Management of Caries 431

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					Management of Caries:

Traditionally  surgical model of management:

  - Target lesion alone.

  - Technique: “drill & fill” but it can lead to more drill & fill 
      Molar cycle.

Recently  " Biological Model of management:"

  - Target patient in holistic way to ensure overall better oral tooth for
      long time.

  - Replace “drill & fill” by  “disease control”.

  - Management consists of: preventive strategies, minimally-invasive
      treatment, and invasive treatment.

Preventive strategies:

(I) Plaque / bacteria:

1. Oral hygiene care measures:

    Tooth brushing (3 times / daily).

    Dental flossing (at least once daily).

    Tooth picks.

    Professional cleansing (at least once/ year).

(2) Enzyme therapy:

It is the inhibitor of enzyme "glucosyltransferase" which is contained in
S. mutans & allow it to produce extracellular polysaccharide (glucan)
from sucrose.

(3) Antibodies:
They are antibodies against glucan to prevent it from adhering S. mutans
to tooth surface. It is prepared by injecting tobacco plant with human
DNA  allow plant to produce human protein (immunoglobulin =
antibodies = plantibodies). Commercially, it is available in "gel" named
"Caro RX" that is painted on tooth surface & last for hours  give action
for 4 months.

(3) Antibiotics:

It is antibiotic to kill cariogenic bacteria. Examples: penicillin and
Erythromycin. Disadvantages: hypersensitivity + suprainfections.

(4) Ethnomedicine:

It is the use of (plants extracts) that is (killing cariogenic bacteria).
Examples: green tea, chewing sticks (miswak), onion.

(5) Xylitol:

It is natural sugar from tree, and characterized by inability of S. mutans to
ferment it + keep sucrose a way from being binded to S. mutans. It's
available commercially in the form of chewing-gum.

(6) Chlorhexidine:

It decreases count of S. mutans. It is available in forms of:

 - Mouthrinse (0.12): not effective conc.

 - Gel (1%): more effective.

 - Varnish (1%): best effect. e.g. Cervitec.

 - Varnish of chlorhexidine / fluoride (Cervitec plus): last for longer
Disadvantages of chlorhexidine:

   - Low substantively (duration of release) in retention areas (crack,
      fissures) because S. mutans can recolonize in these areas easily.

   - Mouth washes  staining + altered taste.

7- Bacterial Replacement Therapy:

Gene therapy that replace cariogenic S. mutans with other one that is
unable to ferment sucrose to acids. It's called non-wild S. mutans.

(II) Diet:

(1) Avoid sugary intake: table sugar, sugary juice, soft drink, sugary
candy, ice cream, milkshake.

(2) Supporting protein/ energy intake:

 - Energy food: vegetables, peanuts, beans, lentils, seeds.

 - Protein food  Animal: Beef

                    Plant: seeds, peanuts.

   - The reason is to avoid “malnutrition” of protein / energy which has
      relation with increased caries due to either:

              Direct relation.

              Indirect relation by enamel hypoplasia: mechanical nitch for
      bacteria, or by salivary gland hypofunction: no protective function
      of saliva.

(III) Host:

   (1) Increasing salivary flow:

       - Chewing sugar-free gum.

       - Xerostomia treatment by cholinergic drug, e.g: pilocarpine, or by
       saliva substitute, e.g.: Xerostome.
       - Function of saliva:

    Clearance of sugars.

    Buffering (dilute acids) by bicarbonate & phosphate

    Immunoglobulins (SIgA).

    Remineralization.

 (2) Decreasing demineralization and increasing remineralization:

 (2.a) Fluoride application:

     - NaF, SnF, Acidulated Phosphate Fluoride (APF).

     - Rinse, gel, varnish.

     - Functions of fluoride:

   1- Form fluroapatite crystals.

   2- Bacteriostatic to S. mutans.

   1- Modify surface energy of enamel to prevent plaque adherence.

   2- Buffer acidity of plaque.

(2.b) Metal fluoride application:

     - Titanium- tetra fluoride

     - Titanium replaces ca in apatite to produce more resistant apatite.

     - Titanium improves uptake capability of enamel toward fluoride.

     - Titanium is more effective in dentin enamel due to protein –
binding property.

(2.c) Calcium enriched tooth paste:

     - It increases salivary concentration of Ca+ for remineralization.
     - It increases deposition of F+ on tooth by forming CaF2-like
reservoirs. e.g. Topacal.

(2.d) Remineralizing paste:

     - Remineralization occurs by growth of existing crystals. However,
reminerlaized dentin is less than normal dentin regarding mechanical

     - Example 1: Cavitat  arginine bicarbonate / calcium carbonate

     - Example 2: MI paste  milk derived; casein calcium phosphate.

(2.e) Remineralizing chewing gum & candies:

     - Last for longer time on tooth than tooth paste.

     - Taken either after sucrose intake (increase remineralization) or
before diet (decrease demineralization).

(2.f) Laser:

    - CO2, Argon, or Nd:YAG.

    - Laser melts and then re-solidify tooth surface  contain reduced
interprismatic space  reduce diffusion of acids.

    - If applied with F+ vehicle  increase transformation of
hydroxyapatite to fluroapatite.

(2.g) Matrix metalloproteinase inhibitor agents:

     - (MMPs) presenting dentin & saliva dissolve organic matrix of
dentin, while inhibitors present in dentin counteract them  balance
between them control remodeling/ degradation

    - Use substance that has MMPs inhibition activity , such as: green
tea, chlorhexidine, avocado, soya bean.

(3) Fissure sealants:
    - May be chemical cured or light cured.

    - May need fissure preparation by tapered diamond or may not need.

    - May be either: filled resin, unfilled, resin, GIC, RMGI, F+ varnish,
titanium tetrafluoride, bonded amalgam.

(4) Genetics:

    - Gene mapping results in identification of genes responsible for
saliva composition & flow, tooth morphology, dietary preference, enamel

    - They discovered sex – dependent genetic factors  caries is more
in females than in males.

Minimally – Invasive Treatment:

(I) Non Surgical:

1. ART (Atraumatic restorative treatment):

    - Excavate cavitated lesion with hand instrument.

    - Restore cavity with F+ releasing restoration.

    - Seal any associated fissure with releasing rest.

(2) Air-Abrasion:

     - Air/ AL2O3 of particle size < 50 um.

     - Advantages:

       1- Mostly no anesthesia (less heat generation, vibration)

       2. More rapid cutting in enamel (because enamel is harder>

      3- Better for composite > amalgam (due to rounded cavity walls).

      4- No need for acid etching  bond to enamel is similar to rotary.
   3- Bond of composite to dentine > bond after rotary.

   - Disadvantages:

       1- Nozzle don't touch tooth no tactile sensation.

       2- Risk of inhalation.

      3- Less rapid cutting in dentin (because dentin is less hard <Al2O3
 energy is lost due to dentine resilience).

(3) Sonic-Abrasion:

    - Diamond coated tip from one side to give high frequency oscillation
+ Al2O3 + water

    - Advantages:

      1- Mostly no anesthesia (less heat + vibration)

      - Disadvantages: absence of advantages of air-abrasion.

(4) Ultrasonic-Abrasion:

    - Same as above, but giving ultra frequency oscillation.

    - Advantages: as above.

    - Disadvantages:

     1- Absence of advantages of air-abrasion.

     2- Calcio-traumatic phenomenon: appearance of alternation bands of
hypomineralizaiton &^ hypermineralizaiton in dentine due to some
demineralzing effect.

(5) Chemo-mechanical removal:

      - Caridex: solution applied to dentin surface  left for seconds 
soften carious dentin  remove softened caries mechanically by
application tip (non-cutting Inst.)
            - Carisolv: two gels mixed together  applies dentin by non-
cutting inst.  left for 60sec  remove softened caries mechanically by

            - Advantages of Carisolv over Caridex: gel remains on dentin
surface for longer time and gel provides mechanical lubricant action to
aid mechanical removal inst.

            - General advantages: mostly no anesthesia (no heat + vibration).

            - Disadvantages:

             1- Absence of advantages of air abrasion.

              2- Inability to soften carious enamel  used only with exposed
large dentin caries.

(6) Laser:

        - Nd:YAG or excimer.

        - Advantages: cut & seal dentinal tubules  postoperative

            - Disadvantages:

             1- Difficult of spotting beam (localizing effect)

             2-Temperature  overcome it by hydrokinetic laser which use
water + laser.

(7) Enzyme:

        -     Proteolytic enzymes to soften carious dentin, e.g. collagens,
pronase  only remove carious dentin.

(8) Ozone:

        - Device ejecting O3 in to handpiece with cup at its end to be
tightened according to size of area needed to be prepared for heal zone 
kill cariogenic bacteria  then apply remineralizing agent  then
restores with ft releasing rest.

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