Dental Caries

Dental Caries
 Dental Caries

Sugar + Dental Plaque

ACID
S
Demineralization
Cavities
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Subsurface
demineralization of
enamel
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Occlusal lesions can

be arrested by
remineralization
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recently cleaned front

teeth with signs of
demineralization and
gingivitis

after some weeks

remineralization has taken
place and the gingivitis is
healed
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No sugar before
sleeping
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Resistance
 Plaque removal
 Sugar reduction
 Fluoride
 Sealants
 Chlorhexidine
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Living tissue
Peritubular dentine
Intertubular dentine
Apatite crystals
Intermolecular cross-linking
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Bacterial Invasion
1

8
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 Bacterial Invasion
1

2
 Bacteria need to have a source of nutrients,
3

4
i.e. from the oral environment.
5

6
 Bacteria are found mostly in the
7

8
biomass with few being found in the
dentine tubules.
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Crystal Removal Process

1

8
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Crystal Removal Process

1  Acid from fermentation process penetrates
2 the dentine tubules ahead of bacterial
3
invasion.
4

5
 This softens the dentine matrix.
6  The collagen fibres are reversibly damaged
7
in the dissolution process.
8

cont’d
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Crystal Removal Process (cont’d)

1  Continuation of acid production dissolves

2 crystals in the peritubular and intertubular
3
dentine.
4

5
 Further continuation of acid production
6 breaks the intermolecular crosslinks of
7 collagen fibres irreversibly.
8
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Defense reaction in dentine

1

8
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Defense reaction in dentine

1  A defence reaction takes place in the dentine.
2  Dissolution alters the hydroxyapatite crystals.
3
 Crystals with a lower hardness and a lower
4

5 calcium density (= whitelockite) remain.

6  The dentine tubules are blocked by
7
precipitated intratubular whitelockite crystals.
8

cont’d
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Defense reaction in dentine (cont’d)

1  These crystals originate from the

2 peritubular and intertubular dentine.
3
 This process is known as TUBULAR
4

5
SCLEROSIS.
6  It is seen clinically as yellow-brownish
7
discoloration of the dentine.
8
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Outer (‘infected’) Inner (‘affected’)

 Bacterial  Few Bacterial
Invasion  Reminerizable
 Unreminerizable  Alive
 Dead  Sensitive
 Without
sensation
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Prerequisites physiological remineralization:

 Presence collagen fibers
 Living odontoblastic process
External remineralization:
 Saliva , calcium and phosphate
 Exposure bio-active agents
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Fissure enamel caries

1

4
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Fissure enamel and

1 dentine caries
2

4
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Fissure cavity
1

3.6 mm
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Lateral spread of
1 fissure cavity
2

3.6 mm
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Enamel demineralization follows the enamel rods.

Initial dentine demineralization does not spread
along the Enamel Dentine Junction (EDJ) beyond
1 the periphery of the lesion in the enamel.
2 This leads to a cone shape lesion with the base at
the EDJ.
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In any pit and fissure system there can be multiple

lesions in different stages of progression. (Stages
A, B and C.)
1

2 Only when there is frank cavitation and a cariogenic

environment, will dentine demineralization spread in
a lateral direction. (Stage D)
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1. Subsurface demineralization of enamel.

1

4
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2. Partial demineralization of dentine

1
directly underneath enamel lesion
2

4
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3. The dentine demineralization follows the

1
dentine tubules
2

4
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4. Lateral spread of dentine caries occurs

1
mainly in cavitated lesions
2

4
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 Progression of approximal caries follows the same

principles as for occlusal caries.

 It follows the enamel rods, but because of the curved

shape of the approximal tooth surface, the lesion does
not lead to a cone shape at the EDJ as present in an
occlusal fossa.
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1
GV Black’s cavity preparations followed
2

3
designs that were largely dictated by the
4 physical properties of the filling materials (e.g.,
amalgam and silicate cement).
These materials needed mechanical retention
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1
Mechanical retention
2

3
 Flat floors
4  Vertical walls
 Triangular retention
niches
 Undercut areas
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1  Shape of the prepared cavity was not limited to the

2
tooth destruction caused by caries.
3

4
 The preparation did not follow the way a dentine
lesion progresses.

 Black's principles could be considered as: 'the

application of a mechanical design on a biological
process'
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‘The application of a mechanical design on a

1

2
biological process'
3

4
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Research findings
 survival time single surface: 10 – 8 years
 survival time multiple surface: 8 - 6 years

Reasons for failures

 secondary caries
 marginal breakdown
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2
Repeat restoration cycle
3  Occlusal lesion and occlusal restoration
 2-Surface restoration
 Extended restoration
 Crown or Extraction
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 ‘Diagnoses’ are uncertain, with

1 considerable variation occurring between
2
dentists.
3
 Extensive cavity preparations (Black) in the
name of outline form and extension for
prevention result in restorations with weak
margins, leading to marginal breakdown
and ‘ditching’.
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 Dentists have an urge to replace restorations

1

2
 Perceived (but erroneous) requirement to
3
‘freshen up’ the cavity walls and margins.
 The teeth inevitably become weaker, thereby
reducing their prognosis.
 The complexity of the restorations increases or
 Tooth needs to be extracted.
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2
 Much sound tooth tissue needs to be
removed.
 Traditionally placed restorations, on
average, do not last long.
 The replacement restorations, in many
cases, last for less time.
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 The end result is a tooth that became

1 weaker and weaker each time a
2
replacement was made.

 The weaker the tooth becomes, the more

likely the restoration will fail, resulting in a
vicious cycle and termed the ‘repeat
restoration cycle’.
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1
 Cavity cleaning
2  Obtaining access
 Removal of dead dentine and enamel
 Anatomy determines the shape
 No preconceived cavity design
 Black's principles are redundant
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2
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 Mechanical retention is no longer needed

1 with adhesive materials.
2

4  Shape of the cavity is determined by the

5
anatomy of the lesion.
6

8
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 Question:
1

3 Is a rotary instrument the best tool

4
when the cavity is determined by
the anatomy of the lesion ?
5

8
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 NO !!!! A rotary instrument is not the best

1
instrument for:
2

3
 removing only soft, completely demineralized tooth
4
tissue and
5

6
 preserving as much as possible remineralizable
7
enamel and dentine.
8
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Hand instrument:
1
 Dental hatchet
2

(e.g., 10 – 6 - 12)
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Hand instrument:
1
 Excavator
2

(e.g., 153 – 154)

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Rotary instruments (only certain circumstances)



3  Slow speed drill

4  with straight bur for further opening of dentinal lesions
5
that have a very small entrance
6
 with round bur for gentle removal of dead tissue.
7

8
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Rotary instruments (only certain circumstances)

1

3
 High speed drill
4
 onlyfor opening cavities that are inaccessible
5

6
 removal of failed restorations.

8
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Why hand instruments?

1
 creates the most ideal (conservative) cavity
2

3
shape
4  gives the operator improved tactile sense
5  does not damage surfaces adjacent to the
6

7
lesion, in the case of approximal lesions and
8
 therefore, does not promote caries
development.
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To stop the caries process

To facilitate plaque removal
To encourage remineralization of inner carious
dentine
To restore function
To restore aesthetics.
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Application of a material that:

 produces a seal against bacterial invasion
 encourages remineralization
 is sufficiently durable
 maintains function.
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Adhesive restorative materials

 composite resins and polyacid-modified composite
resins (‘compomers’)
 glass-ionomers and resin-modified glass-ionomers.
Non-adhesive restorative materials
 amalgam
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4 Preservation =
restoration + prevention
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Sealant
restorations
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2  For carious lesions in occlusal, buccal

3
and lingual surfaces of posterior teeth:
4
 Preventive resin restoration
 Preventive glass-ionomer restoration
 Atraumatic Restorative Treatment (ART)
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2  For carious lesions in approximal

3
surfaces of posterior teeth:
4
 Box-type restorations (outcome: good).
 Tunnel preparation (outcome: dubious).
 ART (outcome: unknown yet).
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Clinical trial in the USA.

 more sound tooth structure was conserved
 restoration margins were better protected
 recurrent caries was less frequent
 clinical survival of restorations was prolonged.
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1  The biological principle to the management of a

2

3
dentine lesion is to only remove soft, completely
4
demineralized tooth tissue. This is best achieved
through using hand instruments and/or a slowly
rotating drill rather than a high-speed drill. In doing
so, less sound tooth tissues are removed and
damage to surfaces of other teeth is minimized.
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 Since only soft, completely demineralized

1

2
tissue is removed, there can be no
3 preconceived cavity design; the anatomy of
4
the carious lesion dictates the size and
shape of the cavity preparation.
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 The treatment is completed by placing an

1

2
adhesive filling material into the cleaned cavity
3
preparation, over its margin, and over the
4 adjacent pits and fissures. This sealant
restoration will arrest caries activity that is
present in dentine and enamel, provided that
the bonding of the material to these tooth
tissues is adequately established.
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 This treatment modality has the potential to:

1

2
 control dentine caries
3  increase survival of the restoration
4
 save tooth tissues and thus
 increase tooth life expectancy.
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Remember:
 TO APPLY PREVENTIVE MEASURES

 TO ENCOURAGE ORAL HYGIENE AND

 TO PROMOTE THE USE OF FLUORIDE

TOOTHPASTE.