Principles of caries management

Question 1

Define caries

• instigation

- consequence

Answer 1

Reversible (in it’s earliest stages) but progressive disease of the dental hard tissue

• action of bacteria upon fermentable carbohydrates in the plaque biofilm on tooth surfaces
• bacterially generated acid demineralisation and ultimately proteolytic destruction of the organic component of the dental tissues

Question 2

What processes causes the cycle between a sound tooth and a tooth with early caries?

Answer 2

Demineralisation and remineralisation

Question 3

What will further demineralisation of a tooth with early caries cause?
What will restoration of a tooth with early caries cause?

Answer 3

Extensive caries

Restored and vital tooth

Question 4

How can a tooth with extensive caries become healthy again?

Answer 4

Restoration

Question 5

Name 4 causative factors of demineralisation (caries)

Answer 5

Diet (high in sugars)
Oral hygiene (plaque)
Oral microbiota
Host factors (saliva flow)

Question 6

Name 6 preventative measures

Answer 6

Diet (low in sugars)
Oral hygiene 
Fissure sealants
Fluoride
Biological management
Population measures

Question 7

Name the 3 most common areas for caries to start

Answer 7

Pits and fissures (especially in more posterior teeth)
Interproximally
Gingival margins

Question 8

Why does caries spread slower through enamel than other hard tissues?

Answer 8

High HA crystals concentration

Question 9

When caries reaches the ADJ from pits and fissures how does it spread and what is the goal of restorative dentistry at this point?

Answer 9

Spreads on a wide front, out and under cusps, simultaneously pulp wards
Goal is to avoid damage to the pulp

Question 10

Where is the most common site of caries? why?

Answer 10

Interproximal recuasse hardest to clean especially if you don’t floss

Question 11

Why are exposed gingival margins less resistant to caries?

Answer 11

Dentine and cementum exposed which have less HA crystals so less resistant than enamel

Question 12

At what point does treatment for caries shift from reversible to thinking about restoration?

Answer 12

When it reaches the dentine

Question 13

How can occlusal caries form such large lesions?

Answer 13

Many potential starting points which can fuse as they grow§

Question 14

When caries reaches the ADJ from approximal lesions how does it spread?

Answer 14

Spreads in a vertical line, simultaneously pulpward

Question 15

What 3 factors are necessary for clinical examinations when diagnosing caries?

Answer 15

Good illumination
Clean teeth
Dry teeth (stops refractive index blocking sight of the white spot lesion)

Question 16

What equipment may be necessary for clinical examinations when diagnosing caries?

Answer 16

Magnification (loupes)
Ortho-seperators = temporary separations so you can see between the tooth
Rounded/ball ended explorers

Question 17

Name the caries diagnosis indices

Answer 17

International caries detection and assessment system (ICDAS)

Question 18

Describe ICDAS

Answer 18

Scale of 0-4
0 = no/slight change in enamel translucency after prolonged drying and no demineralisation
4= gross cavitation in opaque/discoloured enamel exposing underlying dentine, with demineralisation involving inner 1/3 of dentine towards pulp

Question 19

What are the 3 steps of ICDAS?

Answer 19

Monitoring
Dento-legal purposes
Aids patient treatment planning

Question 20

What is the first technique that must be used for caries diagnosis? Why?

Answer 20

Clinical examination, because it can only be seen on radiographs if it has progressed enough through the enamel or is not on the occlusal surface

Question 21

What 3 kinds of radiographs are used to diagnose caries?

Answer 21

Bitewings and dental panoramic tomography DMT and periodical = more detailed bitewings

Question 22

Other than clinical examination and radiographs, what other aids can be used to diagnose caries? (4)

Answer 22

Transillumination
Fluorescence
Electrical (conductance or impedance) - teeth won’t normally conduce because made of HA crystals, other products formed from bacteria may result in conductance
Dyes

Question 23

Why are dyes not recommended for caries diagnosis?

Answer 23

They can also stain dentine swell as bacteria which could cause over treatment

Question 24

Name the 3 approaches for management of caries

Answer 24

Traditional
Contemporary
New thinking

Question 25

Describe the traditional approach to caries management. | Why is it no longer used?

Answer 25

Remove any high risk areas e.g. whole fissure cut out and filled Very destructive

Question 26

Describe the contemporary approach to caries management. | What are the negatives?

Answer 26

Enamel biopsy if there is suspected caries and the preventative resin restoration if caries reached ADJ. Treat each lesion separately, conserving as much tooth as possible using resin. Just treating the affected area Protect (fissure sealant) high risk areas rather than removing them. But, technique depends on early detection, if the caries has spread FS will be inappropriate

Question 27

What are the 3 techniques used in the new thinking approach?

Answer 27

Stepwise excavation technique Ultraconservative (incomplete/selective excavation) No removal, just sealing

Question 28

What is the stepwise excavation technique?

Answer 28

Step by step method to remove caries to prevent it reaching the pulp. First, enter the tooth and remove most of the lesion, leaving some over the plural floor and place a temporary restoration, this is left for 6-9 months causing lower risk of damage to the pulp. re-enter the tooth and take away arrested dentine especially at ADJ, put in permanent restoration

Question 29

What is the ultraconservative technique?

Answer 29

Only enter the tooth want, leaving some infected dentine near the pulp

Question 30

What evidence suggests new thinking approach is the best?

Answer 30

Less exposure No difference in pulpal symptoms or restoration failure Cost effective

Question 31

What are the problems with new thinking approach?

Answer 31

Patient compliance/attendance (especially with stepwise) Regular recalls essential Misdiagnosis on a radiograph

Question 32

What is the hall technique?

Answer 32

A technique used in new thinking approach on primary molars. Non-invasive

Question 33

Describe the hall technique

Answer 33

Seal caries in primary molars with any caries removal or preparation

Question 34

What is the FiCTION trail?

Answer 34

Trial comparing prevention, seal in and contemporary approached in primary molars

Question 35

What philosophy is the patient-centred minimum intervention care cycle based upon?

Answer 35

Minimally invasive dentistry (MID)

Question 36

Describe the patient-centered minimum intervention care cycle.

Answer 36

1. patient assessment/diagnosis 2. non-operative prevention of lesions/control of disease 3. minimally invasive operative intervention 4. review

Question 37

How is caries risk categorised?

Answer 37

1. Caries active/controlled/low risk 2. Caries active/modifiable risk factors/moderate risk 3. Caries active/unmodifiable or unidentifiable risk/high risk

Question 38

What are the contemporary approach option, in order from least severe to severe?

Answer 38

``` Leave and observe (prevention) Fissure sealant when just in enamel Enamel biopsy and FS Enamel biopsy leading to PRR when decay in dentine Conventional restoration ```

Question 39

12 year old patient with caries in primary teeth. They have poor oral hygiene. No obvious decay can be seen on radiograph, but can be seen clinically. What do you do?

Answer 39

Enamel biopsy because they are young and moderate risk. The radiograph doesn't show anything conclusive so you need to investigate further. PRR/FS to fill enamel biopsy, depending on findings

Question 40

82 year old patient with caries in UR6, she has no other fillings. No obvious decay can be seen on radiograph, but can be seen clinically. What do you do?

Answer 40

Just monitor because it is progressing very slowly. Prevention = oral hygiene and monitoring

Question 41

After enamel biopsy what should you do?

Answer 41

PRR

Question 42

25 year old patient, no other caries or restoration. Deep lesion on occlusal surface. What do you do?

Answer 42

Very least enamel biopsy, likely PRR but maybe conventional restoration

Question 43

7 year old patient, no other caries, good oral hygiene and diet, ideal fluoride exposure. Deep lesion on primary tooth. What do you do?

Answer 43

Monitor

Question 44

7 year old patient, all primary molars extracted due to caries. lesion on primary tooth. What do you do?

Answer 44

Fissure sealant and radiograph