Dental Caries

Diagnosis and Treatment Options

Dental Caries
Infectious , multifactorial disease. Characterized by the loss of mineral contents of the calcified tissue. Presents in a spectrum of presentation. Lesion status: incipient/cavitated; active/inactive
Subclinical
Demineralization

Remineralization

Incipient lesion
Remineralization

Demineralization

Cavitated lesion
(Irreversible tooth Morbidity)

Treatment Options
Traditional - detection of caries lesion followed by immediate restoration. Current management philosophy treatment decision should be based on the status of the lesion (incipient vs cavitated, active vs inactive), and other patients factors (age, frequency of visit, oral hygiene status, dental IQ, motivation, risk factor). Non-surgical management (remineralization) of the disease should be part of the treatment plan.

Examples of Treatment Options

Cavitated, active - surgical (restoration) Non-cavitated, active - surgical or nonsurgical (remineralization) Cavitated, inactive - surgical (stress bearing area) or non-surgical (non stress bearing area) Non-cavitated, inactive - non-surgical

Dilemma of Caries Diagnosis

No reliable objective diagnostic technique to differentiate between incipient lesion and cavitated lesion
Proximal lesion - primary: bitewing x-ray; secondary: visual through marginal ridge. Pits and fissures - primary: visual; secondary: bitewing x-ray. Smooth surface lesion - primary: visual; secondary: tactile.

Dilemma of Caries Diagnosis

No reliable objective diagnostic technique to differentiate between active and inactive caries lesion
Currently the rule of thumb is : the darker the color of the lesion, the more inactive it is.

Diagnosis and Treatment Options Based on location

Pits and fissures Smooth surfaces Proximal surfaces Root caries Secondary caries

Pits and Fissures Caries

Demineralization around the wall and bottom of the pits (incipient lesion)

Enamel

Dentin

Once demineralization reach the DEJ, it begins spreading laterally Start infecting the underlying dentin (surgical intervention indicated)

Diagnosis of Pits and Fissures Caries Traditional Method

Using an explorer to probe into the pit/fissure - a feel of catch or a stick indicate the presence of caries at the bottom of the pit/fissure

Problem with the Traditional Method

Even at the stage where surgical treatment is indicated, the occlusal enamel may still be intact

The catch or stick you feel when you use your explorer to probe into an intact pits is a result of the wedging effect

Possible Result of Probing into an Incipient Lesion

Diagnosis of Pits and Fissures Caries - Current Method

Use an explorer to remove plaque and food debris from the fissure orifice Under good lighting, isolation (dry) and magnification; visually inspect for any damage to the enamel Look for any subtle color changes around the pits and fissures

Diagnosis of Pits and Fissures Caries - Current Method

Enamel is low in opacity, thus any changes in color (e.g. caries dentin) in the underlying dentin will show through the enamel Look for a gray shadow or opaque area around the pits and fissures - a halo Ignore the color change within the pits and fissures Bitewing radiographs may be helpful in diagnosing deep lesion

Current Problems Relating to the Diagnosis of Pits and Fissure Caries

Uneven diagnostic conclusion among dentists No reliable objective diagnostic technique to differentiate between incipient lesion and cavitated lesion. No reliable objective diagnostic technique to differentiate between active and inactive caries lesion

New Technologies
New quantitative diagnostic system e.g. DIAGNOdent Laser Fluorescence J Dent 2002;30:129-134 Specificity higher for visual Sensitivity higher for DIAGNOdent
Frequeucy-Domain Infrared Photothermal

Radiometry and Modulated Laser Luminescence. Jeon RJ et al. Caries Res 2004;38:497-513

Treatment Options
Conclusive evidence of the presence of cavitated lesion

Bitewing radiographs Definitive halo around the pits and fissures Cavitated enamel

SURGICAL

Treatment Options
Presence of questionable cavitated lesion
Heavily stained pits and fissures Questionable halo

Sealants or restore with composite

Consider patients age and caries risk status

Treatment Options
Deep pits and fissures

Sealants in young or caries active or prone patients

Treatment Options - Surgical

Lesion specific restoration should be the primary option. Material specific restoration can be considered if unable to isolate or for economic reason.

Important Research
Mertz-Fairhurst EJ et.al. JADA 1998;129:410-412
Large occlusal lesions were treated with acid etch composite restorations, leaving soft, demineralized dentin both at the DEJ and in the base of the cavity. The teeth were followed over 10 years. There were no report of failed restoration, pulpitis or pulp death.

Empirical Evidence
Sealing caries may not work. It will work if you can maintain a complete and absolute seal of the enamel. However, a complete seal is very difficult to achieve. Beside pits and fissures, there may be micro cracks on the enamel.

Proximal Caries - Diagnosis

Bitewing radiographs - primary Trans-illumination - placing the mirror or light source on the lingual side of anterior teeth and directing light through the teeth. Lesion will show through as a dark area Opacity or color change under the marginal ridge (under dry and clean environment)

Radiographic Diagnosis of Proximal Caries

Triangular shaped radiolucency gingival to the proximal contact area - pointing towards DEJ

Radiographic Diagnosis of Proximal Caries

Triangular radiolucency- point end short of DEJ

Point end right at DEJ

Radiolucency in dentin

Treatment Options

Radiolucency in dentin

SURGICAL INTERVENTION

Treatment Options
Triangular radiolucency point ended right at DEJ

SURGICAL OR NON-SURGICAL Should depend on caries status/activities and other patients factors

Treatment Options
Triangular radiolucency point ended short of DEJ

NON-SURGINCAL MANAGEMENT

Treatment Options - Current philosophy

Unless there are clear evidence of radiolucency in dentin, all decision to initiate surgical intervention should take into consideration of patients caries risk status and other patients factors. Reason: these lesions may be arrested lesions or potentially can be converted from active to arrested lesion using various non-surgical management techniques.

Longitudinal Radiographic Data on a Patient (mesial of #3)

1984 1995

1987

2003

Inactive , Cavitated Lesion

Treatment Option - Surgical

Small lesion
Lesion specific restoration should be your primary choice; material specific restoration if unable to isolate or for economic reason

Treatment Option - Surgical

Medium/large lesion
Direct Restoration - lesion specific vs material specific Indirect Restoration - should only be considered if patients caries status become more stable

Current Problems Relating to the Diagnosis of Proximal Caries

Incipient lesion = triangular radiolucency point short of DEJ Cavitated lesion = triangular radiolucency point at or past DEJ Disagreement among dentist in exactly where the point end, and when should surgical intervention indicated

Current Problems Relating to the Diagnosis of Proximal Caries

No reliable objective diagnostic technique to differentiate between active and inactive caries lesion Best evidence: longitudinal radiographic data on the patient Supporting evidence: patients caries risk and other patients factors

Future
Quantitative data on the exact amount of mineral loss (incipient vs cavitated) - e.g. technology use in diagnosing pits and fissure caries (DIAGNOdent) Better understanding in the differences between active and arrested lesion - e.g. qualitative and quantitative differences in the mineral contents; microbiological differences?
Active Time? Arrested

Smooth Surface Caries Diagnosis

Dry, clean, magnified

Plaque covered surface

Cleaned surface

Diagnosis of Smooth Surface Caries

Incipient (chalky white, brown, black) Cavitated

Diagnosis of Smooth Surface Caries

Arrested (Shiny, white, brown)

Active (Matte, white)

Treatment Options

Incipient, active Incipient, arrested Cavitated, arrested

NON-SURGICAL (control measures depends on the caries status of the patient) SURGICAL (patient has esthetic concern)

Treatment Options
Cavitated, active (matte surface)

SURGICAL

Problem with Treatment Option

No objective diagnostic tool to differentiate between active and arrested lesion. Thus sometime it may be difficult to decide when to initiate surgical intervention.

Treatment Options
Composite RMGI - patient with very high caries potential Amalgam

Root Caries
Supragingival caries lesion located at CEJ Diagnostic criteria similar to smooth surface lesion Treatment options similar to smooth surface lesion (1st preference = RMGI)

Disease Trend in Dental Office

Because of the decrease in the incidence of dental caries (primary caries) in most industrialized countries; maintenance of previously inserted restoration has become the major workload in a typical dental practice. THUS

Evaluation of existing restorations is becoming the main focus of the subjective and objective examination of your patient. How you are handling the findings is whats going to define your treatment or your practice philosophy.

Existing Restoration - Clinical Status

Secondary Caries Marginal Integrity
marginal defect overhang open margin

Biomechanical Form
restoration fracture tooth fracture

Esthetic
patients esthetic concern

Contour
proximal contact axial contour occlusion

Secondary Caries
Carious lesion located at the margin of a restoration
It is the most common reason for replacing an existing restoration

Secondary Caries

Diagnosis of Secondary Caries

Diagnosis should NOT be based on using a sharp explorer and trying to get a stick at the margin of a restoration

Tools used for diagnosis are based on the location of the margin

Diagnosis of Secondary Caries

Visually Accessible Area
Primary Diagnostic Tool

Visual
Dry, clean, magnified, properly illuminated

Diagnosis of Secondary Caries

Visually Inaccessible Area

Tools
Tactile & Bitewings Radiograph

Common Mistakes in Diagnosing Secondary Caries

Use of a sharp explorer and probe in to a defect, using a stick as the diagnostic criteria for the presence of secondary caries An uniform radiolucent line around a composite restoration - may be due to the presence of a thick layer of adhesive resin. Radiographic burnout at CEJ

Secondary Caries - Treatment Options

Surgical
Reasons Most of the time when the lesions are detected, they are frank cavitated lesion. These lesions are more likely to be active lesion (time frame of the development of the disease) These lesions are in a very retentive area (limited ability for non-surgical management techniques to work; similar to pits and fissure caries)

Secondary Caries - Treatment Options

Direct vs indirect Financial Patients caries status, oral hygiene status, dental IQ, motivation, risk factors