Management of the Early Carious Lesion by GoPkbJ


									      Early Caries
Detection and Treatment

         September 2011
          Learning Outcomes
Following this lecture you should be able to:

• discuss the carious process

• describe how to recognise ‘early carious
  lesions’ and ways of detecting them

• discuss the principals involved in the
  management of early carious lesions
          The Carious Process
    Four factors are necessary to produce
    dental caries:

•   ?
•   ?
•   ?
•   ?
Dental caries is:

• a disease of the calcified tissues of the

• caused by the action of micro-organisms
  on fermentable carbohydrates

• characterised by demineralisation of the
  mineral portion of enamel and dentine
  followed by disintegration of their organic
In its early stages the disease can be
arrested since it is possible for
remineralization to occur


This disease is not inevitable as it can be
completely prevented by relatively
simple measures
         Susceptible Sites

Sites on the tooth surface which favour
 plaque retention and stagnation are
 particularly prone to decay:
Pits and Fissures
Approximal enamel smooth surfaces
  just cervical to the contact point.
Enamel of the cervical margin of the tooth just coronal to
                  the gingival margin
Where perio disease has resulted in
        gingival recession
The margins of restorations, particularly those that
          are deficient or overhanging
• Tooth surfaces adjacent to dentures and
  bridges which increase the areas where
  stagnation can occur.
   Why is diagnosis of caries in its ‘early
            stages’ important.

• The carious process can be modified by
  preventive treatment so that the lesion
  does not progress
  If caries can be diagnosed at the stage of
  a ‘white spot lesion’ the balance can be
  tipped in favour of arrest by:
• ?
• ?
• ?
                 What is the

• When a cavity is actually present

• A hole in the dental tissues is not expected
  to calcify up from the base
 How can dental caries be diagnosed in its
           ‘EARLY STAGES’
• Sharp eyes
• Good lighting with clean, dry teeth
• Isolate teeth with cotton wool rolls, slow
  suction & buccal pad.

 With what type of probe should you check
                 for caries?
    Interproximally on anterior teeth:
• Operating light is reflected through the
  contact point with the dental mirror
• Carious lesion appears as a dark shadow
  following the outline of the decay
   Interproximally on posterior Teeth:

• Stronger light source is required eg fibre-
  optic light with beam reduced to 0.5mm
  diam. (FOTI)
• Small diam. reduces glare and therefore
  reduces loss of detail
• Useful technique where you want to avoid
  radiation eg pregnancy or where teeth
  would appear overlapped on x-ray due to
• Good bitewing radiographs are also
  essential in diagnosis

• A film holder is used so that the x-ray
  beam passes at right-angles to the long
  axis of the tooth and tangentially through
  the contact area
            Tooth separation

Uses orthodontic separating elastics

After a few days the teeth are separated and
  presence of a cavity can be assessed by:
• Direct vision
• Gentle probing with blunt probe
• Elastomer impression material
             Occlusal Caries

• Direct vision – discolouration, cavitation
  and the grey appearance of enamel
  undermined by caries
• Bitewing radiographs – will only show
  more advanced lesions
• Caries Dyes
• Electronic caries monitors - can be used
  to help diagnose occlusal caries
• Work using the principal of electrical
  resistance since intact enamel is a good
• During the carious process, moisture filled
  porosities act as conductive pathways
  causing the resistance to fall
• These measurements may be repeated at
  recall appointments and comparative
  readings may indicate whether a region is
  growing or not.
     Diagnosing ‘AT RISK’ patients

• Caries is a reversible process
• If the dentist can diagnose the process
  early then the patient can be advised on
  instituting preventive measures to tip the
  balance in favour of arrest
• Diagnosis is more than simply recording
  the decalcified areas, their location and
  their appearance
• The dentist needs to know whether the
  patient is likely to develop new cavities
  and/or whether existing cavities are likely
  to progress.

• To help make these decisions a Caries
  Risk Assessment should be carried out.

      What would this involve?
          Caries Management

  Once caries has been diagnosed, the
  dentist must decide how the process
  should be treated:
• Use preventive measures to attempt to
  arrest the process
• Surgically remove and replace the
  damaged tissues and prevent recurrence
On smooth surfaces:

•   Dietary advice
•   Use of fluoride
•   Improve plaque control
Pits and Fissures:

Difficult to diagnose in early stages so
  Fissure Sealing susceptible teeth as soon
  after eruption as possible is often the
            Indications for FS

•   High caries risk
•   Stagnating plaque
•   Newly erupting molars
•   (Stained and decalcified deep fissure
                Very important
•   Cotton wool rolls
•   Slow suction
•   Buccal pads
•   Rubber dam
Clean occlusal surface with a wet
         prophy brush

    Then wash and dry using 3-in-1
Etch for 20secs with 37%
  Orthophosphoric Acid
Wash for 10 secs

    and then

dry with 3-in-1
Note – ‘frosted’ appearance of enamel
                Apply FS

• Note the use of the ball-ended burnisher
                  Light Cure

• Note orange protective shield should be in
• 470nm wavelength light for 20 secs
        Check the occlusion
• Clear unfilled resins – will adjust with
  occlusion unless excessive material has
  been used

• White filled resins – need to be adjusted at
  chairside for the patient
   Indications for Preventative
    Resin Restoration (PRR)
• High caries risk
• Stained and decalcified deep fissure
• More than 2 other carious lesions in the
• Enamel biopsy shows that lesion is
  confined to enamel
             Procedure for PRR

Follow similar steps as for a Fissure Sealant

  After the prophy brush is used, the stained
  enamel must be removed using a tapered
  diamond bur in the fast handpiece.

   Any decay is then removed using a round bur
  in the slow handpiece.
    The tooth surface can then be restored
    using one of the following options:
•   Flowable composite
•   GI and flowable composite
•   Composite
•   amalgam
Approximal Surfaces

 A lesion limited to the enamel on B/W
 radiograph should be treated preventively:

• Diet advice
• Fluoride
• Plaque control
      Unless the caries risk is very high,
        time is on the patient’s side:
• Research has shown that progression of a
  lesion through enamel, if it occurs, can be
  very slow, taking 2-6years before it is
  evident in dentine radiographically

Ref – Pitts, N.B. (1983). Monitoring of caries progression in permanent and primary
   approximal enamel by bitewing radiography. A review. Community Dent. Oral
   Epidemiol., 11, 228-35.
Radiographically just through enamel and
             into dentine:
In a young patient or high- & medium-risk
patients – advice is to treat operatively

In a low-risk patient – treat preventively.
Show the patient the radiograph and
suggest that it should be repeated in 6
Root Caries:

• Early diagnosis very important as
  advanced lesions can be difficult to
• Meticulous plaque control
• Dietary control
• Use of topical fluoride (as a varnish &/or
                  Diet Advice

•   No snacking between meals
•   Aim for 2-3 sugar attacks per day
•   Never sugar before bed
•   Avoid fizzy drinks but if not possible then
    chose diet variety

Each patient is an individual and will require
 specific advice
  Cariostatic Mechanisms of Fluoride

• Post-eruption - inhibits demineralization
  and promotes remineralization
• Depending on its pH and concentration,
  fluoride can also exert a bacteriocidal or
  antienzymatic effect.
• Pre-eruption – may alter morphology
  making fissures more self-cleansing.
   Modes of Fluoride Application

Patient may be receiving fluorinated water
or taking fluoride tablets.

These facts would be important to know
before prescribing any further fluoride
treatment – WHY?
       Topical application of Fluoride
          falls into 2 categories:
• Frequent-use, low-concentration
  preparations i.e. Toothpastes and

• Periodic-use, high-concentration
  preparations i.e. fluoride varnishes, gels
  and prophylactic pastes
• Toothpastes (525 -1450ppm F)
• Mouthrinses – daily ?% NaF
                  weekly ?% NaF
• NaF varnish (Duraphat) ?%F
  painted on in the surgery

• APF gel ?%F – swabbed onto the tooth
  surface or applied in closely fitting trays

• Prophylaxis paste ?%F – applied in
  surgery with a rubber cup
                Plaque Control

•   Toothbrushing
•   Dental floss/tape
•   Woodsticks
•   Interdental brushes
•   Single tufted brushes
 Current Toothbrushing Advice
• Brush twice daily with fluoridated
  toothpaste containing at least 1,350ppm
• Brush last thing at night and on 1 other
• Spit out after brushing and do not rinse

• It is important to recognise early carious
  lesions as they are reversible
• Be aware of the different techniques used
  to help identify these lesions
• Preventive management is the treatment
  of choice: diet analysis
              effective plaque removal
              appropriate use of Fluoride

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