Y2 S2 Management of deep caries Flashcards
What is the ESE definition of deep caries?
Caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp, which is radiographically detectable when located on an interproximal or occlusal surface.
There is a risk of pulp exposure during operative treatment.
What is the ESE definition of extremely deep caries?
Caries penetrating the entire thickness of the dentine, radiographically detectable when located on an interproximal or occlusal surface.
Pulp exposure is unavoidable during operative treatment.
What are the differences between soft, firm and hard dentine?
- Soft dentine: can be excavated with minimum resistance using hand instruments.
- Firm dentine: resistant to excavation using hand instruments. Easily removed with a bur.
- Hard dentine: sound and resistant to probe penetration and scratching.
Describe what is meant by selective carious-tissue removal.
- Selective removal to soft dentine: soft dentine is left only on the pulpal aspect of the cavity, whilst peripheral carious dentine is removed to hard dentine.
- Selective removal to firm dentine: firm dentine is left only on the pulpal aspect of the cavity, whilst peripheral carious dentine is removed to hard dentine.
Describe what is meant by non-selective carious-tissue removal.
- Complete removal of soft and firm carious dentine from the periphery and central aspects of the cavity until hard dentine is reached.
Less conservative.
Name possible causes of inflammation/infection of the pulp.
- Caries
- Trauma
- Cracks in enamel
- Leakage around restoration
- Periodontal pockets
- Cavity preparation
- Anachoresis (bacteria from blood reaching the blood)
What are the aims of caries management within vital pulp therapy?
Aims to remove microbial irritation and prevent new bacterial insult by placing a sealing dental biomaterial to protect exposed dentine and pulp from external stimuli.
- Manage bacterial contamination
- Arrest caries progression
- Stimulate tertiary dentine formation
- Promote pulpal repair
- Restore the cavity, restore tooth to functional form
- Create a durable seal
- Produce a symptom free and functional tooth with a healthy pulp
What is the biological dilemma facing dentists when diagnosing pulpal conditions?
Challenging to detemine how damaged a pulp actually is and the appropriate treatment choice.
A clinical judgement must be made based on interpretation of the gathered information including:
- The patient’s description of subjective symptoms
- Clinical investigations
- Paraclinical examinations (radiographs for exclusion of apical pathology)
Must decide between reversible and irreversible pulpitis.
What is meant by selective carious tissue removal in one stage?
- Removal to soft or firm dentine, clean periphery
- Application of a biomaterial onto a dentine barrier in an indirect one-stage selective carious tissue removal technique
- Immediate placement of a permanent restoration
What is meant by stepwise excavation?
- Application of a biomaterial in an indirect two-stage selective carious tissue removal technique
- Removal to soft dentine, clean periphery
- GIC placed for 6-12 months
- Temporary restoration removed, and second stage removal to firm dentine, leaving behind solid new dentine at the floor (tertiary dentine)
- Final placement of a permanent restoration
What is indirect pulp capping?
- Removal of all carious tissue to hard dentine, no pulp exposure
- Biomaterial applied to this dentine barrier
- 1 stage procedure
- No longer regarded the treatment of choice in deep carious lesions, with recent consensus considering it as ‘over-treatment’ of the tooth (but used for trauma/non-caries related)
- Called indirect pulp capping because there is no exposed pulp
Used in paeds for crown fractures close to pulp but not exposing pulp.
Which teeth are appropriate for selective carious tissue removal or stepwise excavation?
- Restorable tooth with deep caries
- Tooth with reversible pulptitis
What is the rationale behind selective caries removal and stepwise excavation?
Sealing infected demineralised dentine into a cavity with a restoration that provides a good peripheral seal, deprives the micro-organisms of substrate from the oral cavity.
The bacteria reduce in number and the caries process arrests.
What is the difference between infected vs affected dentine?
Describe the steps of selective carious tissue removal.
1) Apply rubber dam to ensure a saliva free operating site
2) Carefully remove caries to minimise trauma and avoid exposure of the pulp (clean periphery, soft or firm dentine on the floor)
3) Place a layer of bioactive material on the floor e.g. GIC or hydraulic calcium silicate (BioDentine/MTA)
4) Permanent restoration placed above this layer
5) Long-term follow up to monitor pulp condition
What are the concerns regarding selective and stepwise caries removal?
- Inability to correctly diagnose pulp condition on every occasion
- Operative procedures during caries removal may result in irreversible pulpitis
