Management of Caries:
Traditionally surgical model of management:
- Target lesion alone.
- Technique: “drill & fill” but it can lead to more drill & fill
Recently " Biological Model of management:"
- Target patient in holistic way to ensure overall better oral tooth for
- Replace “drill & fill” by “disease control”.
- Management consists of: preventive strategies, minimally-invasive
treatment, and invasive treatment.
(I) Plaque / bacteria:
1. Oral hygiene care measures:
Tooth brushing (3 times / daily).
Dental flossing (at least once daily).
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)
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.
It is antibiotic to kill cariogenic bacteria. Examples: penicillin and
Erythromycin. Disadvantages: hypersensitivity + suprainfections.
It is the use of (plants extracts) that is (killing cariogenic bacteria).
Examples: green tea, chewing sticks (miswak), onion.
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.
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.
(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:
Indirect relation by enamel hypoplasia: mechanical nitch for
bacteria, or by salivary gland hypofunction: no protective function
(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
(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 –
(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).
- 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.
- 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.
- Air/ AL2O3 of particle size < 50 um.
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.
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).
- Diamond coated tip from one side to give high frequency oscillation
+ Al2O3 + water
1- Mostly no anesthesia (less heat + vibration)
- Disadvantages: absence of advantages of air-abrasion.
- Same as above, but giving ultra frequency oscillation.
- Advantages: as above.
1- Absence of advantages of air-abrasion.
2- Calcio-traumatic phenomenon: appearance of alternation bands of
hypomineralizaiton &^ hypermineralizaiton in dentine due to some
(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).
1- Absence of advantages of air abrasion.
2- Inability to soften carious enamel used only with exposed
large dentin caries.
- Nd:YAG or excimer.
- Advantages: cut & seal dentinal tubules postoperative
1- Difficult of spotting beam (localizing effect)
2-Temperature overcome it by hydrokinetic laser which use
water + laser.
- Proteolytic enzymes to soften carious dentin, e.g. collagens,
pronase only remove carious dentin.
- 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.