lec5#management of deep carious lesions

8/2/2019 Lec5#Management of Deep Carious Lesions

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Management of Deep CariousLesions

and

Caries Control Restoration

Dr. Basil Yousif


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Infected and Affected Dentin Infected dentin is the outer layer of

carious dentin where bacteria are

present and the collagen is irreversiblydenatured. It is soft and not remineralizableand must be removed.

Affected dentin is the inner layer of cariousdentin where no bacteriaare present, thecollagen is reversibly denatured andremineralizable and should be preserved.


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To distinguish clinically between thesetwo layers, the operator traditionallyobserves the degree of discoloration

and tests the hardness by explorer.

Bacterial acids precede the bacteria in

dentin caries


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Firm, dry discolored or not-: affected

or minimally infected

Soft wet dentin discolored or not- ,infected

A clinical description of exactly where

infected dentin stops and affecteddentin begins is practically impossible.


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Removal of carious dentin: depends primarily on tactile sensation.

Color differences can not be used as areliable index for complete caries removal

In rapidly advancing lesions, the softeneddentin show little or no color change while

more slowly advancing lesions have morediscoloration.


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Dentin that appears leathery, peels offin small flakes, or can be judiciously

penetrated by a sharp explorer shouldbe removed.

Further excavation uncover harder and

harder dentin


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Evaluate the excavatedarea with a sharp explorer

In slowly progressingcaries, you may end with

sclerotic dentin which isthe ideal final excavation-.

Classical Caries

Excavation: To hear thering of a sharp probe on ahard dentin floor

DEJ should be stain free


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Methods of removal deep

caries: Spoon Excavator: requires

sharp instrument and great

skills


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A slow-speed handpiece with a largeround bur

A high-speed handpiece using a roundbur operated just above stall-out speed


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Chemical Caries Detection

1% acid red 52 ( acidrhodamine B)

Does it stain the irreversiblycarious infected dentin onlyor both infected andaffected????

Some studies reported that

these dyes does notdiscretely discriminate theinfected from affectedtissues


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These dyes do not stain bacteria butinstead stain the organic matrix of less

mineralized dentin. Chemical caries detection may provide a

more conservative tooth preparation


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Removal of all caries initially, regardlessof the size of the lesion and pulp

exposure possibility. OR seal thedeepest layers of carious dentinassuming that is affected and

remineralizable dentin?


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Indirect Pulp Capping In asymptomatic teeth that have

deep lesions where completeexcavation of softened dentin isanticipated to produce pulpalexposure, the softened dentinnearest the pulp may be left


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Medicate this dentin with calciumhydroxide

Calcium hydroxide promotes reparativedentin bridges

Such repair usually occur in 6 to 8

weeks and may be evidentradiographically in 10 12 weeks.


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Technique: Partial removal of the soft caries: leave the

deepest dentin that seems to expose the

pulp if excavated. Ca(OH)2 is applied and then you have to :

Re-opened after 8-10 weeks for further

Excavation

Or place the definitive restoration over theCa(OH)2 in the same visit.


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The object is to arrest the lesion and

allow the formation of tertiary dentin Proper sealing is essential

Most of studies results showed minimal

remaining bacteria and less exposurethan single excavation technique.


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Why Re-Enter?

To be sure there is no exposure andremoves the remaining (minimally)infected dentinfurther excavation-

To verify that remineralization hasoccurred


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Why not Re-enter?

Remineralization will occur and any

remaining bacteria become inviable

Reentry into the excavated area mayproduce additional pulpal irritation.


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The success rate: varied between 74%and 92%

Prognosis is better young permanentteeth

The patient should be informed that the

treatment is a compromise


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Deep Carious Lesion

Completeexcavation

Pulpprotection DefinitiveRestoration

Incompleteexcavation

Leave the deepestsoft dentin and Place

Ca(OH)2

enter-ReFor further excavation

and verification ifremineralization has

occurred or not

enter-t reDonSoft dentin will

remineralized andany remaining

bacteria willbecome inviable


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Current Policy:

Complete excavation of the cariousdentin.

If pulp exposure has occurred, do directpulp capping.


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Direct Pulp Capping

Is a technique for treating a pulp exposurewith a material that seals over the

exposure site and promotes reparativedentin formation.

If the exposure site is the result of

removing softened dentin overlying thepulp, termed a carious pulpal exposure


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If the pulp exposure occurs in an areaof normal dentin usually as a result ofoperator error or misjudgment

instrument or bur-, termed a

mechanical pulpal exposure In both conditions, direct pulp capping

is considered only when the tooth is

symptomless at the time of operation,with no history of irreversible pulpitisand with normal pulp response.


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Types of Pulp Exposure

Mechanical

Trumatic

Carious


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Factors that improve the prognosis ofdirect pulp capping procedure:

Type of exposure No lingered or spontaneous pain

Normal vitality tests

No tenderness to percussion Small exposure, less than 0.5 mm in

diameter


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Controllable bleeding

Clean, uncontaminated field: rubber dam must be placed before

proceeding in cavity preparation

The exposure was relatively atraumatic


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Clinical Procedures:

Rubber Dam placement.

Complete excavation of the soft dentin

Hemorrhage indicates an exposure

The bleeding should be controlled using asterile cottong pellet and any dentin chipsshould be washed away with copiousirrigation with sterile saline


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Do not blow the exposure dry with airsyringe. Dry it with cotton pellete.

Saliva contamination must be avoided.

Cover the exposure with a hard settingcalcium hydroxide cement

Place a layer of resin-modified galssionomer lining material or IRM


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Continuing vitality test should be doneover a long period of time

Radiographic follow up also should beconsidered for dentin bridge formation


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Materials used for DPC:

Calcium Hydroxide:

- The material of choice for a direct pulpcapping technique in general practice(may be due to its antibacterial action).

- It cause superficial necrosis of the pulp,

followed by dentine bridge formationbeneath the layer of coagulativenecrosis


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Clacium hydroxide acts as an initiator

rather that as a substrate for repair. Mineralization of the dentin bridge is by

calcium ions from the blood stream and

not those from the calcium hydroxidematerial.

Calcium hydroxide has been associatedwith internal root resorption when usedas a pulp dressing following pulpotomy indeciduous teeth.


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Direct pulp capping is contraindicated indeciduous teeth

Resin bonding agents Mineral Trioxide Aggregate:

- Current research on these two

materials showed a success rates equalor better than calcium hydroxide butfurther studies is required.


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Studies on germ-free animals haveshown that healing of traumatically

exposed pulp occurs irrespective of thepulp capping agent

It has been suggested that the action of

calcium hydroxide is due to itsantibacterial activity.


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Partial Pulpotomy (Cvektechnique).

Cvek have suggested that deep carious

exposures be opened up so that 1 to 3 mmof exposed pulp can be removed (partialpulpotomy).


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The aim is to remove any infected pulptissue and to remove any dentin chips

inadvertently pushed into the pulptissue cause severe inflammatoryreaction.


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Caries Control Restoration:

Part of Control phase of operativetreatment


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When numerous acute lesions arepresent, the practitioner should treatthese without delay in one or twoappointments with the caries control

procedures. Thus the rate of the carious process is

significantly reduced, potential pulpal

irritation is minimized, and the patient isin a healthier and more comfortablestate.


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It is an intermediate operativeprocedure in which the carious process

is stopped by quick removal of the softcaries and the teeth is restored with atemporary restorative material.


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Indications of Caries ControlRestorations:

1. Acute (rapidly progressing) caries:lesions that have progressed at least

half the distance from the DEJ to thepulp (Usually indicated in patients withhigh risk for caries????)

2. Teeth with questionable pulpalprognosis

3. Inadequate available time


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Objectives:

Remove the decay from all of theadvanced carious lesions (adversepulpal sequelae are soon likely tooccur).

Remove the nidus of caries infection inthe patients mouth

Place appropriate pulpal medication,and restore the lesions with IRM.


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Operative Technique:

1. Anesthesia

2. R.D isolation


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3. Caries removal:

- Initial opening of the

tooth with a largecarbide bur

- Excavation of the softcaries, Retainingunsupported enamelis permissible


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4. Medication andPlacement of IRM.

If a long interval isanticipated between thecaries control proceduresand the permanent

restoration , amalgam as a temporaryrestoration- can be used


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5. It is usually accompanied with plaquecontrol , dietary control, antimicrobial

treatment.

6. Reevaluation for pulp health andgingival health as marker of plaque

control effectiveness


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7. When to replace IRM with a definitiverestoration?

After the condition is stabilized,

Good pulpal health

Further antimicrobial treatment anddietary reassessment is indicated


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lec5#management of deep carious lesions

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