Root Caries

Root Caries

2. Introduction

* Root caries as defined by Hazen, is a soft, progressive lesion that is found
anywhere on the root surface that has lost its connective tissue attachment and

is exposed to the environment.

* Root caries occurs at or apical to the CEJ. Generally root caries lesions have
been described as having a distinct outline and presenting with a discolored

appearance in relation to the surrounding non-carious root.

+ Most common reasons for their occurrence is gingival recession, though other
causes can also be present. With advanced age, there is more gingival recession,
which leaves the root surface exposed to the oral environment and leads to an

increase in the root caries rate.

3. + Root caries can occur in the areas of abrasion, erosion, and abfraction, or as

primary root caries and recurrent decay.

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+ The term “primary” as it is used with root caries refers to new dental caries

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occurring in the absence of a restoration. Secondary (recurrent) root caries

refers to caries occurring adjacent to an existing restoration.

4. Clinical features of Root caries

Root surface caries is initiated when there is periodontal attachment loss

exposing the root surface to the oral environment.

There are no reported clinical symptoms of root caries although pain may be

present in advanced lesions.

An area where root caries has taken place may appear as irregular or round or
oval in shape which then may spread radially and join other areas of root caries.

Root caries are more common in males than females. Most commonly they are
seen in mandibular molars, followed by premolars, canines and incisors. This
order is reversed in the maxilla. The buccal and interproximal surfaces are

more susceptible than the palatal or lingual surfaces.

5. + Initial root caries:
v White at first then may become light brown to yellow.
v Shallow, spreads laterally.
v Without patient symptoms.

+ Active, progressing root caries:
Y” Yellowish, light brown.
Y” Soft or leathery on probing with light pressure.
Y” Its covered by visible plaque.

Y” Its primarily detected by the presence of softness and cavitation.

6. + Inactive root caries:

Y
Y
Y

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Well-defined
Dark brownish or black in color
May be rough or smooth shiny

surface but its cleanable.

Hard on probing with moderate pre
Usually not covered with plaque

Its seen in patients (usually older) whose oral hygiene and diet in
recent years are good. Where discoloration of such areas is common

and usually is associated with remineralization.

* One of the more difficult diagnostic challenges is a patient who has attachment

loss with no gingival recession, thereby limiting accessibility for clinical

inspection.

7. Etiology of ine Root caries

+ The microflora responsible for root caries consists of Streptococcus mutans,
Lactobacillus and Actinobacillus.

* Micro-organisms metabolize sugars into organic acids, these acids then pass
through the root structure and start the process of demineralization. This
process takes place at the pH of 6.4 (5.5 for demineralization of enamel). The
rate of demineralization of root occur at higher pH and is much faster than that
of enamel because the root has much less mineral content (55%) than that of

enamel (99%).

SUGAR nus BACTERIA ros ACID

FROM PLAQUE

“+ eg I

ACID nus HER SN roms DECAY

8. Intraoral factors

= Xerostomia

+ Low salivary buffer capacity

+ Poor oral hygiene

+ Periodontal disease and periodontal surgery

+ Gingival recession

+ Frequency of carbohydrate intake

+ Unrestored and restored coronal and root caries

= Overdenture abutments and removable partial dentures
+ Malocclusion

+ Abfraction lesions

« Tipped teeth which make areas of teeth inaccessible for cleaning.

9. Extraoral factors

= Advanced age

« Medications that decrease the salivary flow

= Lower educational and socioeconomic levels

+ Antipsychotics, sedatives, barbiturates, and antihistamines

= Diabetes, autoimmune disorders (e.g. Sjögren’s syndrome)

= Radiation therapy

= Gender—males are affected more than females

+ Physical disability where patients have limited manual dexter-
ity for cleaning of teeth

= Limited exposure to fluoridated water

+ Consumption of alcohol or narcotics.

10. Diagnosis of ne Root caries

* Clinical examination is best carried out with an explorer. Tooth surface should
be cleaned before examination since plaque covering the lesion can lead to

misdiagnosis.

° Accurate radiographs can also help in diagnosis but they should be free from

overlapping or burnout.

+ Special dyes can be useful for detecting root caries, these dyes stain the infected

dentine and thus allow the clinician to detect caries.

11. Differential diagnosis of root caries

Active root Arrested root Extrinsic stain

caries caries on root surface
Color Light brown Dark brownto Darkin color
black
Surface Soft, leathery, Hardandcan- Hard and rough
texture andelasticin notbecom- texture

nature pressed

12. Proper preventive measures of plaque removal (like educating patients,

maintaining a proper tooth brushing technique, use mouthwash), diet
modification.

Special attention should be given to root caries-prone patients who are
wearing dental prostheses. This can be done by proper management of soft
tissues during fixed prosthesis procedures and avoiding the placement of
restoration margins apical to the surrounding tissue to avoid plaque

accumulation.

13. In patients with low salivary flow, xylitol-containing chewing gum which
stimulates salivary flow and decreases plaque formation has shown to
decrease the caries.

The use of topical fluoride should be advocated because it promoters the

remineralization process and reduces the rate of demineralization. There are

numerous methods by which fluoride can be supplied:

A. Exposure to fluoride in drinking water results in increasing resistance to
root caries.

B. Topical fluoride products are available as 0.05% sodium fluoride rinse,
0.12% chlorhexidine rinse, and as 1.1% neutral sodium fluoride gel in a 5
minutes tray technique, with 4 applications over 2-4 weeks.

C. Other products are dentifrices containing 1100 ppm sodium fluoride.

D. fluoride chewing gum which is effective especially in patients with low
salivary flow.

E. Fluoride-containing varnishes have also been effective against root caries.

14. Treatment of the Root caries

+ Treatment plan for root caries depends on the following factors:
Y” Clinical examination.
v Size of the lesion.
v Type, extent, and site of the lesion.
v Esthetic requirements.

Y” Physical and mental condition of the patient.

+ Root caries lesions are difficult to restore because of their location, which is
usually subgingival. For proper restoration, sufficient access and isolation are
needed.

+ Proper access and isolation to treat root caries are very important, and ideally

involve use of a rubber dam if the lesion is supragingival.

15. If the location of the lesion is near the gingival margin or is subgingival. In that

case, cotton rolls and retraction cords can be used.

If the lesion extends subgingivally and cannot be completely observed, even
with the use of a retraction cord, a releasing incision may be required for

completing the restorative procedure (Periodontal surgery).

To begin with it, root surface is cleaned with pumice to remove the plaque.
Then the excavation of carious tooth tissue is done and restoration walls are
prepared. The margins and retention design depends on the restorative
material used. For example:
Y” When a tooth is to be restored with amalgam, retention grooves are
required occlusally and gingivally.
v For composites, beveling of the coronal margins of the preparation is

required.

16. There is a protocol for treatment of root caries that had putted by Billings in

1985 called (Index of Billings for root caries severity treatment) as following:

I
I.

II.
IV.

Grade 1: Incipient; no surface defect; need remineralizing therapy.
Grade 2: Shallow; surface defect <0.5mm; need recontouring.
Grade 3: Cavitation; surface defect >0.5mm; need filling.

Grade 4: Pulpal carious pulp exposure; need RCT + filling.

Grade 1 Grade 2
INCIPIENT SHALLOW CAVITATED

17. Restorative materials used for
treatment of root caries

Direct filling gold

Properties:
+ Good marginal adaptation compatibility.
+» Isolation is difficult.

+ The use of direct filling gold is

decreased.

18. Amalgam

Properties:

.

Easy to manipulate.
Can be used in areas which are difficult to isolate.
The margins are self-sealing.
Lacks aesthetic appearance.
No therapeutic effect.
Cannot chemically bond to tooth struct
It requires the cutting of healthy tooth |
structure adjacent to the carious
tissue for adequate retention of the

restoration.

19. Traditional glass-ionomer

Properties:

+ Biocompatible.

+ It has chemical bond to tooth structure.

+ Releasing fluoride over extended periods of time.
+ Poor aesthetics.

+ Excessive wear with time.

20. Resin-modified glass ionomer

Properties:

.

Biocompatible.
Bond to tooth.
Have thermal expansion and contraction characteristics that match tooth
structure.

Fluoride releasing feature; also it can be recharged by uptake of fluoride ions
from the oral environment.
They are aesthetic.

Less brittle than the traditional

glass ionomer.

21. Resin composites

Properties:

Highly aesthetic materials.

It bond to enamel and dentin.

Hybrid composites possess improved strength and improved aesthetics
compared with traditional resin composites.

Microfilled composites are recommended for root surface restorations as they
have lower elastic modulus than hybrid composites.

Don’t have any anti-cariogenic effect.

22. » Resin composites are technique-sensitive materials and require proper isolation

for the clinical success of the restoration.

+ Polymerization shrinkage associated with the curing of resin composites is
another concern, since this can result in discoloration of the resin around the
margins and in microleakage that leads to tooth sensitivity and secondary

caries.

° One of the most frequent clinical problems associated with class-I and class-V
cavities in adhesive resin restorations is the weak link of restorative material to
root dental structures, when the cervical margin is located below the CEJ. In
terms of cementum, the tissue-bonding properties have not been adequately

elucidated.

23. It is well known that root surfaces exposed for a long period to the oral
environment develop a superficial hypermineralized layer with limited
permeability, compared with intact cementum. These surfaces may interfere in

the marginal quality of root restorations, especially in elderly population.

Very limited information exists on cementum-bonded restorations. Ferrari et
al. in 1997 reported that cementum treated with dentine bonding systems is

infiltrated by the resin, but the predictability of the bond is unclear.

Furthermore, it is still unclear (whether or not) the problem of bonding to
cementum is related to the structure and properties of the tissue or to a limited

effectiveness of the adhesive materials at the region.

24. * However, the morphology of the periodontitis-affected cementum surface was
highly variable, with islands of dense granular material. Based on these
findings, mechanical removal of the superficial layer of the exposed cementum
prior to any periodontal regenerative treatment has been advised. This

treatment mode may be applied to improve adhesive bonding as well.

+ Modification of intact cementum surfaces to improve adhesion may include a
eproteination step, prior to any adhesive treatment, in order to remove the high

organic content and expose the inorganic substrate, like conditioning with
aqueous solutions of sodium hypochlorite (NaOCl).

+ Sandwich technique is another solution to solve adhesion of composite to root

surface.

25. Fluoride-containing resin
composites

Properties:

.

.

Fluoride-containing resin composites release only small amounts of fluoride.
It has little ability to recharge from the oral environment.
Therefore, they are not recommended for use with high caries-risk patients, but

can be used where aesthetics is a concern.

26. Compomers

Properties:

.

.

They are polyacid-modified resin composites.

They have possess properties of both glass ionomer and resin composites.
They leach fluoride, but to a lesser extent than glass ionomer.

They bond to both enamel and dentin.

They can be used in low-stress areas where esthetics is a concern.

27. Table 2. Restorative materials used for root caries lesion

Material Flouride release Adhesive Aesthetics

Amalgam None No Low

Glass ionomer High Yes Moderate

Resin- modified High Yes Moderately

glass ionomer high

Resin composite None Yes, with High
bonding

Flouride-containing Little Yes, with High

resin composite bonding

Compomer Moderate Yes, with Moderately
bonding high

28. Conelusions

With more elderly people retaining their natural teeth, the need to understand
the nature and causes of root surface lesions is of great importance. Preventive
measures that include proper oral hygiene, plaque control, and fluoride

therapy are required prior to and after dental treatment.

Treatment of root surface caries should be directed and customized to the
individual case by classifying patients in risk groups to achieve maximum

results.

The use of resin-modified glass ionomer materials is recommended for these
restorations because of their anti-cariogenic properties in patients with a high

caries risk.

29. References

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69.

Billings RJ, Brown LR, Kaster AG. Contemporary treatment strategies for root surface caries. Geriodontics 1985;1:20-27.

Blomlof J. Root cementum appearance in healthy monkeys and periodontitis-prone patients after different etching modalities. J Clin
Periodontol 1996; 23:12-18

Burgess JO, Gallo JR. Treating root-surface caries. Dent ClinNAm 2002:46:385-404.

Demarco FF, Ramos OLV,Mota CS, Formolo E, Justino LM. Influence of different restorative techniques on microleakage in class II
cavities with gingival wall in cementum. Oper Dent 2001; 26:253-259

Ferrari M, Cagidiago MC, Davidson C. Resistance of cementum in class II and V cavities to penetration by an adhesive system. Dent
Mater 1997; 13:157-162.

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chapter 5: Dental caries.

Gupta B, Marya C, Juneja V, Dahiya V. Root Caries: An aging problem. The Internet Journal of Dental Science 2006; 5(1).

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cementum. J Prosth Dent 1989; 61:191-197

Shaker RE. Diagnosis, prevention and treatment of root caries. Saudi Dental Journal 2004; 16(2):84-92.

Suzuki M, Jordan RE. Glass ionomers-composite sandwich technique. J AmDent Assoc 1990;120:55.

Tay FR,Gwinnett AJ, Pang KM,Wei SHY. Variability in microleakage observed in a total-etch wet-bonding technique under different
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30. BACTERIA SUGARS SALVA FLUORIDE