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DMD2 > Surgical and Non-Surgical Management of Carious Lesions > Flashcards

Surgical and Non-Surgical Management of Carious Lesions Flashcards

1
Q

What are dental caries?

A

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.

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2
Q

What is a carious lesion?

A

The consequence and manifestation of the disease dental caries

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3
Q

What should caries management be used to describe?

A

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.

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4
Q

What does carious lesion management describe?

A

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.

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5
Q

What is the aim of surgical caries management?

A

To retain the tooth and the health of its pulp for as long as possible.

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6
Q

What are the guiding principles of surgical caries management?

A

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

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7
Q

How are infected and affected dentine different?

A

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

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8
Q

What are the different types of dentine in terms of disease progression?

A

Soft

Leathery

Firm

Hard

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9
Q

What does soft dentine feel like?

A

Deforms when a hard instrument is pressed into it and can easily be scooped up with little force required

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10
Q

What does leathery dentine feel like?

A

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.

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11
Q

What does firm dentine feel like?

A

Physically resistant to hand excavation some pressure needs to be exerted through an instrument to lift it

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12
Q

What does Hard dentine feel like?

A

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

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13
Q

What are the methods of caries removal?

A

Non-selective removal to hard dentine

Selective removal to firm dentine

Selective removal to soft dentine

Stepwise caries removal

No caries removal

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14
Q

How is non-selective caries removal done?

A

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

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15
Q

Where did non-selective removal of caries arise?

A

In GV Black’s manual of operative dentistry.

It is the traditional approach to restorative dentistry.

Debate over evidence for leaving caries behind.

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16
Q

What is the issue of non-selective caries removal?

A

It is least conservative and has a higher risk of pulpal exposure.

Carious pulpal exposure significantly increases treatment burden.

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17
Q

What is the aim of selective caries removal?

A

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.

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18
Q

Why does selective caries removal work?

A

Bacteria are sealed under the restoration and they will start to die over time while also being separated from nutrient source

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19
Q

What is stepwise caries removal?

A

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.

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20
Q

What is atraumatic restorative technique?

A

A technique that uses ART restorations and ART sealants that was originally described for use in community settings.

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21
Q

How is the atraumatic restorative technique conducted?

A
  1. 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
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22
Q

What are the limitations and contraindications of atraumatic restorative technique?

A

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

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23
Q

What is chemomechanical caries removal?

A

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.

24
Q

What are the types of chemomechanical caries removal?

A

CMCR

Sodium hypochlorite-based

Enzyme-based

25
Q

How is sodium hypochlorite used for caries removal?

A

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)

26
Q

What ingredients are used for enzyme-based chemomechanical caries removal?

A

Papain extract

Chloramine

Toluidine blue

Salts, preservative, thickener, stabilizers, deionized water

27
Q

How does enzyme-based chemomechanical caries removal work?

A

It breaks down collagen in caries-infected dentine only

Also has antimicrobial effect

Technique is the same as NaOCl-based gels

28
Q

Why is CMCR not popular if it is so effective and conservative?

A

Operative time is significantly longer than other techniques.

29
Q

What is used for laser caries removal?

A

Er:YAG laser with wavelength 2.94µm

• Er,Cr:YSGG (Erbium-chromium:yttriumselenium-gallium-garnet) wavelength 2.78µm

Water is used with the laser

30
Q

What are the advantages to laser caries removal?

A

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)

31
Q

What are the disadvantages of laser caries removal?

A

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

32
Q

What is air abrasion? What are the features of it?

A

A stream of aluminum oxide is emitted under high pressure.

Particle size usually 27.5µm

Pressure 60-120psi

33
Q

What are the limitations of air abrasion?

A

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

34
Q

What does air abrasion do to teeth?

A

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

35
Q

What is air abrasion more effective for?

A

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

36
Q

What are polymer burs useful for?

A

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.

37
Q

What are the advantages to using polymer burs?

A

Preserves the affected dentine

Operating time may be longer but it is definitely more conservative

38
Q

How are polymer burs recommended to be used?

A

Recommended for use in deepest part of cavity rather than the entire cavity.

39
Q

What are the advantages of using sonics and ultrasonics for caries removal?

A

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

40
Q

What are the disadvantages to using sonics and ultrasonics for caries removal?

A

They are slower

High cost of tips

Little evidence to support use

41
Q

What are caries detector dyes used for?

A

Introduced to differentiate between different layers of carious dentine.

Claimed to reduce the need for Local Analgesia

42
Q

What is fluorescence-aided caries excavation (FACE) used for?

A

Uses fluorescent light source and camera with special computer software to analyse camera feed.

43
Q

What is the hall technique?

A

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.

44
Q

What are the limitations for the hall technique?

A

Strict guidelines in place for indications/contraindications and technique.

Pre-operative radiograph is mandatory

Not intended as a replacement for SSC

45
Q

What is resin infiltration and resin sealing used for?

A

Management of proximal caries in enamel

Less effective for lesions extending to the DEJ

Less effective in primary teeth

46
Q

What is resin infiltration and sealing?

A

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.

47
Q

What is the aim of resin infiltration and sealing?

A

Aim to avoid significant loss of healthy tooth structure involved with traditional class 2 tooth preparation through the marginal ridge

48
Q

Which is more effective resin infiltration or sealing?

A

Both seem equally effective

49
Q

What is the aim of non-restorative cavity treatment?

A

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

50
Q

Where should non-restorative cavity treatment be used?

A

Mainly primary teeth

51
Q

How effective is non-restorative cavity treatment?

A

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

52
Q

How is sodium fluoride varnish used?

A

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

53
Q

How does sodium fluoride varnish work?

A

Multiple mechanisms of action involving remineralisation and interruption of bacterial metabolism

54
Q

How does silver diamine fluoride work?

A

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

55
Q

What are the limitations to using silver diamine fluoride?

A

More useful in smooth surface lesions and anterior teeth

Leads to severe black staining

Use in caries management is off licence use

DMD2 (89 decks)

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