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MANAGEMENT OF DEEP CARIOUS LESIONS

Definition: - Dental caries is an infectious micro-biologic disease of the teeth that results in localized dissolution and destruction of the calcified tissues. - Enamel demineralization occur at pH of 5.5 or less, sometimes, requiring restorative intervention and 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 and 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 at high risk for caries) 2. Preventive measures 3. Treatment modalities N.B: The restorative treatment 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: For caries to occur, three(3) factors must be present simultaneously and in the correct manner: 1. Cariogenic bacteria 2. A susceptible tooth surface 3. Available nutrients to support bacterial growth Mutans streptococci (MS), are the primary causative agents of initial coronal caries because they : 1. Adhere to enamel 2. Produce and tolerate acid 3. thrive in a sucrose-rich environment 4. produce bacteriocins substances that kill off competing organism

Initial decalcification (subsurface) may be 1-2 years before tooth cavitation Enamel cavitations + subsurface has already been affected progression of the destruction by Lactobacillus Plaque + nutrients (sucrose) acids demineralization Ions from saliva cause remineralization to occur Hydroxyapatite + Fluoride fluroapatite The protective mechanisms of saliva include:

1. Bacterial clearance

Due to its large CHO-protein molecules (glycoproteins) that caused bacterial agglutination & then be swallowed as a part of 1.5 L of saliva/day 2. Buffering actions Saliva contains urea, other buffers that help dilute any plaque acids.. 3. Antimicrobial actions Due to various proteins & Antibodies (lyzozyme , lactoferrin, lactoperoxidase, Type A secretory Ig) 4. Remineralization Due to the presence of (Ca2+, Ph3-, K+, F-) Lack of saliva rate of caries development Once the caries process is thoroughly understood, the appropriate diagnosis, prevention and treatment 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 treatment 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 to 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 at a later date, when the factors promoting caries formation have been controlled & the prognosis of the tooth pulp has been determined.. Indications: 1. Teeth with questionable pulpal prognosis. 2. Extensive caries (acute decay) with adverse pulpal sequelae. 3. Removal of nidus of caries infection in patient's mouth. 4. Extensive involvement with time restriction.

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

Treatment options for deeply seated caries lesion: Proceed to conventional procedures insert permanent restoration after complete caries excavation. Indirect pulp capping when complete excavation of softened dentine is anticipated Direct pulp capping requirements!!!! (IMPORTANT) to produce pulp exposure.

Procedures of I.D.P.C & D.P.C Indirect pulp capping: - The deliberate retention of softened dentin near the tooth pulp and medication of the remaining dentin with Ca(OH)2 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 wall 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 and promotes reparative dentin formation..

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

Time intervals: 1 - 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 and proper contour even for proximal or occlusal tooth loss.. The extent of access preparation and tooth structure loss will indicate the need for a matrix Condensation and carving of amalgam should be accomplished in the conventional manner if Using spherical amalgam reduces the chance of pulpal perforation due to exertion of less before placement of the restorative material. we are going to use amalgam. pressure. The interval between the caries control restoration and its replacement with a permanent restoration provides time to complete the following: 1. Assessment of the pulp response to excavation and medication 2. 3. 4. 5. restorations How to evaluate prognosis: Look to the text!!! Treatment of the cariogenic infection with prescribed anticaries measures Assessment of the patient's ability to perform oral hygiene procedures Assessment of the patient's compliance with dietary changes Assessment of caries activity elsewhere in the mouth.

N.B: The previous points are important in choosing the material and technique for the final

Types of temporization or intermediate restorations: * Temporary amalgam *Ca(OH)2 * Resin bonding agents

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