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BDS3 CLINICAL Caries Symposium II > Methods of Caries Management, the biological approach > Flashcards

Methods of Caries Management, the biological approach Flashcards

1
Q

What is detection

A

Determining the presence or absence of the disease

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2
Q

What is diagnosis

A

○ Determining the presence or absence of disease

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

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3
Q

What is required for diagnosis

A

○ 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

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4
Q

What are examples of special tests

A
  • Transillumination
    • FOTI
    • Diagnodent
    • Plaque pH
      Salivary flow rate
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5
Q

What does a direct visual assessment consist of

A

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

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6
Q

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

A

○ 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

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7
Q

What is a 0 in visual detection of coronal caries

A

no/slight change after drying

There is no histological signs of caries

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8
Q

What is a 1 in visual detection of coronal caries

A

A little bit of demineralisation seen in fissure pattern but limited to enamel

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9
Q

What is a 2 in visual detection of coronal caries

A

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

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10
Q

What is a 3 in visual detection of caries

A

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
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11
Q

How do you differentiate from fissure staining and caries

A

○ 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

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12
Q

What is a 4 in visual detection of caries

A

cavity in enamel exposing underling dentine

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

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13
Q

What is tactile assessment of dental caries used for

A

NOT enamel caries

excellent for dentine caries

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14
Q

Why do we not use tactile assessment for enamel caries

A

○ 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

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15
Q

When is tactile assessment useful for dentine caries

A

○ Residual caries in a cavity

Root caries

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16
Q

How can you see proximal caries via visual assessment

A

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

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17
Q

What is transillumination

A
  • 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
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18
Q

What are bitewing radiographs useful for

A 
- Essential for approximal lesions for
		○ Intervention
		○ Prevention
	- Gives us an idea of patient risk 
Safety net for occlusal lesions
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19
Q

What is temporary elective tooth separation

A
  • 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
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20
Q

What does radiolucency in outer half of enamel correlate to

A

0% cavitation so no need for intervention

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21
Q

What does radiolucency in inner half of enamel correlate to

A

10.5% cavitation

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22
Q

What does radiolucency in outer half of dentine correlate to

A

40.9% cavitation

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23
Q

What does radiolucency in inner half of dentine correlate to

A

100% cavitation

24
Q

What are the root caries descriptors

A
  • Primary or secondary
    • Described according to surface of tooth affected (buccal, proximal, etc)
    • Active, arrested or remineralised
25
Q

How do we diagnose root caries

A
  • 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
26
Q

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

A

texture
colour
site
size

27
Q

How does texture indicate disease activity for root caries

A

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

28
Q

How does color indicate disease activity for root caries

A

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

29
Q

How does site indicate disease activity for root caries

A

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

30
Q

How does size indicate disease activity for root caries

A

○ Larger lesions tend to be light brown or yellow

Smaller lesions tend to be darker brown

31
Q

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

A

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

32
Q

What is secondary caries

A

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

33
Q

What is the secondary caries diagnosis criteria

A 
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
34
Q

What is the non operative management

A 
dietary analysis
OHI
increase fluoride exposure 
chlorhexidine varnish 
silver diamine fluoride
CPPAPP
ICON
35
Q

How do we increase fluoride exposure

A

○ 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

36
Q

What is silver diamine fluoride

A

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

37
Q

What is CPPAPP

A

○ 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

38
Q

What is ICON

A

○ 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

39
Q

What is the procedure for ICON

A

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

40
Q

When is dental restorations indicated

A

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

41
Q

What are the functions of a restoration

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

42
Q

When do we operatively intervene in primary coronal caries

A 
○ Visual assessment
			§ Cavitated lesions
			§ Enamel discolouration +/- localised surface destruction 
			§ Plaque trap area
		○ Tactile assessment 
Cavitated lesions
43
Q

When do we operatively intervene in secondary coronal caries

A 
○ Visual assessment
			§ Frankly cavitated lesions
			§ Plaque trap area
		○ Tactile assessment 
Ditches wide enough to admit a perio probe
44
Q

When do we operatively intervene in root surface caries

A

○ 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

45
Q

When are fissure sealants useful

A

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

46
Q

What are the options for deep carious lesions

A

Non selective removal of carious tissue to hard dentine

Selective removal to firm dentine

Stepwise excavation treatment

Selective removal to soft dentine

47
Q

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

A

Most likely to get pulp exposure

48
Q

What is the disadvantage of selective removal to firm dentine

A

§ 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

49
Q

What is the advantage of stepwise excavation treatment

A

§ 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

50
Q

What is the selective removal to soft dentine

A

§ Create a peripheral seal and leave soft dentine behind

Higher survival rate even when compared to step wise technique

51
Q

Compare SW to SRSD

A

○ 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

52
Q

What are the topical application options

A 
- 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
53
Q

What are the non operative options

A
  • 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
54
Q

What are the minimally invasive techniques

A
  • Repair and refurbishment of restorations
    • Preventative resin restorations
    • Ultrasonic minimal reparation (laser, air abrasion)
    • Bioactive linings (biodentine)
    • Partial caries removal
      Step wise excavation
55
Q

What are the principles of minimally invasive techniques

A

○ 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

BDS3 CLINICAL Caries Symposium II (7 decks)

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