Methods of Caries Management, the biological approach Flashcards
What is detection
Determining the presence or absence of the disease
What is diagnosis
○ Determining the presence or absence of disease
Knowing whether or not the disease is active or arrested so appropriate treatment can be planned
What is required for diagnosis
○ Plaque chart
○ Full mouth prophylaxis
○ Good lighting
○ Inspect without drying for dentinal shadowing (best seen in wet conditions)
○ Dry tooth with 3 in 1 for 5-10 seconds
○ Use of magnification
○ CPITN probe can be used to gently remove debris from fissures, to look for cavitation and to look for the consistency of any caries
○ Good quality bitewings
○ Temporary elective tooth separation (TETS)
All lesions between the inner half of enamel and the in outer half of dentine should have TETS performed to confirm cavitation
What are examples of special tests
- Transillumination
- FOTI
- Diagnodent
- Plaque pH
Salivary flow rate
What does a direct visual assessment consist of
○ Using the naked eye (sharp eyes, clean, dry tooth)
○ Magnified vision
○ Transillumination
FOTI
What are the different levels of coronal caries which can be detected visually
○ Normal enamel translucency after 5 seconds of drying
○ Enamel opacity after 5 seconds of drying
○ Enamel opacity without drying
○ Enamel opacity with local surface destruction
○ Enamel discolouration +/- surface destruction
§ Correlates with caries in outer quarter of dentine
○ Surface breakdown opaque enamel
○ Surface breakdown discoloured/opaque enamel
Enamel cavity into dentine
What is a 0 in visual detection of coronal caries
no/slight change after drying
There is no histological signs of caries
What is a 1 in visual detection of coronal caries
A little bit of demineralisation seen in fissure pattern but limited to enamel
opacity visible after drying
What is a 2 in visual detection of coronal caries
opacity visible without drying
○ Can see white demineralised opacity in fissure system without drying
○ Historically the caries has reached the ADJ
○ There is very minimal dentine involvement
What is a 3 in visual detection of caries
localised enamel breakdown in opaque/discoloured enamel +/- discolouration from underlying dentine
○ The white lesion is in enamel and has further spread, it is in the outer quarter of dentine
How do you differentiate from fissure staining and caries
○ Opacity is important as this is different from exogenous staining
○ If it is translucency but dark stain is seen in the middle of the fissure then most likely exogenous staining
What is a 4 in visual detection of caries
cavity in enamel exposing underling dentine
If there is a cavity and a periphery of demineralisation then there is significant dentinal involvement
What is tactile assessment of dental caries used for
NOT enamel caries
excellent for dentine caries
Why do we not use tactile assessment for enamel caries
○ Probing enamel caries can result in the breakdown of fragile surface zone preventing potential remineralisation
○ High incidence of false positives are seen as probe may stick in a sound fissure
Occlusal caries often starts at the sides of a fissure rather than a base so not effective
When is tactile assessment useful for dentine caries
○ Residual caries in a cavity
Root caries
How can you see proximal caries via visual assessment
Demineralisation
Uptake of stain
Normally happens below contact point Cavitation
Can slide a probe through and feel
May be able to see it buccally or lingually through visualisation
What is transillumination
- Carious lesions absorb light
- The surgery light can be used although easier to do that anteriorly but there are tools available to be able to do so posteriorly too
What are bitewing radiographs useful for
- Essential for approximal lesions for ○ Intervention ○ Prevention - Gives us an idea of patient risk Safety net for occlusal lesions
What is temporary elective tooth separation
- Interproximal caries only, allows us to check for cavitation, something a radiograph can’t do
- Orthodontic separator between teeth
- Review minimum 2 days later (usually seen 5 days later) but can leave for a week
- Inspect surface for cavitation
- Take a silicone impression of approximal surface
What does radiolucency in outer half of enamel correlate to
0% cavitation so no need for intervention
What does radiolucency in inner half of enamel correlate to
10.5% cavitation
What does radiolucency in outer half of dentine correlate to
40.9% cavitation
What does radiolucency in inner half of dentine correlate to
100% cavitation
What are the root caries descriptors
- Primary or secondary
- Described according to surface of tooth affected (buccal, proximal, etc)
- Active, arrested or remineralised
How do we diagnose root caries
- Clean teeth as caries cant be seen under plaque
- Tactile assessment using a probe to see if it is hard or soft
- Visual assessment
○ Position in relation to GM
○ Dimensions of lesion
Colour of root caries
What are the clinical signs as indicators of disease activity for root surface caries
texture
colour
site
size
How does texture indicate disease activity for root caries
Soft lesions have higher bacterial loads and are more likely to be active, this is probably the best indicator
How does color indicate disease activity for root caries
Lighter coloured lesions have higher bacterial loads but colour alone is not a reliable indicator
How does site indicate disease activity for root caries
Softer, lighter coloured lesions tend to be <1mm from GM whereas harder, darker coloured lesions tend to be >1mm from the gingival margin
How does size indicate disease activity for root caries
○ Larger lesions tend to be light brown or yellow
Smaller lesions tend to be darker brown
What are the indications for non operative interventions for root surface caries
○ Hard, dark coloured lesion, >1mm from GM
○ Does not trap plaque
○ Not rapidly progressing
Patient able to participate in non-operative management
What is secondary caries
Secondary caries begins on the outside and seeps its way in
For most amalgam and a fifth of composites the site of secondary caries is cervical
What is the secondary caries diagnosis criteria
Wide ditches (which will admit a perio 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
What is the non operative management
dietary analysis OHI increase fluoride exposure chlorhexidine varnish silver diamine fluoride CPPAPP ICON
How do we increase fluoride exposure
○ To tip balance towards remineralisation
○ A study showed that toothpastes with high fluoride concentrations of 2400-2800 ppm are more effective at reducing caries than 1000-1500 ppm but high concentration is expensive so more economical to only use for high risk
○ For patients who used a 5000ppm fluoride toothpaste for primary root caries they found that the caries was
§ Significantly harder
§ Significantly further away from GM
§ Significantly fewer bacteria
○ Fluoride varnish
§ For at risk patients
□ Place on full mouth every 3-6 months depending on risk
What is silver diamine fluoride
○ Effective at arresting caries, more than topical fluoride and varnishes
Turns teeth black
What is CPPAPP
○ The plus version contains fluoride in addition
○ CPP - casein phosphopeptide stabilises
○ ACP - amorphous calcium phosphate
○ It remineralises subsurface enamel
○ Casein peptides dissolve into plaque and supersaturate calcium and phosphate ions from ACP so promote remineralisation
Effect is debatable
What is ICON
○ Effectively like a fissure sealant but for approximal and smooth surface lesions
When a tooth becomes carious it becomes demineralised and as it does that it becomes softer as enamel prisms and rods are separated by the water and the space has developed and so that acid etches that and the lesion is dried off with ethanol and the resin seeps into the pores in the porous enamel
What is the procedure for ICON
§ Etch the lesion
§ Dry the lesion (ethanol)
Infiltrate the lesion
When is dental restorations indicated
only indicated when lesions have advanced to obvious cavitation and where remineralisation techniques have reached their limit
Should use least invasive solution and preserve maximum amount of sound tissue
What are the functions of a restoration
○ Restore significant loss of dental tissue
○ Eliminate plaque retention/stagnation
○ Restore physiological masticatory function
○ Minimise the risk of recurrent disease
Restore aesthetics where appropriate
When do we operatively intervene in primary coronal caries
○ Visual assessment § Cavitated lesions § Enamel discolouration +/- localised surface destruction § Plaque trap area ○ Tactile assessment Cavitated lesions
When do we operatively intervene in secondary coronal caries
○ Visual assessment § Frankly cavitated lesions § Plaque trap area ○ Tactile assessment Ditches wide enough to admit a perio probe
When do we operatively intervene in root surface caries
○ Visual assessment
§ Pale coloured or black lesion, <1mm away from gingival margin
§ Plaque trap
§ Patient unable to participate in non-operative management
○ Tactile assessment
Soft feel with sharp probe
When are fissure sealants useful
Useful for when occlusal caries is visible radiographically and the lesion extends into the middle third of dentine and is heavily infected, the fissure sealant reduces the number of cultivable microorganisms and these lesions appear to arrest and there is no increase in the size over two years as well as no adverse effects on the pulp
What are the options for deep carious lesions
Non selective removal of carious tissue to hard dentine
Selective removal to firm dentine
Stepwise excavation treatment
Selective removal to soft dentine
What is the disadvantage Non selective removal of carious tissue to hard dentine
Most likely to get pulp exposure
What is the disadvantage of selective removal to firm dentine
§ Leathery feel
§ Pulp exposure expected to occur when performed in deep lesions
If pulp exposure happens then direct pulp capping but this results in a very poor prognosis for tooth vitality in the long term
What is the advantage of stepwise excavation treatment
§ Provide a peripheral seal and seal in the caries then go back in months later
§ Avoid pulp exposure and consequently increase tooth vitality
Greater survival rate than SRFD
What is the selective removal to soft dentine
§ Create a peripheral seal and leave soft dentine behind
Higher survival rate even when compared to step wise technique
Compare SW to SRSD
○ No association between pulp necrosis and gender, age and filling material after 5 years
○ Pulp vitality was higher for SRSD than SW treatment but may be due to incomplete SW techniques, for those completed the survival rates were similar
○ Selective removal to soft dentine reduced the risk of pulp failure
Having caries below the restoration does not affect restoration longevity
What are the topical application options
- Topical fluoride application ○ Fluoride toothpaste twice daily - higher strength for higher risk § 1450 ppm § 2800 ppm § 5000 ppm ○ Fluoride varnish - CPC-APC ○ Evidence still lacking - Chlorhexidine for root caries SDF
What are the non operative options
- Active monitoring
- Non-operative tx for root caries
- Non-operative management for smooth surface caries
- Sealing in occlusal caries
- Resin infiltration
Ensuring all areas are self cleansing
What are the minimally invasive techniques
- Repair and refurbishment of restorations
- Preventative resin restorations
- Ultrasonic minimal reparation (laser, air abrasion)
- Bioactive linings (biodentine)
- Partial caries removal
Step wise excavation
What are the principles of minimally invasive techniques
○ As little tooth structure as possible should be removed
○ Take care to protect the adjacent tooth when preparing approximal restorations
○ Establish a contact point
○ Margin 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 2 reasons, new caries or technical failure of the previous restoration.
Always consider where the tooth could be repaired rather than replacing the restoration
