deep caries

7/29/2019 Deep Caries

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Dental caries is an infectious micro-biologic disease of the teeth that results inlocalized dissolution & destruction of thecalcified tissues. requiring restorativeintervention & even extraction..

Definition :


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Etiology

food bacteria

tooth


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Dentine Caries

Affected & Infected Dentin:

In operative procedures, it is convenient toterm dentin as either..

Affected dentin: is softened, demineralizeddentin that is not yet invaded by bacteria innercarious dentin ( does not requires removal ).OR

Infected dentin: outer carious dentin &Bacterial plaque is both softened &contaminated with bacteria ( requires removal ).


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Caries Detecting Die

Caries detection solutions have been usedby clinicians to distinguish between

affected and infected dentin.

These are protein dyes that stain

denatured callagen of carious dentine


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Response to dental caries

In the earliest stages of exposure tomicroorganisms, there is an effort to seal

the tubules. This is accomplished byincreased calcification. The result is avisible change known as transparentdentin or dentinal sclerosis .


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In addition, pulpal odontoblasts, stimulated bythe advancing carious lesion, will rapidly depositdentin. The dentinal tubules in this new dentinare irregular, making them less permeable this

type of dentin is known as : irregular dentin ,reparative dentin , secondary dentin ortertiary dentin . Dentinal sclerosis and

reparative dentin may be successful deterrents ifthe carious lesion progresses slowly.


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When the first operative dentistryguidelines were established, the term

caries excavation was defined as asynonym for cavity preparation, which inturn consisted of mechanical treatment of

the injuries to the teeth produced bydental caries, as would best fit theremaining part of the tooth to receive afilling


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From this definition, it appears that cariesexcavation procedures were regarded as

one of the many mandatory steps toprepare a tooth to receive the fillingmaterial


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Furthermore, it has been described thatthe carious lesion should be excavated

until a hard pulpal floor was reached andthat generally, when the cavity has beencut to form, no carious dentin will

remain.


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In short, carious dentin should beremoved until a sufficiently solid layer of

dentin was reached to supportcondensation of the restorative material(stability form) and to provide adequate

retention for the filling material (retentionform), promoting a successful and long-term survival of the restoration.


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It is thus clear that when nonadhesiverestorations were the only available option

to directly restore decayed teeth, nodistinct separation between caries removaland cavity preparation was made.


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In practical terms, it means thatexcavation of carious dentin was

performed to remove necrotic,softmaterial in order to best accommodate thefilling material.


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The objective is to focus on the:

Diagnosis

ttt modalities

Management of deep caries


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Indirect Pulp Capping

When caries is thought to extend closeto, or into the pulp, excavation of the

pulpal caries can be stopped at softaffected but not infected dentine (affecteddentine could be remineralised if the acid

production was halted). Medication is thenapplied over the pulpal dentine prior toplacement of the definitive restoration.


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Medication is left for 6 8 weeks .

During this waiting period :

The carious process is arrested

Soft caries hardened

A protective layer of reparative dentine is laiddown


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However the difficulty with this tecnique isknowing:

how rapid the carious process has been

how much tertiary dentine has beenformed

knowing exactly when to stop excavatingto avoid pulp exposure.


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Materials used for indirect pulp capping :

Calcium HydroxideAlthough CaOH is the most commonly used ithas been argued that its effect occurs only incase of its direct contact with pulp tissues .

Therefore a material with better sealing abilityshould be used .

Zinc oxide and Eugenol

Recently adhesive resin has been used


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Direct Pulp Capping

Technique for treating a pulp

exposure with a material thatseals over the exposure site &promotes reparative dentinformation..

Requirements of direct pulpcapping:

Asymptomatic vital tooth

Pin-point exposure (0.5mm orless in diameter)

Non-hemorrhagic or easilycontrolled.

Dry, sterile filed

Non-carious atraumaticexposure

Di t P l C i T h i


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Direct Pulp Capping Techniques

Calcium Hydroxide Technique Total etch technique

hemostasis hemostasis

Disinfect cavity Disinfect cavity

CaOH primers

Resin modifieed glass ionomeradhesives

IRM Resin modifieed glass ionomer

Restoration

Restoration


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Calcium Hydroxide Technique:

1. Bleeding must be controlled.This control may be achieved by :

Washing the area with sterile saline and dryingit with either paper points or cotton pellets,

Using cotton pellets soaked with hydrogenperoxide or 5.25% sodium hypochlorite, OR Using a hemostatic agent .

If bleeding fails to stop after two or three

attempts, then endodontic therapy should beconsidered.

A disinfectant should be placed on the cavity

floor.


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2. The area is then air dried

3. Calcium Hydroxide is placed directly in contact

with pulp tissue. This step is very important,for the better the contact of the calciumhydroxide dressing with the pulpal wound, thebetter the healing.

4. The calcium hydroxide should then be coveredwith a resin-modified glass ionomer extendedonto dentin.

5. A permanent restoration is placed, with adentin bonding system used to seal themargins of the restoration.


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An alternative is to place a zinc oxide-eugenolrestoration over the calcium hydroxide cap.Zinc oxide-eugenol provides an excellent sealand, with its anti-microbial properties, makesfor a very good temporary restoration.

After three months, assuming pulp vitality andno symptoms, the zinc oxide-eugenol can beremoved and a more permanent sealed

restoration placed.

Total Etch Technique :


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Total Etch Technique :

1. Enamel and dentin are etched with 32% phosphoric

acid for 15 seconds.2. The acid is rinsed off and the preparation is lightly

dried.

3. The entire preparation , including enamel, dentin andpulpal tissue , is treated with a dentin bonding system.

4. Adhesive resin is applied onto the enamel, dentin andpulpal tissue and light cured, and a thin layer of resin-modified glass ionomer is also applied over and aroundthe exposure site ( mechanically protect the perforation

from intrusion of the restorative material during packingor condensation) and then cured.

5. The restoration is subsequently completed inconventional fashion.


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Chemo-mechanical caries removal

Carisolv is a chemo-mechanical method forminimally invasive caries removal .

The system comprises :

a gel that selectively attacks denaturedcollagen in the carious dentine, thus makingthe carious dentine softer.

a set of specially designedinstruments used forremoval of thesoftened material.


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Carisolv gel consists of two carboxymethylcellulosebased gels:

a red gel containing :

amino acids (glutamic acid, leucine and lysine),

NaClNaOH

Erythrosine (added in order to make the gelvisible during use ).

and a second containing sodium hypochlorite


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The two gels are thoroughly mixed in equalparts at room temperature before use . The

solution has a pH 11.

The positively and negatively charged groups onthe amino acids become chlorinated and further

disrupt the collagen crosslinkage in the matrix ofthe carious dentine.

The gel is then applied onto the exposed carious

dentine and left for 30 to 60 seconds then thesoftened dentine is gently but firmly abraded

away leaving a hard, caries-free cavity

.


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A soft caries lesion Gel application. Let gel slide onto the

lesion. Wait 30 seconds.

The lesion is gently scraped with

a star instrument

Re-applied gel stays clear. Cavity

is hard with a probe.


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The gel is removed with adry pellet Complete caries removal is

checked with an explorer

The cavity is cleaned with

wet pellets

Finished cavity


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Advantages of carisolv

The patients perceive themethod as much morecomfortable than drilling andanaesthetics are seldom needed.

Saves time

Avoids removal of unnecessaryhealthy dental tissues

Action of excavator. Healthy dentine is also removed.

Selective removal of softened dentine caries with the Carisolv

instrument. Healthy dentine is not affected.


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Smartprep instrument

The SMARTPREPTM Instrument is a polymerinstrument that safely and effectively removedecayed dentin, leaving healthy dentin intact.

It is a self-limiting instrument and is not hardenough to penetrate healthy dentin. As it gently

removes decay and contacts the healthy dentin,the instrument's edges become rounded andunable to cut healthy tooth structure.

A high-speed carbide bur is first used to gain

access to the decay. After access has beencreated, the SMARTPREPTM Instrument is usedin a slow speed handpiece (500-800 rpm) tocomplete caries removal.

They are single-patient-use rotary instruments.


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Advantages :

Conserve healthy tooth structure,

Virtually no risk of inadvertent pulp

exposure, Reduce the need for anesthesia and allow

for same-visit cavity preparations onmultiple quadrants,

Designed to reduce post-operativesensitivity.


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deep caries

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