Surgical and Non-Surgical Management of Carious Lesions Flashcards
What are dental caries?
A disease where an ecologic shift within 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.
What is a carious lesion?
The consequence and manifestation of the disease dental caries
What should caries management be used to describe?
It should be limited to situations involving the control of the disease through preventive and non-invasive means. It describes actions taken at a patient level such as plaque control, fluoride application, dietary interventions, and behaviour change techniques. It aims to control the disease and prevent lesion formation or advancement.
What does carious lesion management describe?
Any procedure that involves doing something to an established, non-cleansable carious lesion to stop its progression. This might involve removing non, some, or all of the carious tissues from a non-cleansable lesion.
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
Provision of sound cavity margins to achieve a peripheral seal
How are infected and affected dentine different?
Bacteria are only present in infected dentine whereas 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
What are the different types of dentine in terms of disease progression?
Soft
Leathery
Firm
Hard
What does soft dentine feel like?
Deforms when a hard instrument is pressed into it and can easily be scooped up with little force required
What does leathery dentine feel like?
Does not deform when an instrument is pressed into it but still easily lifted without much force required, may be difficult to differentiate between leathery and firm dentine.
What does firm dentine feel like?
Physically resistant to hand excavation some pressure needs to be exerted through an instrument to lift it
What does Hard dentine feel like?
A pushing force needs to be used with a hard instrument to engage the dentine, only a sharp cutting edge or a bur will lift it. A scratchy sound or “cri dentinaire” can be heard when a straight probe is taken across the surface
What are the methods of caries removal?
Non-selective removal to hard dentine
Selective removal to firm dentine
Selective removal to soft dentine
Stepwise caries removal
No caries removal
How is non-selective caries removal done?
Aim is to remove soft carious tissue to reach hard dentine resembling healthy dentine in all parts of the cavity, including pulpally.
Formerly known as complete caries removal
Where did non-selective removal of caries arise?
In GV Black’s manual of operative dentistry.
It is the traditional approach to restorative dentistry.
Debate over evidence for leaving caries behind.
What is the issue of non-selective caries removal?
It is least conservative and has a higher risk of pulpal exposure.
Carious pulpal exposure significantly increases treatment burden.
What is the aim of selective caries removal?
To leather/firm dentine: The aim is to excavate to leathery or firm dentine in the pulpal aspect of the cavity.
To soft dentine: Involves leaving soft carious dentine in the pulpal aspect of the cavity, but peripheral enamel and dentine should be hard at the end of excavation to allow the best adhesive seal.
Why does selective caries removal work?
Bacteria are sealed under the restoration and they will start to die over time while also being separated from nutrient source
What is stepwise caries removal?
This is a two-stage procedure where Stage 1 is selective removal to soft
dentine (and placement of a provisional restoration considered suitable to
last up to 12 months) and Stage 2 is selective removal to firm dentine 6-12
months later, with placement of a definitive restoration. It has also
previously been known as 2-step excavation
This is to allow time for pulpal defence against the carious insult.
What is atraumatic restorative technique?
A technique that uses ART restorations and ART sealants that was originally described for use in community settings.
How is the atraumatic restorative technique conducted?
- Isolate with cotton wool
- Clean the tooth surface with a wet
cotton pellet - Widen the entrance with a hand
instrument, e.g. hatchet - Remove caries with hand excavator
- Provide pulpal protection if necessary
(setting calcium hydroxide liner) - Clean the occlusal surface with probe
and wet cotton pellet - Condition the cavity and occlusal
surface - 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
What are the limitations and contraindications of atraumatic restorative technique?
Seems easy but is very technique sensitive
ART also involves sealing of all remaining fissures.
Not recommended for use in occluso-proximal lesions
Not recommended for use in multi-surface lesions
What is chemomechanical caries removal?
Works by softening only infected dentine so that it can be removed by hand instruments without having an effect on enamel and affected dentine.
By removing only inected dentine it allows for most conservative cavity preparation.
What are the types of chemomechanical caries removal?
CMCR
Sodium hypochlorite-based
Enzyme-based
How is sodium hypochlorite used for caries removal?
0.475% NaOCl and amino acids (L-glutamic acid, L-leucin, and L-lysine) come with a special hand instrument designed to facilitate removal of softened dentine only(also burs available)
What ingredients are used for enzyme-based chemomechanical caries removal?
Papain extract
Chloramine
Toluidine blue
Salts, preservative, thickener, stabilizers, deionized water
How does enzyme-based chemomechanical caries removal work?
It breaks down collagen in caries-infected dentine only
Also has antimicrobial effect
Technique is the same as NaOCl-based gels
Why is CMCR not popular if it is so effective and conservative?
Operative time is significantly longer than other techniques.
What is used for laser caries removal?
Er:YAG laser with wavelength 2.94µm
• Er,Cr:YSGG (Erbium-chromium:yttriumselenium-gallium-garnet) wavelength 2.78µm
Water is used with the laser
What are the advantages to laser caries removal?
Amount of laser energy can be modified based on what we want to remove
Leaves enamel surface with etched appearance
Does not cause cracking or surface charring as seen with high speed burs
Leaves rough dentine surface with minimal smear layer
Some laser manufacturers report analgesic effect claim that LA is often not needed (not confirmed)
Restoration survival is reported to be similar to use of burs (no long-term follow up studies in both primary and permanent teeth)
What are the disadvantages of laser caries removal?
Takes longer than use of a bur
Lacks tactile feedback requiring use of a separate instrument or technique to determine the extent of caries removal
Can be very noisy
What is air abrasion? What are the features of it?
A stream of aluminum oxide is emitted under high pressure.
Particle size usually 27.5µm
Pressure 60-120psi
What are the limitations of air abrasion?
Some doubt over health effects for clinicians and patients
Aluminium oxide chosen over glass-based materials due to increased
hardness and risk of silicosis
Often used with water jet to help contain particle stream
What does air abrasion do to teeth?
Due to the shape of the stream and nature of abrasive particles, air abrasion leaves rounded cavosurface margins and internal line angles
Also leaves halo of abraded healthy enamel
surrounding cavity outline
Leaves roughened surface
Can lead to occlusion of dentinal tubules
What is air abrasion more effective for?
Abrasive power is more effective on hard surfaces than soft surfaces meaning more likely to remove healthy dentine than soft carious dentine and therefore is not suitable for selective caries removal techniques
Provides no tactile feedback
Bio-active glass compound has been tested in vitro and found to be more selective for carious enamel than alumina particles
What are polymer burs useful for?
Designed to facilitate removal of carious dentine while limiting removal of healthy dentine
Made of polymer compound with hardness between that of infected dentine and that of healthy dentine
Single use as the bur wears away and loses cutting efficiency as it approaches the affected dentine.
What are the advantages to using polymer burs?
Preserves the affected dentine
Operating time may be longer but it is definitely more conservative
How are polymer burs recommended to be used?
Recommended for use in deepest part of cavity rather than the entire cavity.
What are the advantages of using sonics and ultrasonics for caries removal?
Ample visibility during cavity prep
Easy removal of caries on hard-to reach places due to specific angled tips
Lower chance of iatrogenic damage to neighbouring teeth
Low noise level
Better tolerated by patients
What are the disadvantages to using sonics and ultrasonics for caries removal?
They are slower
High cost of tips
Little evidence to support use
What are caries detector dyes used for?
Introduced to differentiate between different layers of carious dentine.
Claimed to reduce the need for Local Analgesia
What is fluorescence-aided caries excavation (FACE) used for?
Uses fluorescent light source and camera with special computer software to analyse camera feed.
What is the hall technique?
Using stainless steel crown over a primary molar tooth with an active carious lesion without any local analgesia, caries removal, or tooth preparation.
The idea is to seal the caries with the crown preventing them from progressing.
What are the limitations for the hall technique?
Strict guidelines in place for indications/contraindications and technique.
Pre-operative radiograph is mandatory
Not intended as a replacement for SSC
What is resin infiltration and resin sealing used for?
Management of proximal caries in enamel
Less effective for lesions extending to the DEJ
Less effective in primary teeth
What is resin infiltration and sealing?
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 is the aim of resin infiltration and sealing?
Aim to avoid significant loss of healthy tooth structure involved with traditional class 2 tooth preparation through the marginal ridge
Which is more effective resin infiltration or sealing?
Both seem equally effective
What is the aim of non-restorative cavity treatment?
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
Where should non-restorative cavity treatment be used?
Mainly primary teeth
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
How is sodium fluoride varnish used?
22,600ppm (5%)
Different concentration, indications and uses to other fluoride modalities
Requires repeated applications
Can be flossed into contacts for proximal lesions with good efficac
How does sodium fluoride varnish work?
Multiple mechanisms of action involving remineralisation and interruption of bacterial metabolism
How does silver diamine fluoride work?
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
What are the limitations to using silver diamine fluoride?
More useful in smooth surface lesions and anterior teeth
Leads to severe black staining
Use in caries management is off licence use
