

remineralise by brushing as lesion easy access for OH

62
Q

discuss a minimally invasive technique approach

A

access buccally (not normal)

  • repair small lesion – without having to remove sound marginal ridge
63
Q

4 aspects of non operaative caries management

A
  • Patient education
    • Generic dental caries education material
    • Personalised Caries risk assessment and feedback
  • Dietary modification
    • Three day diet diary
    • Reduce the frequency and amount of sugar
  • OHI
    • Tooth brushing twice daily
    • Interdental cleaning (Floss/ID brushes)
  • Professional prophylaxis
64
Q

4 things that can be topically applied to help manage caries

A
  • Topical fluoride application
    • Fluoride Toothpaste twice daily
      • 1450 ppm
      • 2800 ppm
      • 5000ppm
    • Fluoride Varnish
  • CPC-APC?
  • Chlorhexidine
  • Silver Diamine Fluoride
65
Q

6 strategies that can be employed for non operative caries management

A
  • Active monitoring
  • Non operative treatment of root caries
  • Non operative management of smooth surface caries
  • Sealing in occlusal caries
  • Resin infiltration
  • Ensuring areas are self cleansing
66
Q

6 strategies for minimally invasive operative caries techniques

A
  • Repair and refurbishment of restorations
  • Preventative resin restoration
  • Ultrasonic minimal preparation
  • Bioactive linings
  • Partial caries removal
  • Stepwise caries excavation
67
Q

6 key principles of minimally invastive techniques

A
  • As little tooth structure as possible should be removed to preserve the strength of the remaining tooth.
  • Take care to protect the adjacent tooth when preparing an approximal restoration,
  • Establish a contact point.
  • The margins should fit, which is a challenge cervically.
  • When deciding to replace a restoration, be very clear as to why this option has been chosen. There are two reasons—new caries or technical failure of the previous restoration.
  • Always consider whether the tooth could be repaired, rather than replacing the restoration.

BDS3 Caries Symposium II (7 decks)

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