Management of Deep Carious Lesions

Definition:
- Dental caries is an infectious micro-biologic disease of the teeth that results in localized dissolution & destruction of the calcified tissues. - Enamel demineralization occur @ PH of 5.5 or less, sometimes, r equiring restorative intervention & even extraction..

Affected & Infected Dentin:

- In operative procedures, it is convenient to term dentin as either infected, and thus requires removal, or affected, which doesn't require removal.. - Affected dentin: is softened, demineralized dentin that is not yet invaded by bacteria (Zones 2&3) inner carious dentin - Infected dentin: (Zones 4&5) outer carious dentin & Bacterial plaque is both softened & contaminated with bacteria. - How to differentiate?? By dyes

Objectives:
The objective is to focus on the: 1. Diagnosis (esp. identifying those people @ high risk for caries) 2. Preventive measures 3. ttt modalities
N.B: The restorative ttt doesn't cure the caries process, so identifying & eliminating the causative factors for caries must be the primary focus, in addition to the restorative repair of damage caused by caries.. **(Diet- oral hygiene caries index)**

Review of cariology:
l For caries to occur, 3 factors must be present simultaneously & in the correct manner: 1. Cariogenic bacteria 2. A susceptible tooth surface 3. Available nutrients to support bacterial growth

l Mutans streptococci (MS), are the primary causative agents of initial coronal caries because they : 1. adhere to enamel 2. Produce & tolerate acid 3. thrive in a sucrose-rich environment 4. produce bacteriocins substances that kill off competing organism l Initial decalcification (subsurface) may be 1 -2 years before tooth cavitation Enamel cavitations + subsurface has already been affected progression of the destruction by Lactobacillus l Plaque + nutrients (sucrose) l Ions from saliva

acids demineralization

cause remineralization to occur fluroappetite

l Hydroxyappetite + Fluoride

l The protective mechanisms of saliva include: Due to its large CHO-protein molecules (glycoproteins) that 1. Bacterial caused bacterial agglutination & then be swallowed as a part of clearance 1.5 L of saliva/day 2. Buffering actions Saliva contains urea, other buffers that help dilute any plaque acids.. Due to various proteins & Antibodies (lyzozyme , lactoferin, 3. Antimicrobial lactoperoxidase, Type A secretary Ig actions

4. Remineralization
l Lack of saliva

Due to the present of (Ca, Ph, K, F) rate of caries development

l Once the caries process is thoroughly understood, the appropriate diagnosis, prevention & ttt of caries can occur..

Caries Control restoration

Objectives:
1. The primary objective of the caries control tooth preparation is to provide adequate visual & mechanical access to facilitate the removal of the infected portion of carious dentin 2. Remove the decay from all the advanced carious lesions 3. Place appropriate pulpal medication 4. Restore the lesions in the most expedient manner 5. Prevent pulp exposure N.B: Temporary (Intermediate) restorative materials (IRM) are usually the ttt materials of choice.

Advantages:
1. Allows quick removal of the caries & placement of temporary restorations 2. Provide a suitable delay that gives the pulp time t o recover, allowing a better assessment of the pulpal status 3. Generate some time while many of the other associated dental problems can be treated N.B: Temporary restoration usually should be replaced with more permanent restorations @ a later date, when the factors promoting caries formation have been controlled & the prognosis of the tooth pulp has been determined..

Indications:
1. 2. 3. 4. Teeth with questionable pulpal prognosis. Extensive caries (acute decay) with adverse pulpal sequelae. Removal of nidus of caries infection in patient mouth. Extensive involvement with time restriction.

Effective caries removal can be accomplished with:

l Hand instrumentation using spoon excavator .. The use of spoon excavator may result in peeling off amount of softened dentin la rger than intended & therefore result in inadvertent pulp exposure, thus hand instruments required great skill & sharp instruments.. l A slow-speed hand piece using a round bur.. OR l A high-speed hand-piece using a round bur operated just above stall-out speed (low-speed) provide good control l Rotary instruments: 1) provide good control 2) Required less skill

Treatment options for deeply seated caries lesion:

k Proceed to conventional procedures insert permeneat restoration after

complete caries excavation.

k Indirect pulp capping

when complete excavation of SD is anticipated to

produce pulp exposure.

k Direct pulp capping

requirements!!!! (IMPORTANT)

Procedures of I.D.P.C & D.P.C Indirect pulp capping:

- The deliberate retention of softened dentin near the t ooth pulp & medication of the remaining dentin with CaOH - An Indirect Pulp Cap is a procedure that is used when the dentist gets close to the pulp when removing decay. This is a perfectly proper dental procedure, and is used in cases where the pulp would be exposed if all the decay were removed from the cavity. Regarded as a conservative treatment, the application of medicated cement in the temporary filling helps the pulp of the tooth to repair itself by containing the decay and allowing the buildup of a wa ll of tooth structure between the pulp and the decayed material .

Direct pulp capping:

Technique for treating a pulp exposure with a material that seals over the exposure site & promotes reparative dentin formation..

Requirements of direct pulp capping:

Good prognosis of D.P.C: 1. Asymptomatic tooth with normal response to normal vitality test. 2. Pin-point exposure (0.5mm or less in diameter) 3. Non-hemorrhagic or easily controlled. 4. Dry, sterile filed (R.B) 5. Atraumatic exposure with minimal manipulation of cavity floor.

Time intervals: - 1 1/2 _ 2 months = 6-8 weeks

- If a long interval is anticipated between the caries control procedure & the permanent restoration, amalgam will ensure better maintenance of the tooth position & proper contour even for proximal or occlual tooth loss.. - The extent of access preparation & tooth structure loss will indicate the need for a matrix before placement of the restorative material. - Condensation & carving of amalgam should be accomplished in the conventional manner if we ganna use amalgam. - Using spherical amalgam reduces the chance of pulpal perforation due to exertion of less pressure. - The interval between the caries control restoration & its replacement with a permanent restoration provides time to complete the following:
1. Assessment of the pulp response to excavation & medication 2. ttt of the cariogenic infection with prescribed anticaries measures 3. Assessment of the patient's ability to perform oral hygine procedures 4. Assessment of the patient's compliance with dietary changes 5. Assessment of caries activity elsewhere in the mouth.
N.B: The previous points are important in choosing the material & technique for the

final restorations

How to evaluate prognosis: Look to the text!!!

Types of temporarization or intermediate restorations: * Temporary amalgam *CaOH * Resin bonding agents

G D LUCK
Strawberry