04 Dental Caries

8/3/2019 04 Dental Caries

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Dental Caries

Diagnosis and Treatment Options


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Dental Caries

Infectious , multifactorial disease.

Characterized by the loss of mineral contents ofthe calcified tissue.

Presents in a spectrum of presentation.Lesion status: incipient/cavitated;active/inactive

Subclinical

Incipient lesion

Cavitated lesion(Irreversible tooth Morbidity)

Demineralization

Remineralization

Demineralization

Remineralization


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Treatment Options

Traditional - detection of caries lesionfollowed by immediate restoration.

Current management philosophy -treatment decision should be based on thestatus of the lesion (incipient vs cavitated,active vs inactive), and other patientsfactors (age, frequency of visit, oralhygiene status, dental IQ, motivation, riskfactor).

Non-surgical management(remineralization) of the disease should bepart of the treatment plan.


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Examples of Treatment

OptionsCavitated, active - surgical (restoration)

Non-cavitated, active - surgical or non-

surgical (remineralization)

Cavitated, inactive - surgical (stressbearing area) or non-surgical (non

stress bearing area)

Non-cavitated, inactive - non-surgical


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Dilemma of Caries Diagnosis

No reliable objective diagnostictechnique to differentiate between

incipient lesion and cavitated lesion

Proximal lesion - primary: bitewing x-ray;secondary: visual through marginal ridge.

Pits and fissures - primary: visual; secondary:bitewing x-ray.

Smooth surface lesion - primary: visual;secondary: tactile.


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Dilemma of Caries Diagnosis

No reliable objective diagnostictechnique to differentiate between

active and inactive caries lesion

Currently the rule of thumb is : the darker the

color of the lesion, the more inactive it is.


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Diagnosis and Treatment Options

Based on location

Pits and fissures

Smooth surfaces

Proximal surfaces

Root cariesSecondary caries


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Enamel

Dentin

Pits and Fissures Caries

Demineralization around the

wall and bottom of the pits

(incipient lesion)

Once demineralization

reach the DEJ, it begins

spreading laterally

Start infecting the

underlying dentin (surgical

intervention indicated)


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Diagnosis of Pits and Fissures Caries -

Traditional Method

Using an explorer to probe

into the pit/fissure - a feel of

catch or a stick indicate

the presence of caries at the

bottom of the pit/fissure


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Problem with the Traditional Method

Even at the stage where surgicaltreatment is indicated, the

occlusal enamel may still be

intact

The catch or stick you feel

when you use your explorer to

probe into an intact pits is a

result of the wedging effect


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Possible Result of Probing into

an Incipient Lesion


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Diagnosis of Pits and Fissures

Caries - Current MethodUse an explorer toremove plaque andfood debris from the

fissure orificeUnder good lighting,isolation (dry) andmagnification; visuallyinspect for any

damage to the enamelLook for any subtlecolor changes aroundthe pits and fissures


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Diagnosis of Pits and Fissures

Caries - Current Method

Enamel is low in opacity, thusany changes in color (e.g. cariesdentin) in the underlying dentin

will show through the enamelLook for a gray shadow oropaque area around the pits andfissures - a halo

Ignore the color change withinthe pits and fissures

Bitewing radiographs may behelpful in diagnosing deep lesion


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Current Problems Relating to the

Diagnosis of Pits and Fissure Caries

Uneven diagnostic conclusion amongdentists

No reliable objective diagnostictechnique to differentiate betweenincipient lesion and cavitated lesion.

No reliable objective diagnostictechnique to differentiate betweenactive and inactive caries lesion


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New Technologies

New quantitative diagnostic system e.g.DIAGNOdent

Laser Fluorescence

J Dent 2002;30:129-134

Specificity higher for visual

Sensitivity higher for DIAGNOdent

Frequeucy-Domain Infrared Photothermal

Radiometry and Modulated Laser Luminescence.

Jeon RJ et al. Caries Res 2004;38:497-513


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Treatment OptionsConclusive evidence of the presence of cavitated lesion

Bitewing radiographs

Definitive halo around

the pits and fissures

Cavitated enamel

SURGICAL


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Treatment Options

Deep pits and fissures

Sealants in young or caries active or prone

patients


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Treatment Options - Surgical

Lesion specific restoration should be theprimary option.

Material specific restoration can beconsidered if unable to isolate or foreconomic reason.


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Important Research

Mertz-Fairhurst EJ et.al. JADA1998;129:410-412

Large occlusal lesions were treated with acid etchcomposite restorations, leaving soft, demineralized

dentin both at the DEJ and in the base of the

cavity. The teeth were followed over 10 years.There were no report of failed restoration, pulpitis

or pulp death.


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Empirical Evidence

Sealing caries may not work.

It will work if you can maintain a

complete and absolute seal of theenamel.

However, a complete seal is verydifficult to achieve.

Beside pits and fissures, there may bemicro cracks on the enamel.


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Proximal Caries - Diagnosis

Bitewing radiographs - primary

Trans-illumination - placing the mirror or light

source on the lingual side of anterior teeth anddirecting light through the teeth. Lesion will

show through as a dark area

Opacity or color change under the marginal

ridge (under dry and clean environment)


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Radiographic Diagnosis of

Proximal CariesTriangular

radiolucencypoint

end short of DEJ

Point end right at DEJ

Radiolucency in dentin


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Treatment Options

Radiolucency in dentin

SURGICAL INTERVENTION


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Treatment Options

Triangularradiolucency

point ended rightat DEJ

SURGICAL OR NON-SURGICAL -

Should depend on caries status/activities and other

patients factors


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Treatment Options - Current

philosophy

Unless there are clear evidence of radiolucency

in dentin, all decision to initiate surgicalintervention should take into consideration of

patients caries risk status and other patients

factors.

Reason: these lesions may be arrested lesions or

potentially can be converted from active to

arrested lesion using various non-surgical

management techniques.


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Longitudinal Radiographic Data

on a Patient (mesial of #3)

1984

1987

1995

2003


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Inactive , Cavitated Lesion


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Treatment Option - Surgical

Small lesion

Lesion specific restoration should be your

primary choice; material specificrestoration if unable to isolate or foreconomic reason


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Treatment Option - Surgical

Medium/large lesion

Direct Restoration - lesion specific vs

material specificIndirect Restoration - should only beconsidered if patients caries status

become more stable


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Diagnosis of Proximal CariesIncipient lesion = triangular radiolucencypoint short of DEJ

Cavitated lesion = triangularradiolucency point at or past DEJ

Disagreement among dentist in exactly

where the point end, and when shouldsurgical intervention indicated


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Diagnosis of Proximal Caries

No reliable objective diagnostic

technique to differentiate betweenactive and inactive caries lesion

Best evidence: longitudinal

radiographic data on the patientSupporting evidence: patients caries

risk and other patients factors


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Future

Quantitative data on the exact amount ofmineral loss (incipient vs cavitated) - e.g.

technology use in diagnosing pits and fissurecaries (DIAGNOdent)

Better understanding in the differencesbetween active and arrested lesion - e.g.qualitative and quantitative differences in themineral contents; microbiological differences?

Active Arrested

Time?


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Smooth Surface Caries -

DiagnosisDry, clean, magnified

Plaque covered surface Cleaned surface


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Diagnosis of Smooth Surface CariesIncipient

(chalky white,brown, black)

Cavitated


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Diagnosis of Smooth Surface Caries

Active (Matte, white)

Arrested (Shiny, white, brown)


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Treatment Options

Incipient, active

Incipient, arrested

Cavitated, arrested

NON-SURGICAL (control measures depends on thecaries status of the patient)

SURGICAL (patient has esthetic concern)


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Treatment Options

Cavitated, active (matte surface)

SURGICAL


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Problem with Treatment Option

No objective diagnostic tool to differentiate

between active and arrested lesion. Thus

sometime it may be difficult to decide whento initiate surgical intervention.


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Treatment Options

Composite

RMGI - patient with very high caries

potentialAmalgam


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Root Caries

Supragingivalcaries lesion

located at CEJDiagnostic criteriasimilar to smoothsurface lesion

Treatment optionssimilar to smoothsurface lesion (1stpreference = RMGI)


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Because of the decrease in the incidence of dental

caries (primary caries) in most industrialized

countries; maintenance of previously inserted

restoration has become the major workload

in a typical dental practice.

THUS

Evaluation of existing restorations is becoming

the main focus of the subjective and

objective examination of your patient. How

you are handling the findings is whats going

to define your treatment or your practice

philosophy.

Disease Trend in Dental Office


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Existing Restoration - Clinical Status

Secondary Caries

Marginal Integrity

marginal defect

overhang

open margin

Contourproximal contact

axial contour

occlusion

Biomechanical Form

restoration fracture

tooth fracture

Esthetic

patients esthetic

concern


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Secondary Caries

Carious lesionlocated at the marginof a restoration

It is the mostcommon reason forreplacing an existingrestoration


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Secondary Caries


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Diagnosis of Secondary

CariesDiagnosis should NOT be based on using a

sharp explorer and trying to get a stick

at the margin of a restoration

Tools used for diagnosis are based on the location of

the margin


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Diagnosis of Secondary CariesVisually Accessible Area

Primary Diagnostic Tool

Visual

Dry, clean, magnified,properly illuminated


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Diagnosis of Secondary CariesVisually Inaccessible Area

Tools

Tactile

&

BitewingsRadiograph


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Common Mistakes in Diagnosing

Secondary Caries

Use of a sharp explorer andprobe in to a defect, using astick as the diagnosticcriteria for the presence ofsecondary caries

An uniform radiolucent linearound a compositerestoration - may be due tothe presence of a thick layerof adhesive resin.

Radiographic burnout at CEJ


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Secondary Caries - Treatment Options

Surgical

Reasons

Most of the time when the lesions are detected, they arefrank cavitated lesion.

These lesions are more likely to be active lesion (timeframe of the development of the disease)

These lesions are in a very retentive area (limited abilityfor non-surgical management techniques to work; similarto pits and fissure caries)


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Secondary Caries - Treatment Options

Direct vs indirect

Financial

Patients caries status, oral hygienestatus, dental IQ, motivation, risk factors

04 Dental Caries

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