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Clinical Signs of Enamel Caries

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					Week 11

 WHY HAVE I GOT A HOLE IN
       MY TOOTH ?
         Part 3

             DCP I 2006
Dr. Manal Awad, University of Sharjah
    Dr Lekkas, Adelaide University

                                   slide 1
Clinical Context

Ms Hashim was quite fascinated with your
explanation of how caries actually occurs
within enamel and dentine and asks to
explain to her
  – Hpw can it be diagnosed and managed




                                          slide 2
1.Diagnosis of dental caries

• Early and accurate diagnosis
  important especially for early lesions
    Diagnosis
  - of whether a carious lesion exits
  - of whether a lesion is reversible or
  requires
  mechanical intervention


                                      slide 3
Clinical Signs of Enamel
Caries

• Discolouration
  white spot
  grey appearance of undermined
  enamel
• Surface roughness
• Change in surface translucency
• Cavitation
                                   slide 4
Clinical Signs of Dentine
Caries
• Discolouration - light brown to dark
  brown
• Soft and Leathery consistency
  and texture




                                    slide 5
 Diagnostic aids

• Dry field
  use of air syringe important to detect any
  subtle changes in the tooth surface

• Vision (sharp eyes)
  to detect changes in surface
  translucency/colour, surface texture

• Magnification
  used to increase detection of surface detail
                                               slide 6
  8a. Diagnostic aids

• Light
  (strong, intense lighting) to detect changes in
  surface colour,translucency.
• Transillumination
   use of a small intense light (halogen or
  tungsten) source (fibreoptic) used in a dark field
  to detect shadows in the subsurface.
• Dental explorer
  using the side of the tip, feel texture of the
  surface.
                                               slide 7
Use of transillumination




                           slide 8
Use of magnification




 (Designs for vision: Denta-loupes pamphlet)


                                               slide 9
  8a. Diagnostic aids

Radiographs
Used to detect occlusal and especially proximal caries.
Need good bitewing radiographs with no overlapping
contacts.
Limitations:
   – early histological lesions do not appear
   – underestimates the size of the lesion.
   – severely limited in detecting initial enamel caries in
     fissures.


                                                     slide 10
Review: Diagnostic aids

   radiographs
                       magnification        light

   dental explorer   dry
                     field &
                                  transillumination
                     vision

To make a diagnosis (of dental caries)
  need to use all of these aids in
  combination.
                                              slide 11
Caries risk tests- Saliva testing

A. Unstimulated Salivary flow tests
Resting saliva (submandibular gland) - Ask patient (sitting upright in
chair) to drool into a collection cup for 5 mins
   ml/min
                  more than 0.25 normal
                  0.1 – 0.25        low
                  less than 0.1     v low
Or
A simple method is to visually assess the saliva production from the
minor salivary glands on the lower lip mucosa. revert the lower lip,
block with labial mucosa with a piece of tissue and observe the time
taken for droplets of saliva to form.
                  less than 30 secs        high
                  30-60 secs               normal
                  more than 60 secs        low
                                                              slide 12
Caries risk tests- Saliva testing


B. Saliva viscosity test
  Visually inspect the viscosity of resting saliva – if
  stringy, frothy or bubbly may indicate low water
  content in saliva because of low saliva
  production


C. Resting pH of unstimulated Saliva
  Resting Saliva is added to pH paper strip.
     Healthy resting pH = 6.8-7.8
     Moderately acidic resting pH = 6.0-6.6
     Acidic resting pH = 5.0-5.8
                                               slide 13
Caries risk tests- Saliva testing


E. Stimulate flow - Salivary buffering
 capacity test
 Stimulated saliva is added to a test strip, acids in test
 strip dissolve and pH drops. If saliva can buffer, the
 pH will rise and the indicator will show final pH




                                                    slide 14
slide 15
Caries risk tests- Saliva testing




• S mutans, lactobacillus tests
  – lab test kits used chairside.
  – If high levels detected– risk of caries




                                          slide 16
A kit used to estimate a S.mutans count. The spatula is
rotated on the patients tongue and incubated in a special
culture medium. It is then compared with the
manufacturer’s chart to estimate the s.mutans count.




                                                     slide 17
  8c. Differential diagnosis
• LOCATION
   – coronal surface
   – root surface
• CARIES ACTIVITY
   – Active (demineralised) -Reversible or Irreversible
   – Arrested (remineralised)
• Need to distinguish caries (differential diagnosis) from
   – intrinsic stains
   – extrinsic stains
   – tooth development or maturation disturbances

                                                    slide 18
Differential diagnosis of cervical lesions

              Incipient         Arrested          Intrinsic stains
              caries            caries            Developmental enamel
                                                  defects

   Colour     When dried –      When dried –      When dried –Shiny white
              chalky white      Shiny white or
                                brown/black in
                                colour

   Surface    Porous or         Firm and          Firm and smooth
   texture    rough             smooth

   Location   Located at        Located at        Located any where on
              sites of plaque   sites of plaque   tooth; not necessarily
              accumulation      accumulation      assoc with plaque
                                                  accumulation.
                                                  Usually present on contra-
                                                  lateral tooth.



                                                                               slide 19
Differential diagnosis of root caries



             Active root caries       Arrested root         Extrinsic stain on root
                                      caries                surface


Colour         light brown to dark    dark brown -black     dark
             brown                    (NB. but also a
                                      dark stained
                                      lesion can also
                                      mean a chronic
                                      progression)
                                      border of lesion is
                                      more defined
Surface      soft and leathery, can   hard and non          hard and rough
texture &    be compressed with a     compressible
hardness     blunt instrument and
of dentine   returns to shape
Cavitation   +/-                      +/-                   none

                                                                                 slide 20
       DIAGNOSIS OF CARIES CAN BE A
          SUBJECTIVE JUDGEMENT


IF IN DOUBT

 check with radiograph (nb. Limitation of
  radiographs in detecting early enamel caries)
 use preventive measures
 wait and see




                                            slide 21
How can dental caries be
managed and prevented ?




                           slide 22
. Management of dental
caries
Traditional approach = Surgical approach
• mechanically cut out the diseased tooth tissues (carious
  lesion)
  and replace the missing tooth tissue with restorative
  materials.
  Remaining susceptible pits/fissures were cut to in order to
  prevent
  further caries “ extension for prevention”
• no real attempts to reverse/heal early lesions – these were
  usually restored
• defective restorations were replaced

……..resulted in destruction of tooth structure rather than
 preservation

                                                         slide 23
Current approach = Minimal
Intervention Dentistry
Aim is to preserve tooth structure
• early caries diagnosis
• classification of caries depth and progression (clinically,
  radiographs)
• assessment of individual caries risk
• reduction of cariogenic bacteria to decrease risk of
  demineralisation
• remineralisation and monitoring of non cavitated/early
  lesions
• arresting active lesions
• the placement of restorations in teeth with cavitated lesions
  using minimal cavity design
• the repair rather than replacement of defective restorations
• assessing disease management outcomes at regular
  intervals

                                                          slide 24
Minimal Intervention : Management
of caries involves

 Treatment of the disease which causes
  caries.
   Evaluate
   Control disease – remineralise and or prevent
   Monitor

 Treatment of cavitated caries - Repair
  damage which is a result of the disease.


                                             slide 25
 Treatment of the disease which causes caries.
STAGES
Evaluate
  - diagnosis of caries
  - determining caries activity
  - determining caries risk of the individual
Control disease
  - remineralisation and monitoring of non cavitated/early lesions
  - arresting active lesions
  - preventing new caries formation; disrupting demineralisation
  cycles and maximising remineralisation potential of the oral
  environment
  - patient education & motivation
Monitor


                                                               slide 26
Review of the caries process

Caries activity - Coronal caries
Active
- demineralisation > than remineralisation
- early enamel lesion: change in colour of enamel due to
  subsurface demineralisation & change in texture
- radiographically radiolucency present (may not be detectable
    if very early stages of caries process)
Arrested
- remineralisation > than demineralisation
-   change in colour of enamel due to stains trapped and
    regaining of mineral in subsurface & change in texture
- radiographically no radiolucency present
- borders of the lesion become more defined




                                                                 slide 27
Remineralisation of early caries &
Prevention of dental caries

• Caries is a Multi-factorial disease hence
  remineralisation/prevention takes on a multi-
  strategy approach
a) Evaluate: Identify caries, identify factors causing
   caries
    in the individual and determine caries risk status
b) Control disease: Implement actions against the
   aetiological factors: tip balance towards
   remineralisation; involve patient
c) Monitor: Review and assess effectiveness

                                                  slide 28
A) Evaluate

• What do you need to assess ?

 - determine caries risk of the
 individual
    -- evaluate caries aetiological
 factors

    Be systematic, thorough

                                  slide 29
Evaluate caries aetiological
factors

 Dental Plaque (Biofilm)
  - presence/location of plaque, thickness
  - bacterial numbers (S mutans; lactobacilli) and activity
    eg. lactic acid production

 Diet
  - amount of cariogenic foods/drinks; acidic foods/drinks
  - timing: in between meal snacking/before bed
  - consistency/physical form of the cariogenic food
  - frequency of consumption of cariogenic foods/drinks;
      acidic foods/drinks



                                                        slide 30
Host factors – Susceptible tooth



• Those that favour accumulation of plaque
   - Tooth anatomy– shape of pits and fissures,
      defects on enamel surface
   - Crowding
   - Overhanging restorations

• Those that favour demineralisation
  - enamel which is easily dissolved by acids
  eg., low F content, crystal size smaller,
       less mineralised enamel


                                                slide 31
Host environment


  Fluoride
 - Past and present contact with fluoride
    (systemic and topical fluoride)

  Saliva
 - Quantity and quality of saliva ie: unstimulated
   flow rate, viscosity of resting saliva, resting pH
   of unstimulated saliva, stimulated flow rate,
   buffering capacity of stimulated saliva



                                                slide 32
History/Lifestyle assessment


• Age of patient
• Medical history (eg., medications, illnesses,
  physical impairments, acid reflux)
• Social history (eg., stress, smoking, occupation,
  socioeconomic factors, activities/hobbies/lifestyle,
  compliance, motivation)
• Dental history (eg., how often they attend
  dentist; motives/beliefs, number of past lesions,
  site of past lesions, number of restorations, what
  type of advise
  they have received in the past re; management of
  dental caries)


                                                 slide 33
a) Evaluate
After detailed history taking, clinic & radiographic examination,
(use of saliva tests, bacterial tests, diet diary), assessing patient
motivation and analysis of all results

Determine Caries Risk:
Low risk =        no active caries or a few arrested; caries
   aetiological factors well controlled
Moderate risk = several active non-cavitated and/or 1 active
cavitated caries lesion; caries aetiological factors
not controlled
High risk =       multiple active cavitated and non-cavitated
   caries; caries aetiological factors not controlled




                                                                        slide 34
b) Control disease:
Implement actions against the aetiological
factors.
Tip balance towards remineralisation

1. Increase host resistance
a. Fluoride
   Action: aids in remineralisation and
    increases resistance of tooth against
    caries
   Sources of Fluoride:
    - Topical fluoride: fluoride mouth
    rinses/ fluoride toothpastes/
    professionally applied fluorides
    - Systemic fluoride: water fluoridation

                                             slide 35
b) Control disease:


Pit and fissure sealants
  - to prevent plaque accumulation in
  susceptible pits/fissures
stimulate salivary flow (flushing,
  buffering)
  - eliminate lifestyle factors which affect
  salivary flow eg caffeine, smoking,
  stress

                                        slide 36
Control disease:
Oral hygiene instruction/plaque
control

Aims:
 Reduce thickness of plaque; remove bacteria
 physically; interfere with growth of the biofilm;
 taking fluoride to tooth site.

Methods:
  – Mechanical control of plaque

  – Chemical control of plaque
     ie., chlorhexidine mouthrinse/gel
          xylitol chewing gum


                                                 slide 37
Control disease:
Involve the patient

- inform patient about their caries
  problem/risk category

- explain to them that they play an impt
  part in the management of their caries

- motivate patient to instigate changes,
  to monitor their progress and attend
  recalls

                                      slide 38
c) Monitor Review and assess
effectiveness

 Recall - Set appropriate period
 -After initial examination and assessment of
     caries risk & detection of active caries recall
     patient within 2-3 weeks to check compliance
 - If have instigated a plan to reverse early caries
 lesions then need to follow-up regularly
 eg. every 6mths
 - Once caries problem under control ie. no new
     lesions
 formed or early lesions arrested or caries risk
     factors
 eliminated or reduced, can increase recall
     period eg. 12 mthly
                                             slide 39
Improvement of oral hygiene
arrested a caries lesion. No
filling was needed
                          •   A patient come to the dental
                              clinic with several cavities.
                              The tooth illustrated in the Fig
                              to the left showed active
                              caries with rapid tooth
                              destruction. Bottom of lesion
                              was soft. Gingiva started to
                              bleed if touched, indicating
                              gingivitis (and bad oral
                              hygiene). It would have been
                              difficult to make a good filling
                              that day due to the blood.
                              The patient was instructed to
                              brush this particular site very
                              carefully twice daily and to
                              return later on.
Source:
http://www.db.od.mah.se/car/data/hygiene
1.html                                                 slide 40
  Improvement of oral hygiene
  arrested a caries lesion. No
  filling was needed
                             • Mr X returned after
                               two weeks. The
                               situation was already
                               much better. The
                               gingiva was not
                               bleeding anymore.
                               Also, the caries lesion
                               showed signs of
                               improvement. It was
                               decided not to make a
                               filling, but to wait.
                               Reinstructions in oral
Source:                        hygiene were given
http://www.db.od.mah.se/car/d
ata/hygiene1.html                                    slide 41
 Improvement of oral hygiene
 arrested a caries lesion. No
 filling was needed
                               • After a few further
                                 weeks, the tooth
                                 showed clear signs of
                                 arrested caries. It was
                                 not necessary to
                                 make a filling. The
                                 patient was not
                                 disturbed by the
                                 appearance of the
Source:                          tooth.
http://www.db.od.mah.se/car/
data/hygiene1.html
                                                   slide 42
 Arrested a caries lesion

                           • Several months
                             later the situation
                             was under full
                             control. The caries
                             lesion was not
                             progressing any
                             more.


Source:
http://www.db.od.mah.se/car/data/hygiene1.html   slide 43

				
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