Surgical and Non-surgical management of dental caries Flashcards
What are dental caries?
A disease where an ecological shift in the dental biofilm environment driven by frequent
access to fermentable dietary carbohydrates,
leads to a move from a balanced population of
microorganisms of low cariogenicity to a
microbiological population of high cariogenicity
(more aciduric and acidogenic) and to an
increased production of organic acids. This
promotes dental hard tissue net mineral loss
and results in a carious lesion.
How is a carious lesion different to dental caries?
Lesion is the consequence and manifestation o=of the disease dental caries
What is the aim of surgical caries management?
To retain the tooth and the health of its pulp for as long as possible
What are the guiding principles of surgical caries management?
preservation of dental tissues
• maintenance of pulpal health
• avoidance of pulp exposure
• avoidance of dental anxiety (in children and adults alike)
• and provision of sound cavity margins to achieve a peripheral seal
What is the difference between infected dentine and affected dentine?
Bacteria in infected dentine only • Bacterial products extend into affected dentine • Bacterial products advance further into dentine, causing odontoblastic processes to recede, causing “dead tracts” for bacteria to advance into • Gradual breakdown of inorganic and organic components of dentine lead to changing hardness and colour of dentine
How are soft, eathery, firm, and hard dentine different to each other?
Soft: deforms when a hard instrument is pressed into it and can easily be scopped up with little force
Leathery: Does not deformwhen
What are the types of dentine removal?
Non-selective removal to hard dentine (Aim is to remove all soft-carious tissue to reach hard dentine resembling healthy dentine in all parts of the cavity including pulpally.)
Selective removal to firm dentine (excavate until the leathery and firm dentine. All unsupported enamel must be caries free. Need good peripheral seal, if restoration leaks this risks bacterial entry)
Selecting removal to soft dentine (Leaving soft carious dentine in the pulpal aspect of the cavity, DEJ is kept clean, and the peripheral enamel and dentine should be hard at the end of excavation to allow the best adhesive to be used)
Stepwise caries removal (2 stages; stage 1 is selective removal to soft dentine placing temporary filling and step 2 is selective restoration to firm dentine and placement of final restoration this is to allow dentine to repair with tertiary dentine)
No caries removal
What is the effect of performing a restoration over active caries?
Sealing the bacteria does not kill the bacteria but it deprives the bacteria of nutrients so the lesion will not progress.
What does knowing the fact that carious lesions dont progress if restored without leakage help with?
No need to replace a restoration if there is a radiolucency underneath the caries.
What is the most important limitation with stepwise removal?
More than 1/3rd of patients were found not to attend the second appointment
What is the atraumatic restorative technique?
Originally described for use in community settings.
This is a very specific technique (Probably most misused technique)
How is ART performed?
Isolate with cotton wool 2. Clean the tooth surface with a wet cotton pellet 3. Widen the entrance with a hand instrument, e.g. hatchet 4. Remove caries with hand excavator 5. Provide pulpal protection if necessary (setting calcium hydroxide liner) 6. Clean the occlusal surface with probe and wet cotton pellet 7. Condition the cavity and occlusal surface 8. Mix GIC 9. Insert GIC into cavity and slightly overfill, also place over pits and fissures 10.Press Vaseline-coated, gloved finger onto occlusal surface 11.Check the occlusion with articulating paper 12.Remove excess material with a carver 13.Recheck and adjust the occlusion until comfortable 14.Cover filling/sealant with Vaseline or varnish 15.Instruct patient not to eat for at least one hour
Where is ART usually performed?
In a community setting
When should ART be used?
Very technique sensitive
Involves sealing all remaining fissures
Can be considered for use in occlusal cavities
Not recommended for use in occluso-proximal lesions
Not recommended for use in multi-surface lesions
What is chemomechanical caries removal?
Use of sodium-hypochlorite based gels or enzyme-based gels to soften the infected dentine so that it can be removed with a special hand instrument specifically designed to only remove the dentine.
What are the limitations to using chemomechanical caries removal?
local anaesthesia is rarely required
NaOCl-based gels may affect microtensile bond strength (No difference seen with papacarie)
Generally considered to be effective and conservative
Regardless of chosen , operative time is significantly longer
Local analgesia is rarely required
• NaOCl-based gels may affect microtensile bond strength (no difference
seen with Papacarie)
• Generally considered to be effective and conservative
• Regardless of chosen agent, operative time is significantly longer than
other techniques
• CMCR not popular for this reason
What lasers are used for laser caries removal?
2 types used:
Er:YAG (2.94 micrometer wavelength)
Er,Cr:YSGG
What are the advantages to using a laser for caries removal?
Leaves enamel with etched appearance
Does not cause cracking or surface charring as seen with high
What is air abrasion?
Emit stream of aluminium oxide particles under high pressure
What is air abrasion?
Emit stream of aluminium oxide particles under high pressure
What are the disadvantages to using air abrasion?
More effective on hard dentine compared to soft dentine.
Provides no tactile feedback
Bio-active glass compound has been tested in vitro and found to be more effective than silica.
What are polymer burs used for?
Designed to facilitate to removal of carious dentine while limiting removal of healthy dentine.
Made of polymer compound with hardness between that of infected dentine and healthy dentine.
What are caries detector dyes?
Introduced to differentiate between different layers of carious dentine, as
described by original authors: (i) softening, (ii) discolouration, (iii) bacterial
• For practical purposes, dye intended to differentiate between infected and
affected dentine
• Originally red Fuchsian dye used (discontinued due to carcinogenicity) in
propylene glycol carrier
• propylene glycol thought to only penetrate loosened collagen fibres with
broken intermolecular crosslinks
• 1.0% red acid dye, brilliant blue dye, polypropylene glycol carrier all
currently available
• Claimed to reduce the need for local analgesia
What are the disadvantages to using red acid dye?
1.0% red acid dye appears to interact with lactic acid
produced by cariogenic bacteria, leading to staining of
only infected dentine
Further research showed that red acid dye also interacts in different ways as it tends to over-stain around the DEJ and close to the pulp due to differences in dentine mineral content (could lead to excess caries removal in these areas
(and potentially a pulp exposure))
Use relies on subjective determination of colour:
No objective measure leads to differences between practitioners and variations depending on lighting conditions
Dentine colour after caries detector dye and bacterial sampling reveals a poor correlation between colour and bacterial count
Manufacturers recommend removal until “pale pink” but this remains subjective
Some concerns of effect of dyes on dentine bond strength in vitro
What is Fluorescence-Aided Caries Excavation?
FACE
Uses fluorescent light source and camera with special computer software to analyse camera feed
At certain wavelengths, fluorescence of dentine affected by dentine hardness
Has been shown to leave minimal bacteria but remain more conservative than some other techniques
BEWARE: do not confuse with quantitative light fluorescence used for caries detection (e.g. DIAGNOdent) - this has proven unreliable for
determining extent of caries removal
What is the Hall technique?
Involves placement of a stainless steel crown over a primary molar tooth with an active carious lesion without any local analgesia, caries removal or
tooth preparation
Has been described as the biggest discovery in paediatric dentistry in the
last ten years, set to revolutionise children’s dentistry
What are stainless steel crowns?
Preformed metal crowns.
Come in a range of sized
Pre-contoured
Traditional preparation involves occlusal and proximal reductions under LA and rubber dam isolation
How does the hall technique reduce the progression of caries?
Stainless steel crowns seal the carious lesion isolating the bacteria from their nutrients preventing them from growing and preventing the carious lesion from progressing.
92% success rate seen at 4 - 5 years.
When should fissure sealants be used?
Traditionally it is used for prevention.
How effective are fissure sealants at preventing progression of fissure sealants?
As long as the sealant remains intact the lesion will not progress even in dentine.
What is resin inflitration and resin sealing used for?
Management of proximal caries in enamel:
Aim to avoid significant loss of healthy tooth structure
involved with traditional Class 2 tooth preparation
through the marginal ridge
What is the difference between infilltration and sealing in resing based restoration?
Infiltration: HCl etches and dehydrates enamel to open
porous structure of carious enamel, infiltrates resin
into the porous enamel
Sealing: standard etch and resin bonding system used
to cover lesion
What are the indications and contra-indications for using resin infiltration and resin sealing?
Effective for proximal lesions in enamel: when placed under ideal conditions in permanent teeth
Less effective for lesions extending to the DEJ
Less effective in primary teeth
Infiltration and sealing seem equally effective
What is non-restorative cavity treatment and what does it aim to do?
AKA non-operative control of cavities
Aim: use a high-speed handpiece to open a cavitated carious lesion to make it cleansable and allow for remineralisation of carious dentine and arrest of the lesion, thus preventing pain and discomfort or other sequelae of carious lesions.
Intended for use in primary teeth
Accompanied by special OHI to aid brushing perpendicular to the dental arch
Usually accompanied by regular fluoride varnish applications
How effective is non-restorative cavity treatment?
Often results in dentine sensitivity, lesion progression, food packing or eventual pain and infection
May make restoration later more difficult due to
removal of sound tooth structure
Approx. 50% failure after 2 years
What is sodium fluoride varnish and how is it used?
22,600ppm (5%)
Different concentration, indications and uses to other fluoride modalities
Requires repeated applications
Multiple mechanisms of action involving remineralisation and interruption of bacterial metabolism
Can be flossed into contacts for proximal lesions with good efficacy
How does silver diamine fluoride varnish work?
SDF
Two-fold mechanism of action:
Fluoride uptake to form fluoroapatite crystals
Silver forms silver phosphate, which interferes with
biofilm formation and leads to cell death
More useful in smooth surface lesions and anterior teeth
Leads to severe black staining
Use in caries management is off license use. (no approval for use in australia; only usable for dentine hypersensitivity)
