the management of deep caries

Question 1

give an example of a basic treatment plan

Answer 1

1. emergency relief of pain
2. establish a healthy oral environment
3. corrective therapy
4. replace missing teeth

Question 2

what treatment can be involved in establishing a healthy oral environment

Answer 2

diet diary 
PFS 
preventative advice for caries
OHI/scaling 
caries stabilisation

Question 3

what steps can be included in corrective therapy

Answer 3

permanent restorations
RSD
endodontic treatment
crowns

Question 4

what is caries

Answer 4

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

Question 5

what structures are included in the pulp

Answer 5

odontoblasts 
blood vessels 
nerves
lymphatic system 
stem cells 
connective tissue

Question 6

which nerves are found in the pulp

Answer 6

a delta nerves and c fibre nerves

Question 7

describe a delta nerves

Answer 7

myelinated fast response
short sharp pain
tooth sensitivity described like an electric shock or sharp pain

Question 8

describe c fibres

Answer 8

unmyelinated slow response timing

and is a dull throbbing pain

Question 9

what components cause demineralisation of the tooth surface

Answer 9

the fermentable carbohydrates and cariogenic bacteria producing lactic acid and this causes demineralisation of the tooth surface

Question 10

what causes demineralisation of the tooths surface

Answer 10

fluoride and saliva flow can help remineralise early white spot lesions

Question 11

what can we use to help diagnose caries

Answer 11

radiographs

3-in-1 will show WSL as chalky

Question 12

when does a white spot lesion form

Answer 12

when there is more demineralisation than demineralisation occurring at the tooth surface but this is still reversible

Question 13

what is a brown spot lesion

Answer 13

occurs when there is repeated demineralisation and remineralisation leading to pigments from blood or food being incorporated into the enamel

Question 14

how deep is a BSL

Answer 14

still only superficial will not progress into a cavity if kept clean and fluoride varnish applied

Question 15

how does the tooth respond when a lesion starts to form

Answer 15

1. arterial flow to the pulp increases
2. causes an increase in dentinal tubular fluid
3. fluid acts to flush out bacterial toxins and carries anti bacterial components such as IgE and lactoferrin
4. peritubular dentine gets deposited and the tubules become narrower and creating a barrier to the bacteria(sclerosis)
5. affected odontoblasts produce tertiary dentine
6. can be arrested at this stage

Question 16

what happens if demineralisation continues of the WSL

Answer 16

secondary dentine is laid down and cavitation may occur- then starts to spread laterally at the ADJ

Question 17

when carrying out cons treatment what do we need to remove

Answer 17

infected enamel and infected dentine we can leave the affected dentine as it protects the pulp

Question 18

what happens when caries gets close to the pulp

Answer 18

the pulp becomes inflamed and a delta fibres are triggered and there’s pain- this is reversible pulpitis which can be reversed

Question 19

what happens when we have a very deep cavity

Answer 19

the bacteria approach the pulp and inflammation becomes irreversible- removing the caries can’t reverse the pulpitis but can treat painful toothache

Question 20

which fibres are the last to die in pulp necrosis

Answer 20

c fibres are the last to die

Question 21

what happens once the pulp is dead

Answer 21

the bacteria thrive on the dead tissue and there is no more defence

Question 22

what does caries management depend on

Answer 22

the status of the pulp

Question 23

what do we do if there is vital pulp

Answer 23

try to keep the tooth alive

Question 24

what do we do if the tooth has irreversible pulpitis or pulpal necrosis

Answer 24

RCT or extraction

Question 25

how do we test if the tooth is alive or not

Answer 25

symptoms
clinical appearance
special tests
radiographs

Question 26

what are sensitivity tests

Answer 26

such as ethyl chloride or electric pulp test (EPT)

Question 27

what is the issue with sensitivity tests

Answer 27

no 100% reliable and many false positives and false negatives

Question 28

what do the numbers of the electric pulp test mean

Answer 28

shouldn’t be inferred as meaning something-eg any number under 80 means probably alive

Question 29

what can help with diagnosing whether the pulp is dead or alive

Answer 29

evidence of periodical changes

sometimes a dead tooth looks darker

Question 30

how do we maintain pulp vitality when carrying out a treatment

Answer 30

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

Question 31

what kills the pulp

Answer 31

bacteria and dentists-therefore wanna keep bacteria out

Question 32

how do we protect the pulp if the caries is nearing closer to it

Answer 32

create a sela with RMGIC liner-fuji liner and only place it on the dentine

Question 33

what size are the tubules near the pulp

Answer 33

tubules are wider nearer the pulp

Question 34

what are the three types of pulpal exposure

Answer 34

iatrogenic-the dentist exposes the pulp during caries removal
carious
traumatic-– trauma causes a fracture of the tooth involving the pulp

Question 35

how do we manage iatrogenic pulpal exposure

Answer 35

if perviously asymptomatic then

1. rubber dam
2. wash cavity
3. dry with cotton wool
4. then get tutor

Question 36

what do we do if the dentine around the exposure is carious

Answer 36

if carious RCT required

Question 37

what do we od if the size of the exposure is greater than 2mm

Answer 37

then RCT

Question 38

what do we do if the size of the exposure is less than 2mm

Answer 38

place Ca(OH)2 over the exposure and dress the tooth and monitor

Question 39

what is setting calcium hydroxide also known as in clinic

Answer 39

drycal
MTA( mineral trioxide aggregate)
biodentine( bio silicate material )

Question 40

give examples of non setting calcium hydroxide

Answer 40

hypocal or calsept

Question 41

what are the properties of calcium hydroxide

Answer 41

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

Question 42

when is pulp cap most successful

Answer 42

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)

Question 43

what are clinical procedures to avoid exposure of the pulp

Answer 43

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

Question 44

what is the stepwise excavation technique

Answer 44

1. Establish sound enamel margins & caries free ADJ
2. Remove “infected” dentine and leave a layer of “affected” dentine
3. Place layer of calcium hydroxide liner over very deep affected dentine
4. 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)
5. 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