the management of deep caries Flashcards
give an example of a basic treatment plan
- emergency relief of pain
- establish a healthy oral environment
- corrective therapy
- replace missing teeth
what treatment can be involved in establishing a healthy oral environment
diet diary PFS preventative advice for caries OHI/scaling caries stabilisation
what steps can be included in corrective therapy
permanent restorations
RSD
endodontic treatment
crowns
what is caries
a disease of the hard tissues of the teeth characterised by demineralisation and proteolytic destruction of the tissues by acids produced by bacteria in dental plaque feeding on dietary carbohydrates
what structures are included in the pulp
odontoblasts blood vessels nerves lymphatic system stem cells connective tissue
which nerves are found in the pulp
a delta nerves and c fibre nerves
describe a delta nerves
myelinated fast response
short sharp pain
tooth sensitivity described like an electric shock or sharp pain
describe c fibres
unmyelinated slow response timing
and is a dull throbbing pain
what components cause demineralisation of the tooth surface
the fermentable carbohydrates and cariogenic bacteria producing lactic acid and this causes demineralisation of the tooth surface
what causes demineralisation of the tooths surface
fluoride and saliva flow can help remineralise early white spot lesions
what can we use to help diagnose caries
radiographs
3-in-1 will show WSL as chalky
when does a white spot lesion form
when there is more demineralisation than demineralisation occurring at the tooth surface but this is still reversible
what is a brown spot lesion
occurs when there is repeated demineralisation and remineralisation leading to pigments from blood or food being incorporated into the enamel
how deep is a BSL
still only superficial will not progress into a cavity if kept clean and fluoride varnish applied
how does the tooth respond when a lesion starts to form
- arterial flow to the pulp increases
- causes an increase in dentinal tubular fluid
- fluid acts to flush out bacterial toxins and carries anti bacterial components such as IgE and lactoferrin
- peritubular dentine gets deposited and the tubules become narrower and creating a barrier to the bacteria(sclerosis)
- affected odontoblasts produce tertiary dentine
- can be arrested at this stage
what happens if demineralisation continues of the WSL
secondary dentine is laid down and cavitation may occur- then starts to spread laterally at the ADJ
when carrying out cons treatment what do we need to remove
infected enamel and infected dentine we can leave the affected dentine as it protects the pulp
what happens when caries gets close to the pulp
the pulp becomes inflamed and a delta fibres are triggered and there’s pain- this is reversible pulpitis which can be reversed
what happens when we have a very deep cavity
the bacteria approach the pulp and inflammation becomes irreversible- removing the caries can’t reverse the pulpitis but can treat painful toothache
which fibres are the last to die in pulp necrosis
c fibres are the last to die
what happens once the pulp is dead
the bacteria thrive on the dead tissue and there is no more defence
what does caries management depend on
the status of the pulp
what do we do if there is vital pulp
try to keep the tooth alive
what do we do if the tooth has irreversible pulpitis or pulpal necrosis
RCT or extraction
how do we test if the tooth is alive or not
symptoms
clinical appearance
special tests
radiographs
what are sensitivity tests
such as ethyl chloride or electric pulp test (EPT)
what is the issue with sensitivity tests
no 100% reliable and many false positives and false negatives
what do the numbers of the electric pulp test mean
shouldn’t be inferred as meaning something-eg any number under 80 means probably alive
what can help with diagnosing whether the pulp is dead or alive
evidence of periodical changes
sometimes a dead tooth looks darker
how do we maintain pulp vitality when carrying out a treatment
Use rubber dam
Remove caries from the walls of the cavity first
Never use a high speed for removing caries
On the floor of the cavity only use excavators, gently scrape away anything soft, never use force
Leave affected dentine over the pulp
Use RMGIC liner to seal affected dentine
what kills the pulp
bacteria and dentists-therefore wanna keep bacteria out
how do we protect the pulp if the caries is nearing closer to it
create a sela with RMGIC liner-fuji liner and only place it on the dentine
what size are the tubules near the pulp
tubules are wider nearer the pulp
what are the three types of pulpal exposure
iatrogenic-the dentist exposes the pulp during caries removal
carious
traumatic-– trauma causes a fracture of the tooth involving the pulp
how do we manage iatrogenic pulpal exposure
if perviously asymptomatic then
- rubber dam
- wash cavity
- dry with cotton wool
- then get tutor
what do we do if the dentine around the exposure is carious
if carious RCT required
what do we od if the size of the exposure is greater than 2mm
then RCT
what do we do if the size of the exposure is less than 2mm
place Ca(OH)2 over the exposure and dress the tooth and monitor
what is setting calcium hydroxide also known as in clinic
drycal
MTA( mineral trioxide aggregate)
biodentine( bio silicate material )
give examples of non setting calcium hydroxide
hypocal or calsept
what are the properties of calcium hydroxide
Very high pH (>pH 11)
Creates an alkaline environment i.e. bactericidal (highly toxic to bacteria)
Stimulates odontoblasts to lay down new reparative dentine in the dentinal tubules
Stimulates stem cells in the pulp tissue to create new odontoblast-like cells to create dentine bridges across pulpal exposures
when is pulp cap most successful
Absence of signs or clinical symptoms of pulpitis before you start opening the tooth up
Normal response to vitality tests by the tooth
Younger patients without previous history of restorative work on the tooth in question
Tooth is isolated (Rubber dam) and there is no salivary contamination
Small exposure <2mm in diameter
Exposure is not probed, or blown dry (damaging pulp tissue directly)
what are clinical procedures to avoid exposure of the pulp
step wise excavation
remove caries until near the pulp and stop
fill with GIC
reevaluate after 6 months and replace restoration if symptom free and vital
what is the stepwise excavation technique
- Establish sound enamel margins & caries free ADJ
- Remove “infected” dentine and leave a layer of “affected” dentine
- Place layer of calcium hydroxide liner over very deep affected dentine
- If cavity cannot be restored in a single visit then:
Restore the whole cavity with RMGIC (RMGIC marginal seal is critical
to prevent any micro-leakage at the & review 6 months later) - If cavity can be restored in 1 visit, then use RMGIC to restore the
“dentine depth, leaving 2-3 mm coronally for your definitive composite
or amalgam restoration
