Methods of Caries Management, the biological approach

Question 1

What is detection

Answer 1

Determining the presence or absence of the disease

Question 2

What is diagnosis

Answer 2

○ Determining the presence or absence of disease

Knowing whether or not the disease is active or arrested so appropriate treatment can be planned

Question 3

What is required for diagnosis

Answer 3

○ 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

Question 4

What are examples of special tests

Answer 4

• Transillumination
  
  • FOTI
  • Diagnodent
  • Plaque pH
    Salivary flow rate

Question 5

What does a direct visual assessment consist of

Answer 5

○ Using the naked eye (sharp eyes, clean, dry tooth)
○ Magnified vision
○ Transillumination
FOTI

Question 6

What are the different levels of coronal caries which can be detected visually

Answer 6

○ 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

Question 7

What is a 0 in visual detection of coronal caries

Answer 7

no/slight change after drying

There is no histological signs of caries

Question 8

What is a 1 in visual detection of coronal caries

Answer 8

A little bit of demineralisation seen in fissure pattern but limited to enamel
opacity visible after drying

Question 9

What is a 2 in visual detection of coronal caries

Answer 9

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

Question 10

What is a 3 in visual detection of caries

Answer 10

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

Question 11

How do you differentiate from fissure staining and caries

Answer 11

○ 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

Question 12

What is a 4 in visual detection of caries

Answer 12

cavity in enamel exposing underling dentine

If there is a cavity and a periphery of demineralisation then there is significant dentinal involvement

Question 13

What is tactile assessment of dental caries used for

Answer 13

NOT enamel caries

excellent for dentine caries

Question 14

Why do we not use tactile assessment for enamel caries

Answer 14

○ 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

Question 15

When is tactile assessment useful for dentine caries

Answer 15

○ Residual caries in a cavity

Root caries

Question 16

How can you see proximal caries via visual assessment

Answer 16

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

Question 17

What is transillumination

Answer 17

• 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

Question 18

What are bitewing radiographs useful for

Answer 18

- Essential for approximal lesions for
		○ Intervention
		○ Prevention
	- Gives us an idea of patient risk 
Safety net for occlusal lesions

Question 19

What is temporary elective tooth separation

Answer 19

• 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

Question 20

What does radiolucency in outer half of enamel correlate to

Answer 20

0% cavitation so no need for intervention

Question 21

What does radiolucency in inner half of enamel correlate to

Answer 21

10.5% cavitation

Question 22

What does radiolucency in outer half of dentine correlate to

Answer 22

40.9% cavitation

Question 23

What does radiolucency in inner half of dentine correlate to

Answer 23

100% cavitation

Question 24

What are the root caries descriptors

Answer 24

• Primary or secondary
  
  • Described according to surface of tooth affected (buccal, proximal, etc)
  • Active, arrested or remineralised

Question 25

How do we diagnose root caries

Answer 25

• 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

Question 26

What are the clinical signs as indicators of disease activity for root surface caries

Answer 26

texture
colour
site
size

Question 27

How does texture indicate disease activity for root caries

Answer 27

Soft lesions have higher bacterial loads and are more likely to be active, this is probably the best indicator

Question 28

How does color indicate disease activity for root caries

Answer 28

Lighter coloured lesions have higher bacterial loads but colour alone is not a reliable indicator

Question 29

How does site indicate disease activity for root caries

Answer 29

Softer, lighter coloured lesions tend to be <1mm from GM whereas harder, darker coloured lesions tend to be >1mm from the gingival margin

Question 30

How does size indicate disease activity for root caries

Answer 30

○ Larger lesions tend to be light brown or yellow

Smaller lesions tend to be darker brown

Question 31

What are the indications for non operative interventions for root surface caries

Answer 31

○ Hard, dark coloured lesion, >1mm from GM
○ Does not trap plaque
○ Not rapidly progressing
Patient able to participate in non-operative management

Question 32

What is secondary caries

Answer 32

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

Question 33

What is the secondary caries diagnosis criteria

Answer 33

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

Question 34

What is the non operative management

Answer 34

dietary analysis
OHI
increase fluoride exposure 
chlorhexidine varnish 
silver diamine fluoride
CPPAPP
ICON

Question 35

How do we increase fluoride exposure

Answer 35

○ 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

Question 36

What is silver diamine fluoride

Answer 36

○ Effective at arresting caries, more than topical fluoride and varnishes
Turns teeth black

Question 37

What is CPPAPP

Answer 37

○ 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

Question 38

What is ICON

Answer 38

○ 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

Question 39

What is the procedure for ICON

Answer 39

§ Etch the lesion
§ Dry the lesion (ethanol)
Infiltrate the lesion

Question 40

When is dental restorations indicated

Answer 40

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

Question 41

What are the functions of a restoration

Answer 41

○ Restore significant loss of dental tissue
○ Eliminate plaque retention/stagnation
○ Restore physiological masticatory function
○ Minimise the risk of recurrent disease
Restore aesthetics where appropriate

Question 42

When do we operatively intervene in primary coronal caries

Answer 42

○ Visual assessment
			§ Cavitated lesions
			§ Enamel discolouration +/- localised surface destruction 
			§ Plaque trap area
		○ Tactile assessment 
Cavitated lesions

Question 43

When do we operatively intervene in secondary coronal caries

Answer 43

○ Visual assessment
			§ Frankly cavitated lesions
			§ Plaque trap area
		○ Tactile assessment 
Ditches wide enough to admit a perio probe

Question 44

When do we operatively intervene in root surface caries

Answer 44

○ 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

Question 45

When are fissure sealants useful

Answer 45

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

Question 46

What are the options for deep carious lesions

Answer 46

Non selective removal of carious tissue to hard dentine

Selective removal to firm dentine

Stepwise excavation treatment

Selective removal to soft dentine

Question 47

What is the disadvantage Non selective removal of carious tissue to hard dentine

Answer 47

Most likely to get pulp exposure

Question 48

What is the disadvantage of selective removal to firm dentine

Answer 48

§ 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

Question 49

What is the advantage of stepwise excavation treatment

Answer 49

§ 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

Question 50

What is the selective removal to soft dentine

Answer 50

§ Create a peripheral seal and leave soft dentine behind

Higher survival rate even when compared to step wise technique

Question 51

Compare SW to SRSD

Answer 51

○ 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

Question 52

What are the topical application options

Answer 52

- 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

Question 53

What are the non operative options

Answer 53

• 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

Question 54

What are the minimally invasive techniques

Answer 54

• Repair and refurbishment of restorations
  
  • Preventative resin restorations
  • Ultrasonic minimal reparation (laser, air abrasion)
  • Bioactive linings (biodentine)
  • Partial caries removal
    Step wise excavation

Question 55

What are the principles of minimally invasive techniques

Answer 55

○ 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