Dental Caries
Infectious , multifactorial disease. Characterized by the loss of mineral contents of the calcified tissue. Presents in a spectrum of presentation. Lesion status: incipient/cavitated; active/inactive
Subclinical
Demineralization
Remineralization
Incipient lesion
Remineralization
Demineralization
Cavitated lesion
(Irreversible tooth Morbidity)
Treatment Options
Traditional - detection of caries lesion followed by immediate restoration. Current management philosophy treatment decision should be based on the status of the lesion (incipient vs cavitated, active vs inactive), and other patients factors (age, frequency of visit, oral hygiene status, dental IQ, motivation, risk factor). Non-surgical management (remineralization) of the disease should be part of the treatment plan.
Enamel
Dentin
Once demineralization reach the DEJ, it begins spreading laterally Start infecting the underlying dentin (surgical intervention indicated)
The catch or stick you feel when you use your explorer to probe into an intact pits is a result of the wedging effect
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
Treatment Options
Conclusive evidence of the presence of cavitated lesion
Bitewing radiographs Definitive halo around the pits and fissures Cavitated enamel
SURGICAL
Treatment Options
Presence of questionable cavitated lesion
Heavily stained pits and fissures Questionable halo
Treatment Options
Deep pits and fissures
Important Research
Mertz-Fairhurst EJ et.al. JADA 1998;129:410-412
Large occlusal lesions were treated with acid etch composite 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.
Empirical Evidence
Sealing caries may not work. It will work if you can maintain a complete and absolute seal of the enamel. However, a complete seal is very difficult to achieve. Beside pits and fissures, there may be micro cracks on the enamel.
Treatment Options
Radiolucency in dentin
SURGICAL INTERVENTION
Treatment Options
Triangular radiolucency point ended right at DEJ
SURGICAL OR NON-SURGICAL Should depend on caries status/activities and other patients factors
Treatment Options
Triangular radiolucency point ended short of DEJ
NON-SURGINCAL MANAGEMENT
1987
2003
Future
Quantitative data on the exact amount of mineral loss (incipient vs cavitated) - e.g. technology use in diagnosing pits and fissure caries (DIAGNOdent) Better understanding in the differences between active and arrested lesion - e.g. qualitative and quantitative differences in the mineral contents; microbiological differences?
Active Time? Arrested
Cleaned surface
Treatment Options
NON-SURGICAL (control measures depends on the caries status of the patient) SURGICAL (patient has esthetic concern)
Treatment Options
Cavitated, active (matte surface)
SURGICAL
Treatment Options
Composite RMGI - patient with very high caries potential Amalgam
Root Caries
Supragingival caries lesion located at CEJ Diagnostic criteria similar to smooth surface lesion Treatment options similar to smooth surface lesion (1st preference = RMGI)
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.
Biomechanical Form
restoration fracture tooth fracture
Esthetic
patients esthetic concern
Contour
proximal contact axial contour occlusion
Secondary Caries
Carious lesion located at the margin of a restoration
It is the most common reason for replacing an existing restoration
Secondary Caries
Tools used for diagnosis are based on the location of the margin
Visual
Dry, clean, magnified, properly illuminated
Tools
Tactile & Bitewings Radiograph