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Dental Caries
Diagnosis and Treatment Options
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Dental Caries
Infectious , multifactorial disease.
Characterized by the loss of mineral contents ofthe calcified tissue.
Presents in a spectrum of presentation.Lesion status: incipient/cavitated;active/inactive
Subclinical
Incipient lesion
Cavitated lesion(Irreversible tooth Morbidity)
Demineralization
Remineralization
Demineralization
Remineralization
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Treatment Options
Traditional - detection of caries lesionfollowed by immediate restoration.
Current management philosophy -treatment decision should be based on thestatus of the lesion (incipient vs cavitated,active vs inactive), and other patientsfactors (age, frequency of visit, oralhygiene status, dental IQ, motivation, riskfactor).
Non-surgical management(remineralization) of the disease should bepart of the treatment plan.
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Examples of Treatment
OptionsCavitated, active - surgical (restoration)
Non-cavitated, active - surgical or non-
surgical (remineralization)
Cavitated, inactive - surgical (stressbearing area) or non-surgical (non
stress bearing area)
Non-cavitated, inactive - non-surgical
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Dilemma of Caries Diagnosis
No reliable objective diagnostictechnique to differentiate between
incipient lesion and cavitated lesion
Proximal lesion - primary: bitewing x-ray;secondary: visual through marginal ridge.
Pits and fissures - primary: visual; secondary:bitewing x-ray.
Smooth surface lesion - primary: visual;secondary: tactile.
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Dilemma of Caries Diagnosis
No reliable objective diagnostictechnique to differentiate between
active and inactive caries lesion
Currently the rule of thumb is : the darker the
color of the lesion, the more inactive it is.
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Diagnosis and Treatment Options
Based on location
Pits and fissures
Smooth surfaces
Proximal surfaces
Root cariesSecondary caries
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Enamel
Dentin
Pits and Fissures Caries
Demineralization around the
wall and bottom of the pits
(incipient lesion)
Once demineralization
reach the DEJ, it begins
spreading laterally
Start infecting the
underlying dentin (surgical
intervention indicated)
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Diagnosis of Pits and Fissures Caries -
Traditional Method
Using an explorer to probe
into the pit/fissure - a feel of
catch or a stick indicate
the presence of caries at the
bottom of the pit/fissure
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Problem with the Traditional Method
Even at the stage where surgicaltreatment is indicated, the
occlusal enamel may still be
intact
The catch or stick you feel
when you use your explorer to
probe into an intact pits is a
result of the wedging effect
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Possible Result of Probing into
an Incipient Lesion
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Diagnosis of Pits and Fissures
Caries - Current MethodUse an explorer toremove plaque andfood debris from the
fissure orificeUnder good lighting,isolation (dry) andmagnification; visuallyinspect for any
damage to the enamelLook for any subtlecolor changes aroundthe pits and fissures
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Diagnosis of Pits and Fissures
Caries - Current Method
Enamel is low in opacity, thusany changes in color (e.g. cariesdentin) in the underlying dentin
will show through the enamelLook for a gray shadow oropaque area around the pits andfissures - a halo
Ignore the color change withinthe pits and fissures
Bitewing radiographs may behelpful in diagnosing deep lesion
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Current Problems Relating to the
Diagnosis of Pits and Fissure Caries
Uneven diagnostic conclusion amongdentists
No reliable objective diagnostictechnique to differentiate betweenincipient lesion and cavitated lesion.
No reliable objective diagnostictechnique to differentiate betweenactive and inactive caries lesion
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New Technologies
New quantitative diagnostic system e.g.DIAGNOdent
Laser Fluorescence
J Dent 2002;30:129-134
Specificity higher for visual
Sensitivity higher for DIAGNOdent
Frequeucy-Domain Infrared Photothermal
Radiometry and Modulated Laser Luminescence.
Jeon RJ et al. Caries Res 2004;38:497-513
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Treatment OptionsConclusive evidence of the presence of cavitated lesion
Bitewing radiographs
Definitive halo around
the pits and fissures
Cavitated enamel
SURGICAL
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Treatment Options
Deep pits and fissures
Sealants in young or caries active or prone
patients
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Treatment Options - Surgical
Lesion specific restoration should be theprimary option.
Material specific restoration can beconsidered if unable to isolate or foreconomic reason.
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Important Research
Mertz-Fairhurst EJ et.al. JADA1998;129:410-412
Large occlusal lesions were treated with acid etchcomposite restorations, leaving soft, demineralized
dentin both at the DEJ and in the base of the
cavity. The teeth were followed over 10 years.There were no report of failed restoration, pulpitis
or pulp death.
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Empirical Evidence
Sealing caries may not work.
It will work if you can maintain a
complete and absolute seal of theenamel.
However, a complete seal is verydifficult to achieve.
Beside pits and fissures, there may bemicro cracks on the enamel.
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Proximal Caries - Diagnosis
Bitewing radiographs - primary
Trans-illumination - placing the mirror or light
source on the lingual side of anterior teeth anddirecting light through the teeth. Lesion will
show through as a dark area
Opacity or color change under the marginal
ridge (under dry and clean environment)
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Radiographic Diagnosis of
Proximal CariesTriangular
radiolucency- point
end short of DEJ
Point end right at DEJ
Radiolucency in dentin
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Treatment Options
Radiolucency in dentin
SURGICAL INTERVENTION
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Treatment Options
Triangularradiolucency
point ended rightat DEJ
SURGICAL OR NON-SURGICAL -
Should depend on caries status/activities and other
patients factors
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Treatment Options - Current
philosophy
Unless there are clear evidence of radiolucency
in dentin, all decision to initiate surgicalintervention should take into consideration of
patients caries risk status and other patients
factors.
Reason: these lesions may be arrested lesions or
potentially can be converted from active to
arrested lesion using various non-surgical
management techniques.
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Longitudinal Radiographic Data
on a Patient (mesial of #3)
1984
1987
1995
2003
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Inactive , Cavitated Lesion
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Treatment Option - Surgical
Small lesion
Lesion specific restoration should be your
primary choice; material specificrestoration if unable to isolate or foreconomic reason
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Treatment Option - Surgical
Medium/large lesion
Direct Restoration - lesion specific vs
material specificIndirect Restoration - should only beconsidered if patients caries status
become more stable
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Current Problems Relating to the
Diagnosis of Proximal CariesIncipient lesion = triangular radiolucencypoint short of DEJ
Cavitated lesion = triangularradiolucency point at or past DEJ
Disagreement among dentist in exactly
where the point end, and when shouldsurgical intervention indicated
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Current Problems Relating to the
Diagnosis of Proximal Caries
No reliable objective diagnostic
technique to differentiate betweenactive and inactive caries lesion
Best evidence: longitudinal
radiographic data on the patientSupporting evidence: patients caries
risk and other patients factors
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Future
Quantitative data on the exact amount ofmineral loss (incipient vs cavitated) - e.g.
technology use in diagnosing pits and fissurecaries (DIAGNOdent)
Better understanding in the differencesbetween active and arrested lesion - e.g.qualitative and quantitative differences in themineral contents; microbiological differences?
Active Arrested
Time?
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Smooth Surface Caries -
DiagnosisDry, clean, magnified
Plaque covered surface Cleaned surface
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Diagnosis of Smooth Surface CariesIncipient
(chalky white,brown, black)
Cavitated
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Diagnosis of Smooth Surface Caries
Active (Matte, white)
Arrested (Shiny, white, brown)
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Treatment Options
Incipient, active
Incipient, arrested
Cavitated, arrested
NON-SURGICAL (control measures depends on thecaries status of the patient)
SURGICAL (patient has esthetic concern)
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Treatment Options
Cavitated, active (matte surface)
SURGICAL
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Problem with Treatment Option
No objective diagnostic tool to differentiate
between active and arrested lesion. Thus
sometime it may be difficult to decide whento initiate surgical intervention.
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Treatment Options
Composite
RMGI - patient with very high caries
potentialAmalgam
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Root Caries
Supragingivalcaries lesion
located at CEJDiagnostic criteriasimilar to smoothsurface lesion
Treatment optionssimilar to smoothsurface lesion (1stpreference = RMGI)
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Because of the decrease in the incidence of dental
caries (primary caries) in most industrialized
countries; maintenance of previously inserted
restoration has become the major workload
in a typical dental practice.
THUS
Evaluation of existing restorations is becoming
the main focus of the subjective and
objective examination of your patient. How
you are handling the findings is whats going
to define your treatment or your practice
philosophy.
Disease Trend in Dental Office
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Existing Restoration - Clinical Status
Secondary Caries
Marginal Integrity
marginal defect
overhang
open margin
Contourproximal contact
axial contour
occlusion
Biomechanical Form
restoration fracture
tooth fracture
Esthetic
patients esthetic
concern
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Secondary Caries
Carious lesionlocated at the marginof a restoration
It is the mostcommon reason forreplacing an existingrestoration
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Secondary Caries
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Diagnosis of Secondary
CariesDiagnosis should NOT be based on using a
sharp explorer and trying to get a stick
at the margin of a restoration
Tools used for diagnosis are based on the location of
the margin
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Diagnosis of Secondary CariesVisually Accessible Area
Primary Diagnostic Tool
Visual
Dry, clean, magnified,properly illuminated
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Diagnosis of Secondary CariesVisually Inaccessible Area
Tools
Tactile
&
BitewingsRadiograph
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Common Mistakes in Diagnosing
Secondary Caries
Use of a sharp explorer andprobe in to a defect, using astick as the diagnosticcriteria for the presence ofsecondary caries
An uniform radiolucent linearound a compositerestoration - may be due tothe presence of a thick layerof adhesive resin.
Radiographic burnout at CEJ
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Secondary Caries - Treatment Options
Surgical
Reasons
Most of the time when the lesions are detected, they arefrank cavitated lesion.
These lesions are more likely to be active lesion (timeframe of the development of the disease)
These lesions are in a very retentive area (limited abilityfor non-surgical management techniques to work; similarto pits and fissure caries)
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Secondary Caries - Treatment Options
Direct vs indirect
Financial
Patients caries status, oral hygienestatus, dental IQ, motivation, risk factors