Principles of caries management Flashcards
Define caries
- instigation
- consequence
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
What processes causes the cycle between a sound tooth and a tooth with early caries?
Demineralisation and remineralisation
What will further demineralisation of a tooth with early caries cause?
What will restoration of a tooth with early caries cause?
Extensive caries
Restored and vital tooth
How can a tooth with extensive caries become healthy again?
Restoration
Name 4 causative factors of demineralisation (caries)
Diet (high in sugars)
Oral hygiene (plaque)
Oral microbiota
Host factors (saliva flow)
Name 6 preventative measures
Diet (low in sugars) Oral hygiene Fissure sealants Fluoride Biological management Population measures
Name the 3 most common areas for caries to start
Pits and fissures (especially in more posterior teeth)
Interproximally
Gingival margins
Why does caries spread slower through enamel than other hard tissues?
High HA crystals concentration
When caries reaches the ADJ from pits and fissures how does it spread and what is the goal of restorative dentistry at this point?
Spreads on a wide front, out and under cusps, simultaneously pulp wards
Goal is to avoid damage to the pulp
Where is the most common site of caries? why?
Interproximal recuasse hardest to clean especially if you don’t floss
Why are exposed gingival margins less resistant to caries?
Dentine and cementum exposed which have less HA crystals so less resistant than enamel
At what point does treatment for caries shift from reversible to thinking about restoration?
When it reaches the dentine
How can occlusal caries form such large lesions?
Many potential starting points which can fuse as they grow§
When caries reaches the ADJ from approximal lesions how does it spread?
Spreads in a vertical line, simultaneously pulpward
What 3 factors are necessary for clinical examinations when diagnosing caries?
Good illumination
Clean teeth
Dry teeth (stops refractive index blocking sight of the white spot lesion)
What equipment may be necessary for clinical examinations when diagnosing caries?
Magnification (loupes)
Ortho-seperators = temporary separations so you can see between the tooth
Rounded/ball ended explorers
Name the caries diagnosis indices
International caries detection and assessment system (ICDAS)
Describe ICDAS
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
What are the 3 steps of ICDAS?
Monitoring
Dento-legal purposes
Aids patient treatment planning
What is the first technique that must be used for caries diagnosis? Why?
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
What 3 kinds of radiographs are used to diagnose caries?
Bitewings and dental panoramic tomography DMT and periodical = more detailed bitewings
Other than clinical examination and radiographs, what other aids can be used to diagnose caries? (4)
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
Why are dyes not recommended for caries diagnosis?
They can also stain dentine swell as bacteria which could cause over treatment
Name the 3 approaches for management of caries
Traditional
Contemporary
New thinking
Describe the traditional approach to caries management.
Why is it no longer used?
Remove any high risk areas e.g. whole fissure cut out and filled
Very destructive
Describe the contemporary approach to caries management.
What are the negatives?
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
What are the 3 techniques used in the new thinking approach?
Stepwise excavation technique
Ultraconservative (incomplete/selective excavation)
No removal, just sealing
What is the stepwise excavation technique?
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
What is the ultraconservative technique?
Only enter the tooth want, leaving some infected dentine near the pulp
What evidence suggests new thinking approach is the best?
Less exposure
No difference in pulpal symptoms or restoration failure
Cost effective
What are the problems with new thinking approach?
Patient compliance/attendance (especially with stepwise)
Regular recalls essential
Misdiagnosis on a radiograph
What is the hall technique?
A technique used in new thinking approach on primary molars. Non-invasive
Describe the hall technique
Seal caries in primary molars with any caries removal or preparation
What is the FiCTION trail?
Trial comparing prevention, seal in and contemporary approached in primary molars
What philosophy is the patient-centred minimum intervention care cycle based upon?
Minimally invasive dentistry (MID)
Describe the patient-centered minimum intervention care cycle.
- patient assessment/diagnosis
- non-operative prevention of lesions/control of disease
- minimally invasive operative intervention
- review
How is caries risk categorised?
- Caries active/controlled/low risk
- Caries active/modifiable risk factors/moderate risk
- Caries active/unmodifiable or unidentifiable risk/high risk
What are the contemporary approach option, in order from least severe to severe?
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
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?
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
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?
Just monitor because it is progressing very slowly. Prevention = oral hygiene and monitoring
After enamel biopsy what should you do?
PRR
25 year old patient, no other caries or restoration. Deep lesion on occlusal surface. What do you do?
Very least enamel biopsy, likely PRR but maybe conventional restoration
7 year old patient, no other caries, good oral hygiene and diet, ideal fluoride exposure. Deep lesion on primary tooth. What do you do?
Monitor
7 year old patient, all primary molars extracted due to caries. lesion on primary tooth. What do you do?
Fissure sealant and radiograph
