Management of dental caries

Management of dental caries

1. Man age™ ent of

De:
ental Caries

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$c. Of conservative ye DentistrY

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2. Introduction

> Cariology is a science which deals with the study of etiology, histopathology,

epidemiology, diagnosis, prevention and treatment of dental caries.

> Dental caries is defined as a microbiological disease of the hard structure of
teeth, which results in localized demineralization of the inorganic portion and

destruction of the organic substances of the tooth.

3. > Dental plaque is an adherent deposit of bacteria and their prod:

forms on all tooth surfaces.

Dental plaque is important for beginning of caries because it pro
environment for bacteria to form acid, which causes deminerali

tissue of teeth.

4. Paihogenesis of caries

Susceptible tooth surface
Formation of biofilm and microbial deposits
Acid a PH change
Shift in dynamic = of minerals
Dissolution of minerals

NA

Initiation of caries

5. Theories of clental caries

> Dental caries is a multifactorial disease of tooth which has been explained by
many theories. Though there is no universally accepted theory of the etiology
of dental caries, but following three theories are considered in etiology of

dental caries:

1. Acidogenic theory: (WD Miller in 1882). Its most accepted and supported

theory.

fermentation of dietary decalcification of tooth substance
carbohydrates by oral => acid ===) with subsequent disintegration of
bacteria organic matrix.

6. 2. Proteolytic theory: (Heider and Bodecker in 1878) and (Abbott in 1879).

Microorganism attack the organic part of enamel leaving the generated acid
responsible for further decalcification of inorganic part.

3. Proteolysis-Chelation theory: (Schatz and his coworkers).

Organic part of the enamel is attacked first then followed by chelation process
that removes calcium from enamel and dentine without acid.

Chelation is independent of the pH of the medium.

7. Progression of dental caries

Normal tooth

y

White chalky spot
y

Incipient lesion
y
Cavitation
If not treated
Involvement of dentine and pulp

Pulp inflammation

y

Pulp necrosis

Periradicular lesion

8. Local factors affecting ne incidence of caries

+ Tooth (Host)
- Variation in morphology

- Camnacitian

IS
Y e

Substrate

ana Lactovacutus.
« Time period

9. Caries Balance Concept
(Proposed by Feathersione in 1999)

> According to the caries balance theory, caries does not result from a single

factor; rather, it is the outcome of the complex interaction of pathologic and

I The “Caries Balance”
protective factors.

Pathological Factors Protective Factors

. fermentable carbohydrates chlorhexidine, xylitol) |
+ Poor oral hygiene « Good oral hygiene

| |

Demineralization Remineralization
(Caries) A (No caries)

10. : Diagnosis of dental caries

Various methods for diagnosis of dental caries
… Visual-tactile method

+ Conventional methods
i. Tactile examination
ii. Visual examination.

+ Advances

in visual method

i. Illumination

a
b
C.
d
e

ii. De

. Ultrasonic illumination
. Ultrasonic imaging

Fiberoptic transillumination (FOTI)

. Wavelength dependent FOTI

Digital imaging FOTI (DIFOTI).

iii. Endoscopy filtered fluorescence (EFF) method.

11. Diagnosis of dental caries

+ Conventional methods
i, Intraoral periapical X-rays (IOPA)
ii. Bitewing radiographs
iii. Panorex radiography
iv. Xeroradiography.
+ Recent advances in radiographic techniques
i. Digital imaging
ii, Computerized image analysis
iii. Substraction radiography
iv. Tuned aperture computerized tomography (TACT)
v. Magnetic resonance microimaging (MRMI).

12. Diagnosis of dental caries

+ Diode lasers

+ Qualitative laser fluorescence

+ Diagnodent (Quantitative laser fluorescence}

+ Optical coherence tomography

+ Polarization sensitive optical coherence tomography (PSOCT)
+ Dye enhanced laser fluorescence,

13. High caries risk patients

= One new lesion on smooth surface during past one year
= New carious lesion on root surface
= Patient on medication which causes hyposalivation
= Systemic disorder
= Past dental history with multiple restorations
= Exposure to sugary snacks for more than three times a day
= Senility
= Following factors are commonly seen in patients with high-risk
caries:
= Status of oral hygiene
+ Poor oral hygiene
+ Nonfluoridated toothpaste
+ Lowfrequency oftooth cleaning
+ Orthodontic treatment
+ Partial dentures

14. High caries risk patients

= Dental history

+ History of multiple restorations
+ Frequent replacement of restorations
Medical factors

+ Medications causing xerostomia
+ Gastric reflux

+ Sugar containing medications

+ Sjógren's syndrome

Behavioral factors

+ Bottle feeding at night

+ Eating disorders

+ Frequent intake of snacks

+ More sugary foods

+ Nonfluoridated toothpaste
Socioeconomic factors

+ Low education status

+ Poverty

+ No fluoride supplement.

+

4

.

15. = Prevention of lena caes _
=i Methodstoneduce-deminenalizing taciors

A. Dietary Measures:

1. Sugar substitutes: Xylitol, Sorbitol.

= Xylitol reduces plaque formation
= |t reduces bacterial adherence
SS jt inhibits enamel demineralization ===
= |t has a direct inhibitory effect on $ mutans
= Increases salivary flow
= It is nonfermentable
SSS = It increases concentration of amino acids which neutralize the ===
plaque acidity.

'

17. B. Methods to-improve oral hygiene:

1. Dental-prophylaxis: Polishing-of roughened tooth surfaces and replacement of
faulty restorations is done so as to decrease the formation of dental plaque,
therefore,-resulting-in-less-incidence-of-caries.—— == =

= Tooth brushing. — == == E === —=

3. Interdental-cleaning.

18. Substances interfering with carbohydrate degradation
through enzymatic alterations:

- Vitamin K

- Sarcocide

Substances interfering with bacterial growth and

metabolism
- Chlorhexidine
lodine
Urea and ammonium compounds
Nitrofurans
Glutaraldehyde.

19. ll. Meihods to Incredss arorseiiive factors

A: Methods to improve flow, quantity and quality of saliva:
In patients with hyposalivation, baking soda may help to neutralize acids. The
mouth rinse is prepared by mixing two teaspoons of baking soda in eight oz of

water. This solution is:used-for mouthrinsing after eating.

B-Chemicals altering the tooth surface or tooth structure:
= Fluorides: It found as clinical fluoride products such-as (professional topical
fluorides, fluoride varnishes, mouthrinses, dentifrices, supplements in the form

of fluoride tablets and drops, fluoridated salt). Also, it found in human diet: -

"— Silver nitrate

“Zinc chloride

20. === ~ Formation of fluoroapatite (less soluble than hydroxyapatite) E
AA » Inhibits demineralization === ==
= Induces remineralization
= Inhibits bacterial metabolism
= + Inhibits plaque formation = =

C-Application of remineralizing agents: = = =

Remineralizing agents are available in various forms like dentifrices,

mouthwashes, chewing-gums, and foods and-beverages.-Various-approaches have

been-employed:-to enhance the remineralization of teeth. === uns

- - = Seal pits and fissures mechanically making them resistant to
D. Use of pit and fissure sealants: — food impaction
>= = Make pits and fissures self-cleansable
= Halt incipient carious lesion,

25. A

26. Management of dental caries

o The invention and application of engine driven or rotary instruments in
operative treatment of carious lesions has resulted in removal of considerable
tooth structure. But now a days other procedures have also been used for
removal of caries like Air abrasion, Ozone treatment of dental caries,

Chemomechanical caries removal and Lasers.

27. Air abrasion

< The study of the use of air abrasion technology for dental applications initiated
by Dr. Robert Black in the 1940's was successfully introduced in 1951 with the

Airdent air abrasion unit (S.S. White).

“+ Kinetic energy is used to remove carious lesion. In this method, a powerful fine

stream of aluminum oxide particles is targeted against the surface to be

removed.

28. < There are 2 sizes of aluminum oxide particles:
y” 27um (more comfortable, less effective cutting).

v 50um (more abrasive cutting, but more discomfort).

“ The abrasive particles hit the tooth with high velocity and remove small
amounts of tooth structure. Tip distance must be (0.5 to 2 mm) from carious

lesion.

< Nowadays, a number of variations in tip angulations and nozzle diameters are

aller nozzle diameters can be used for areas that are difficult to
The various tip angulations allow easy placement and orientation of the

andpiece thus easing the strain off the operator's hands.

29. Advantages of Air abrasion

Non-traumatic.
No micro chipping or micro fracturing.
Less discomfort.

No anesthesia.

yf YF SP E

Decreased thermal buildup.

Disadvantages of Air abrasion

1. Lack of tactile sensation.
2. Risk of cavity over preparation and inadequate caries dentine removal.

minum oxide around dental operatory.

of air emphysema.
aired indirect view.

Damaged of dental mirror, optical devices like magnifying lopes.

30. Air abrasion used in

Cavity preparation.
Internal cleaning of tunnel preparation.

Micro abrasion of while spot enamel hypoplasia.

Ba PP

Stain removal.

Air abrasion not used in

aration.

aries defect.

algam removal.

31. Contraindications of Air abrasion

Patients with dust allergy, asthma.
Patients with advanced periodontal disease.

Patients with fresh extraction.

Ba PP

Patients with recent placement of orthodontic appliances.

Precautions taken wiih Air abrasion

Use surgical mask, dry vacuum systems to reduce respiratory exposure.

r dam, protective eyeglass and metal matrix to protect adjacent

se disposable mirrors.

34. Ozone therapy

e
+

Within the past few years, ozone therapy has been launched as a new method

for treating caries by Edward LyGh.

fe

“

Ozone (O3) is a gas with a characteristic, penetrating odor that is present in

small amounts in atmospheric air.

a

+ Ozone reacts with numerous inorganic and organic compounds. It bleaches
dyes and kills bacteria.

“ Ozone destroys the bacterial cell membrane, where after the bacteria die. As

use caries, it was natural to investigate whether ozone could be used

35. “+ The ozone unit for dental use was initially developed by CurOzone Inc.
(Canada) and subsequently manufactured under license and distributed by
KaVo-Dental GmbH & Co. (Germany) under the name ‘HealOzone’.

< The new version of HealOzone (Mark3) was launched in July 2004. According
to the manufacturer previous models can be upgraded to the most recent
technical functions.

< Oxygen delivery unit (Ozone unit - HealOzone) consists of:

1. Polyurethane console:

C. Desiccant.

D. Hydrophobic filter.

36. Handpiece:

Y” Stainless steel, contra angle handpiece.

v Disposable polymer sealing cup attaches to the head (differently
shaped silicone cups are available that correspond to the form of
various teeth and their surfaces; 5 sizes from 3 to 8 mm in diameter).
This ensures close contact between the silicone cup and the carious

area of the tooth so that the ozone does not escape).

v Handpiece attaches to the
console by detached hose.
Y” Delivers ozone at a rate of

13:33ml/sec.

atient kit: tooth paste, oral rinse,

37. < Polymer cup adapted to carious lesion and air sucked to create a vacuum.

“+ Ozone gas delivered for 10 seconds at minimum into the cup around the tooth
surface.

< The ozone in the silicone cup is collected again and reconverted to oxygen by

the apparatus (suction activated for 10 seconds while cup is still attached to

carious lesion to remove residual).

38. “ The procedure usually takes between 20 and 120 seconds per tooth.
Immediately after ozone application the tooth surface is treated with a
remineralizing solution (reductant) containing fluoride, calcium, zinc,

phosphate and xylitol dispensed from a 2ml ampoule.

< Patients are also supplied with a patient kit, which consists of toothpaste, oral
rinse and oral spray, all containing fluoride, calcium, zinc, phosphate and

xylitol, and aims to enhance the remineralization process.

39. “+ One of the study to assess the effect of ozone therapy in combination with the
daily use of remineralizing products on root caries. The control period was up
to 18 months, and the patients were recalled for examination and repeat

treatment after 3, 6, 12 and 18 months.

“ The trial showed that 69-100% of the ozone-treated lesions (duration of

treatment 40 sec) became harder during the 18-month trial and none became

softer.

40. Indications of Ozone

1. Primary root carious lesions.

2. Primary pit and fissure caries.

Advantages of Ozone

1. Kills more than 99% of microorganisms in carious lesion at a concentration of
2,200 ppm.

2. Oxidizes caries and speeds up remineralization.

3. Helps to remove organic debris on carious lesion.

4. Potentially whitens discolored caries.

eatment time.

nt painless and noiseless.
s not cause any allergic reaction.

Microorganisms do not developed resistance to Ozone.

41. Chemomechanical caries removal (CMCR)

“ Chemomechanical caries removal (CMCR) involves the selective removal of
carious dentine. The reagent is prepared by mixing solutions of amino acids

and sodium hypochlorite (NaOCl).

< Reagents commonly available in market are Caridex and Carisolv.

42. Development of Caridex, Carisolv, Papacarie

<% The idea of chemo-mechanical caries removal has been developed in 1970s by
Goldman who was primarily an Endodontist, while using sodium hypochlorite
(NaOCl) in removing organic materials in the root canals. This chemical has
got the ability to dissolve carious dentine and since that time, the idea of

removing caries chemically was borne.

+ Caridex was introduced in the US market in 1984 by National Patent Medical.

duced in 1997 by Swedish Medi Team.

ed in Brazil in 2003, by Bassadori et al, (Papacarie: a

43. Comparison of Various CMCR Agents:

CARIDEX CARISOLV PAPACARIE
Solution | 1% NaOCl 0.5% NaOCl Single Gel
Solution Il 0.1M Amino butyric 0.1 MGlutamic Acid/ Endoprotein - Papain
acid glycine Leucine/Lysine and Chloramines
0.1M NaCl NaCl
0.1M NaOH NaOH
Dye Erythocin Toluidine Blue
pH 11 11 1
Physical Properties Liquid Gel Gel
Volume Needed 100-500 ml 0.2-1.0 ml 0.2-1.0 ml
Time Required 10-15 minutes 10-15 minutes 5-8 minutes
Equipment Required Applicator Unit None None
Instruments Applicator tips Specially Designed No Special Instruments Required
mr re Thour 20 minutes No mixing

active after mixing

44. Application & Mode of action of Caridex

+ The delivery system of Caridex consisted of:
v Reservoir for the solution.
v Heater: warmed liquid to the body temperature.
v Pump: passed the warmed liquid through a tube to a hand piece and
applicator tip (20 gauge hypodermic needle, the tip of which had been

modified into spoon shape).

“+ It involves the chlorination and disruption of the partially degraded collagen

fibers in carious dentine with N-monochloro-D-2 aminobutyrate (NMAB).

us dentine then becomes easier to remove by excavation using the

ified needle tip.

45. Advantages of Caridex

1. No need for local anesthesia.
2. Conservation of sound tooth structure.

3. Reduced risk of pulp exposure.

Disadvantages of Caridex
1. Instruments may still be needed for the removal of caries or material.
2. It leaves a surface with many overhangs and undercuts.

3. Large volumes of solution are needed.

low.

effective in the removal of hard eburnated parts of the

t requires heating or a delivery system which is not available commercially.

46. Application & Mode of action of Carisolv

< The contents of the two syringes should be mixed immediately before use as its

effectiveness begins to deteriorate after 20 minutes.

“ The mixed gel is applied to the carious lesion for 30 seconds and then the
carious dentine can be gently removed, using Carisolv specially designed, non-

traumatic hand instruments.

e procedure is continuously repeated until removing clear gel is

lieved.

47. 1 the Carisolv gel is m ed on the

rious |

ed & ap}

for 30 sec.

mino acids bind chlorine and form
chloramines at a high pH.

no acids are difterently charged sc
ystatic attraction to different a
protein in

ophilic

atches.

red

+ Ve charged

+ Hydrophobic:

Destroy the bonds which hold the fibrous
struct)

e together

Bicak the degraded col

retore more
mines

It has an open structure and 1s tl
susceptible to further breakdown by ch}

ens the ¢
healthy tissue is unaffecte

on charged (inner side)

nents used to remove this
. Which has sharp edge and

blunt cutting angle.

48. Advantages of Carisolv

No need for local anesthesia.

Conservation of sound tooth structure.

Reduced risk of pulp exposure.

Volume required is less.

Does not require heating or a delivery system.

Since it involves gel not liquid, it is much easier to use than caridex.
Better contact with the carious lesion.

Isacvantages Of Carisoly

ents may still be needed for the removal of caries or material.

50. Action of Carisolv instruments in

Instrument tips have sharp edges
but a blunt angle. They thus
provide excellent depth control
when the dentist scrapes away
the carious dentine that has been
softened by the carisolv gel.

¿comparison with other instruments

Instruments with sharper Worn out burrs or excavators with
cutting angles are designed rounded cutting angles slide over the
to work themselves down surface and the scraping effect is
into dental tissue and make therefore [poor

it difficult to control the

depth

51. Initial aspect of dentin carious
lesion present on the 53

Rubber dam isolation and
Carisolv application onthe 53

(go

Soft infected dentin excavation
using spoon excavator.

ve
>

y

Final aspect of the cavity after Restoration of 53 with composite

removal of the carious lesion resin (3M ESPE Filtek 2350)

52. Application & Mode of action of Papacarie

“ Papacarie when applied to the contaminated dentine has proteolytic,
chlorinating and oxidating properties on the affected collagen, without acting

on the sound dentine.

“+ It is able to remove the smear layer, which facilitates the penetration of
adhesives, thereby enhancing the adhesional properties of restorative materials,

mising.on.the.shear.bond strength.

53. Advantages of Papacarie

It does not require special instruments or equipments.
Easy to manipulate.
Fast acting.

Ideal consistency.

Disadvantages of Papacarie

Instruments may still be needed for the removal of caries or material.

55. Lasers

+ The use of lasers for cavity preparation and caries removal is based on the
ablation mechanism, in which dental hard tissue can be removed by thermal

and/or mechanical effect during laser irradiation (Keller et al., 1998).

<

+ Lasers have shown to remove caries selectively while leaving the sound enamel

and dentin. They can be used without application of local anesthetics.

% Commonly used lasers for caries removal are Er: YAG and Er.Cr:YSGG lasers.

rial contains a higher water content compared with surrounding

ental hard tissues. Consequently, the ablation efficiency of caries is

ter than for healthy tissues.

57. Mechanism of action of Lasers
on hard tissue ablation

Lasers have photomechanical effects, Laser light is highly energetic and when

exposed causes fast heating of dental tissues in small area.

+ Fast mechanical shock waves occur due to photo-vaporization of water within

the tooth.

e creates high pressure, removing and destroying selective areas of

ent tooth.

58. Technique of Laser application

* Recommended setting for Er:YAG laser:
Y” Caries : 100-200mj.
Vv Dentin : 150-200mj.
v Enamel, 200-250mj.

* Gently touch target tissue with tip end.
* Direct water stream to the target tissue.

+ Always keep operation area wet.

ip moving to provoke effective ablation and better cooling.

r deep cut move the tip constantly up and down (pumping action).

59. Advantages of hard tissue laser treatment

1. Pulp vitality not compromised.

2. Can remove caries effectively.

3. Can perform cavity preparation effectively.

4. Quality of cavity preparation equivalent to that with the handpiece.
5. Less anxiety, pain free and anesthesia free.

6. Little or no post-operative discomfort.

7. Ideal for children and adults (comforting for both patient and parent).

IniteKeJSs OF narel tissue laser recaiment

imitation of ErYAG: do not ablaze amalgam, gold and porcelain.

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