DETECTION
VISUAL
 TACTILE (?)
 TRANSILLUMINATION
 RADIOGRAPHS
ELECTRIC RESISTANCE MEASUREMENT
CARIES DETECTOR
LASER CARIES DIAGNOSIS SYSTEM

VISUAL DETECTION
Only 12% to 31% of
occlusal lesions have
been detected visually.
DETECTION OF PIT AND
FISSURE CARIES
Softening at base of pit or fissures
Opacity surrounding the pit or fissure
Softened enamel that may be flaked away
explorer
U S Public Health Services
VISUAL DETECTION
50% of visually inspected ‘sound’
permanent molars unexpectantly had
occlusal dentine radiolucencies
detected on BW radiographs.
Weerheijm et al. 1992
HIDDEN CARIES
Term used to describe occlusal dentine
caries that is missed on a visual
examination, but is large enough and
demineralized enough to be detected
radiographically.
Ricketts et al
Int Dent J (1997) 47, 259-265
HIDDEN CARIES
HIDDEN CARIES
= COVERT CARIES
= FLUORIDE SYNDROME
= OCCULT CARIES
AETIOLOGY OF HIDDEN CARIES
Hypotheses:
Due to particular type of groove
pattern or bacteria
Due to remineralization of outer
enamel by fluoride
VISUAL DETECTION
GOOD ILLUMINATION
 DRY FIELD
 PLAQUE AND STAIN FREE
 PROSTHESES REMOVED

Pit and Fissure Caries
Not cavitated: (caries free pits
and fissures)
 No radiolucency below occlusal
enamel
 Deep grooves may be present
 Superficial staining may be
present in grooves
Pit and Fissure Caries
Cavitated:
Extensive enamel
demineralization has lead
to destruction of the walls
of the pit or fissure and
bacteria invasion has
occurred. Demineralization
of the underlying dentine
is usually extensive by the
time cavitation has
occurred.
Pit and Fissure Caries
Cavitated (diseased) pits and
fissures
Chalkiness of enamel on walls
and base of pit and fissure
 Softening at the base of a pit
and fissure
 Brownish-grey discolouration
under enamel adjacent to pit
and fissure
 Radiolucency below occlusal
enamel.
TACTILE DETECTION
EXPLORERS (Caries)
 EXCAVATOR (Caries free)

TACTILE DETECTION
IS
STICKINESS = CARIES?
TACTILE DETECTION
Only 14%-24% of carious fissures are
detected with an explorer.
Lussi 1993
TACTILE DETECTION
Sharp explorers do not detect
more occlusal caries than visual
inspection alone.
Lussi 1993
TACTILE DETECTION
Explorers do not
detect caries but
frictional resistance,
which increases with
steep narrow fissures.
TACTILE DETECTION
Explorers can damage sound
enamel and convert incipient
non-cavitated lesions into
cavitated lesions requiring
restorations.
Ekstrand et al. 1987
TACTILE DETECTION
The “sticky fissure ” is an
unreliable sign of fissure caries
and is a term which should
become a phrase of the past.
Paterson et al. 1991
TACTILE DETECTION
BLUNT EXPLORERS
VS
SHARP EXPLORERS
TRANSILLUMINATION
 1970-Friedman
&
Marcus
suggested its use
for detection of
carious lesions
TRANSILLUMINATION
 Stephen
KW, Russell JI, Creanor
SL, Burchell CK. Community Dent
Oral Epidemiol 1987;15:90-4
 Sidi
AD, Nay Lor MN. Brit Dent
J 1988;164:15-8
DETECTION
OPERATORY LIGHT
LIGHT CURE UNIT
FIBER OPTIC TRANSILLUMINATION (FOTI)
TRANSILLUMINATION

FOTI could be used as an
adjunct to clinical or
radiographic examination,
especially where approximate
overlap occurs and
interproximal lesions are
undetectable by
probing/radiographs.
Soli K Choksi et al
JADA Vol 125 Aug 1994
TRANSILLUMINATION
 “Good
especially for
anterior teeth
 But unacceptable
replacement for BW
radiograph for reliable
identification of
approximate caries”
TRANSILLUMINATION
Useful for detecting enamel lesions in
anterior teeth and dentinal lesions in
posterior teeth.
RADIOGRAPHIC DETECTION
1
2
3
4
Bite wings
Periapicals
Digitized radiographic images
(indirect digital imaging)
Direct digital imaging
(radiovisiography)
Digitized radiographic images
(indirect digital imaging)
Digitizing traditional X-ray images
Radiovisiography
(direct digital imaging)
Computerized imaging system that utilizes
an electronic sensor instead of X-ray film.
Radiovisiography
(direct digital imaging)
Sensors produce sharp and clear images
that appear almost instantly on computer
screen. Images also use up to 90% less
radiation than conventional X-ray films
RADIOGRAPHIC DETECTION
Bite wing radiographs + visual inspection
can detect up to 75% of occlusal lesions.
Ketley and Holt, 1993
RADIOGRAPHIC DETECTION
Over 90% of interproximal
lesions are detected by
radiographs.
Kidd and Pitts, 1990
RADIOGRAPHIC
CLASSIFICATION OF CARIES
R1: Radiolucency confined to the outer
half of the proximal enamel.
RADIOGRAPHIC
CLASSIFICATION OF CARIES
R2: Radiolucency extending into the
inner half of the proximal
enamel, but not involving dentine.
RADIOGRAPHIC
CLASSIFICATION OF CARIES
R3: Radiolucency extending into
the outer half of the dentine.
RADIOGRAPHIC
CLASSIFICATION OF CARIES
R4: Radiolucency extending into
the inner half of the dentine.
RADIOGRAPHIC DETECTION
IRRADIATION GEOMETRY
Relationship between x-ray
beam, jaw and film position.
RADIOGRAPHIC DETECTION
Benn and Watson 1989
Horizontal angular changes of only 3° in the
direction of the x-ray beam were sufficient to
throw outer enamel radiolucencies over the inner
half of enamel.
CARIES RESISTANCE METERS
MEASURES THE
RELATIONSHIP
BETWEEN THE
ELECTRICAL
RESISTANCE AND
THE CARIES
STATUS OF THE
TOOTH.
CARIES RESISTANCE METERS
Occlusal caries diagnosis
Pincus P, 1951
Vanguard Electronic Caries Detector
(Massachusetts Manufacturing Corp.)
1980s
Caries Meter L (GC International Corp.)
ECM (P Borsboom, Sensortechnology and
Consultancy B V)
CARIES RESISTANCE METERS
Electrical resistance measurement is a
valuable aid in the diagnosis of
occlusal caries.
Rock & Kidd 1988
McKnight-Hanes et al 1990
Verdonschot et al 1993
CARIES RESISTANCE METERS
Enamel
Fall in
resistance
Caries
Conductive
Enamel
Enamel
CARIES RESISTANCE METERS
“A re-evaluation of electrical resistance
measurements for the diagnosis of occlusal
caries ” Ricketts, Kidd et Wilson. BDJ
1995(Jan)178:11-17
The study supports the renewed interest in
resistance measurements as a diagnostic technique
and indicates that the in vitro model used gives
results comparable to those in vivo.
CARIES DETECTOR
0.5% BASIC FUCHSIN OR
1.0% ACID RED 52 (FOOD
RED 106) DYE SOLUTION
IN PROPYLENE GLYCOL
Fusayama 1979
INFECTED
VS
AFFECTED DENTINE
INFECTED DENTINE
OUTER CARIOUS DENTINE
INFECTED
UNREMINERALIZABLE
DEAD
STAINED RED WITH CARIES
DETECTOR
AFFECTED DENTINE
INNER CARIOUS DENTINE
 UNINFECTED
 REMINERALIZABLE
 ALIVE
 DOES NOT STAIN RED WITH
CARIES DETECTOR

Laser fluorescence system
Diagnodent KaVo

for improved detection of fissure caries
Laser fluorescence system
Carious dentine/enamel is detected by
fluorescence induced by laser diagnostic
system.
Laser fluorescence system
“Clinical validation of a laser caries diagnosis
system” Reich, Marrawi,Pitts & Lussi 1998
24 patients examined with radiographs &
Diagnodent.
The laser fluorescence system was found to
have detected caries in all cases. More data
are needed to differentiate between lesions in
enamel and dentine.
Laser fluorescence system
“Comparison of visual & electrical methods with a
new device for occlusal caries detection”
Longbottom et al 1998
“The new caries detection device produced
promising results with in vivo sensitivity and
specificity values broadly similar to those
obtained for the ECM. Further investigation
using histological validation is required.”
Laser fluorescence system
Reich et al 1998
“Fluorescence of different dental materials
in a laser diagnostic system” concluded:
“Some restorative materials showed similar
fluorescent values as for carious dentine.”
“Application of laser system for the
detection of secondary caries seems
questionable.”
DETECTION OF PROXIMAL
CARIES
1 Interproximal wedge
2 Tooth separator
3 Dumbell
4 Orthodontic elastic separator
5 Radiographs
PROXIMAL CARIES
Not cavitated
Surface intact
 Opacity of proximal enamel may be present
 Radiolucency may be present
 Marginal ridge is not discoloured
 Opaque area may be seen in enamel by
transillumination

PROXIMAL CARIES
Cavitated
Surface broken
 Opacity of proximal enamel may be
present
 Radiolucency is present
 Marginal ridge may be discoloured
 Opaque area in dentine by transillumination

ENAMEL CARIES
CLINICAL
PRESENTATION
Chalky white, opaque
areas that are
revealed only when
the tooth is
desiccated.
“BROWN “ SPOT LESIONS
Remineralized,
arrested, incipient
carious lesion.
Clinical characteristics of normal and
altered enamel
Hydrated Desiccated
Surface Surface
texture hardness
Normal enamel TranslucentTranslucent Smooth
Hard
Hypocal’d enamel Opaque
Hard
Opaque
Smooth
Incipient caries Translucent Opaque
Smooth
Softened
Active caries
Opaque
Opaque
Cavitated
V. soft
Arrested caries
Opaque,
dark
Opaque,
dark
Roughened
Hard
MANAGEMENT
OF
CARIES
Microorganisms
Host
&
Teeth
caries
Substrate
DENTAL CARIES
PERIODIC
DEMINERALIZATION
AND
REMINERALIZATION
Progression of carious lesions
Depends on site of origin and the
conditions in the mouth. The time for
progression from incipient caries to clinical
caries (cavitation) on smooth surfaces is
estimated to be 18 months, plus minus 6
months.
Ooshima et al 1985
Progression of carious lesions
Occlusal pit and fissure lesions
develop in less time than smooth
surface caries.
Progression of carious lesions
Radiation induced
xerostomia can lead
to clinical caries
development
in as little as 3 months
from the onset
of the radiation.
Progression of carious lesions
Both poor oral hygiene and frequent
exposures to sucrose-containing food can
produce incipient (white spot) lesions
(first clinical evidence of demineralization)
in as little as 3 weeks.
Progression of carious lesions
Peak rates for the incidence of new lesions
occurs 3 years after the eruption of the
tooth.
Ooshima et al 1985
DENTAL CARIES
RESULTS PRIMARILY
FROM A BACTERIAL
INFECTION
GOALS OF CARIES
MANAGEMENT
REDUCE BACTERIAL INFECTION
WHICH CAUSES CARIES
REMINERALIZE CARIOUS SITES
RESTORE CAVITATED LESIONS
WHICH ARE UNLIKELY TO
REMINERALIZE
MANAGEMENT OF
DENTAL CARIES
In an age where caries no longer runs
rampant, surgical model of caries
management represents an “outdated
treatment philosophy” and “a default
standard of care”.
MANAGEMENT OF
DENTAL CARIES
MEDICAL MODEL FOR CARIES
CONTROL assumes the disease to be
the clinical symptom of a bacterial
infection….
MANAGEMENT OF
DENTAL CARIES
...diagnosis should therefore demand
bacterial investigation and treatment
focus on the reduction or elimination of
odontopathogens.
MANAGEMENT OF
DENTAL CARIES
“MEDICAL MODEL OF CARE”
Anderson et al. JADA Vol. 124 June 1993,
37-44
Addresses the clinical manifestation of the
infection (caries) and the cause of the disease
process (Streptococci mutan, Lactobacilli)
MANAGEMENT OF DENTAL
CARIES BY MEDICAL MODEL
1
2
3
4
5
6
Limit substrate
Modify microflora
Plaque disruption
Modify tooth surface
Stimulate salivary flow
Restore tooth surfaces
MANAGEMENT OF
DENTAL CARIES
RISK FACTORS OF THE PATIENT SHOULD
BE TAKEN INTO CONSIDERATION WHEN
DECIDING ON THE TYPE OF TREATMENT
OR WHETHER ANY TREATMENT IS
REQUIRED AT ALL.
MANAGEMENT OF
DENTAL CARIES
E.g. No. of restorations/ lesions present,
amount of plaque present, bacterial count,
saliva flow rate and buffering capacity etc.
PATIENT ASSESSMENT
RISK STATUS
High risk or low risk for
developing new /recurrent
disease
Clinical risk assignment for caries
Do bacteriologic testing when patient has one or
more medical health history risk factors:




After antimicrobial therapy
The patient presents with new incipient lesions
Undergoing orthodontic care
The patient’s treatment plan calls for extensive
restorative dental work
Clinical risk assignment for caries
1
High Strep. Mutans counts
2
Any two of the following factors are
present:
Two or more active carious lesions
Large no. of restorations
Poor dietary habits
Low salivary flow
Caries activity tests
Caries risk assessment program by Krasse
1985:
1 Microbiological testing for presence of S
mutans and Lactobacillus.
2 Analyses of diet and saliva.
DIAGNOSIS, SEVERITY AND
ACTIVITY OF CARIES
ESTIMATION OF THE SEVERITY AND
ACTIVITY OF A LESION DETERMINES
WHETHER:
DIAGNOSIS, SEVERITY AND
ACTIVITY OF CARIES
1 NO TREATMENT
2 TOPICAL FLUORIDE TREATMENT
3 CHLORHEXIDINE RINSES
4 FISSURE SEALANTS
5 PREVENTIVE RESIN RESTORATIONS
6 CONVENTIONAL RESTORATIONS
ARE NECESSARY.
CARIES PREDICTION
BACTERIOLOGICAL TESTS
 SALIVA TESTS

CARIES PREDICTION
Dentocult SM and LB (Vivadent)
Streptococci mutans-associated with the
initiation of caries. Indicative of
cavitation in the near future.
Lactobacilli -associated with active
caries
CARIES PREDICTION
GC Saliva check
Flow rate
 Buffering capacity

MANAGEMENT OF
DENTAL CARIES
“Restorative procedures should be
undertaken only when the long term
advantages to the patient outweigh the
disadvantages”
R J Elderton
MANAGEMENT OF
DENTAL CARIES
Swedish study
It took 38 months for caries to
progress through the first half of
enamel and 47 months to get
through second half
MINIMAL INTERVENTION
FLUORIDE APPLICATION
ADHESIVE DENTISTRY
- FISSURE SEALANTS
- PREVENTIVE RESIN RESTORATIONS (PRR)
- COMPOSITE RESINS
- GLASS IONOMER CEMENTS
TREATMENT OF SMOOTH “WHITE”
OR “BROWN “ SPOT LESIONS
1
2
3
4
No dental handpieces
Topical fluoride application
Reinforce oral hygiene
Diet counselling
ENAMEL CARIES
Incipient caries= white spot lesion
ENAMEL CARIES
CLINICAL PRESENTATION
Enamel lose their translucency
because of the extensive
subsurface porosity caused by
demineralization.
ENAMEL CARIES
White spot incipient
lesions
Dev’tal white spot
hypocal’n of enamel
Partially or totally
disappear visually
when the enamel is
wet
Remains white when
dry or wet
FLUORIDE APPLICATION
GENERAL
TOPICAL
FLUORIDE
Anticaries effect by 3 mechanisms:
1 Precipitation of fluorapatite from Ca &
PO4 ions in saliva.
2 Remineralizes incipient carious lesions
3 Antimicrobial activity
FLUORIDE APPLICATION
Frequent supply of low
concentrations of fluoride
rather than infrequent use
of high concentrations.
GENERAL FLUORIDE
APPLICATION
INDICATIONS:
1
Moderate and high risk children
2
Prior to and during orthodontic
treatment
GENERAL FLUORIDE
APPLICATION
1.
2.
3.
4.
5.
Prophylaxis is not necessary (Ripa
1985)
Fluoride gel loaded into preformed
polystyrene tray
Dry teeth, tray kept in place for 4
minutes
No food / drink for at least one hour
Apply 6 monthly or 2 weeks prior to
orthodontic banding
GENERAL FLUORIDE
APPLICATION
1.23% APF Gel
or
10% SnF2
TOPICAL FLUORIDE
APPLICATION
INDICATIONS:
1
Early enamel lesions with intact surface
2
Areas of decalcification
3
Susceptible pits and fissures where the
tooth cannot be isolated for a fissure
TOPICAL FLUORIDE
APPLICATION
Duraphat varnish (0.5% NaF)
TOPICAL FLUORIDE
APPLICATION
1.
2.
3.
4.
5.
Prophylaxis is not necessary
Isolate tooth
Apply a thin layer / floss through
interproximal contacts
No food / drink for at least one hour
Apply for 3 consecutive visits (preferably
within the week)
ADJUNCTIVE THERAPIES
CHLORHEXIDINE MOUTHRINSE
-Highly effective against ms
infection
-Cationic charge
-High substantivity
ADJUNCTIVE THERAPIES
XYLITOL GUM CHEWING
-Turku sugar studies
-Anti-cariogenic, not fermentable
substrate for ms
-Naturally occurring in fruits and
vegetables
-Hypo or non acidogenic
-Inhibits growth of ms
PROTOCOL
-Chew 2 pieces, q.d.s.after meals
TO RESTORE
OR
NOT TO RESTORE ??
ASSESS CARIES RISK
ORAL HEALTH STATUS
DIET
DIAGNOSTIC TESTS
ADJUNCTIVE THERAPIES
“Use of slow fluoride releasing variety of
pit and fissure sealants recommended in
all premolars and molars of caries susceptible patients.”
Maxwell H Anderson
ANTIMICROBIAL TREATMENT
OF CARIES
30 seconds rinse with 1/2 ounce of
chlorhexidine mouthwash at bedtime will
suppress streptococcus mutans to safe
levels within 14 days, with the
suppression lasting 12 to 26 weeks.
CLASSIFICATION OF DENTAL
CARIES
1
Severity of attack
2
Site of attack
3
Radiographic
CLASSIFICATION OF DENTAL
CARIES BY SEVERITY OF ATTACK
1
2
3
4
5
Rampant
Slow
Arrested
Occult
Initial
CLASSIFICATION OF DENTAL
CARIES BY SITE
1
2
3
4
5
6
Pit and fissure
Smooth surface
Interproximal
Root
Gingival
Next to restorations (2 Caries)
0
RADIOGRAPHIC
CLASSIFICATION OF DENTAL
CARIES
R1
R2
R3
R4
lesion
lesion
lesion
lesion
NEW CLASSIFICATION FOR
CARIOUS LESIONS
Graham Mount 1997
The proposed new classification arises
from recognition that these are only 3
areas on the crown or root of a tooth
which will accumulate plaque and become
carious.
NEW CLASSIFICATION FOR
CARIOUS LESIONS
SIZE
Minimal
1
SITE
Pit/fissure
Moderate
Enlarged
Extensive
3
2
4
1.1
1.2
1.3
1.4
2.1
2.2
2.3
2.4
3.1
3.2
1
Contact area
2
Cervical
3
3.3
3.4
NEW CLASSIFICATION FOR
CARIOUS LESIONS
These sites are:
1 Pits and fissures on otherwise smooth
surfaces
2 Contact areas between any two teeth
3 Gingival or cervical margins around the full
circumference of a tooth
NEW CLASSIFICATION FOR
CARIOUS LESIONS
The other part of the classification takes
into account the increasing problem
associated with the continuing enlargement
of a cavity either as a result of patient
neglect or replacement dentistry. Cavities
will extend in form, sizes or stages as
follows:
NEW CLASSIFICATION FOR
CARIOUS LESIONS
SIZE
Minimal
1
SITE
Pit/fissure
Moderate
Enlarged
Extensive
3
2
4
1.1
1.2
1.3
1.4
2.1
2.2
2.3
2.4
3.1
3.2
1
Contact area
2
Cervical
3
3.3
3.4
NEW CLASSIFICATION FOR
CARIOUS LESIONS
1 Minimal-just beyond healing through
remineralization
2 Moderate-a little larger but there is still
sufficient sound tooth structure remaining
to support a plastic restorative material.
NEW CLASSIFICATION FOR
CARIOUS LESIONS
3 Enlarged-the cavity has extended to the
stage where it is necessary to use the
restorative material to support the
remaining tooth structure through a
protective cavity design.
4 Extensive-there has already been loss of
bulk tooth structure such as a cusp or
incisal edge.
TREATMENT OF
QUESTIONABLE
FISSURES
1
2
3
4
Lesion within outer
half of enamel
Fissure sealant
Clean and dry the tooth
Good illumination
Radiographs
Widen fissures with smallest round
bur / KCP 2001 J
Lesion within
enamel
Posterior CR / PRR
Lesion within
dentine
PRR / Posterior CR /
AR
Dependent on the condition of
the surrounding fissure system
Pit & Fissure caries treatment
decision making
Post . Tooth
Clinical Dx
Not
cavitated
Pit &
fissure
Cavitated
Predict’n / obs’n
Caries
unlikely/
no progress
Caries likely/
progress
Treatment
No treatment
Sealant & antimicrobial / F-
Rest’n & antimicro
/ F-
RONDOFLEX (plus)
Defined powder particles are accelerated
into a focused air stream which gently
polishes or abrades away tooth structure
RONDOFLEX (plus)
Powder:
Aluminum Oxide -27 or 50 microns
SEALANT RESTORATION
SIMONSEN AND STALLARD 1977
PREVENTIVE RESIN RESTORATION
(PRR)
R. J. SIMONSEN 1985
PREVENTIVE RESIN
RESTORATION
(PRR)
POSTERIOR COMPOSITE RESIN
OVERLAY WITH FISSURE
SEALANT
MANAGEMENT OF CARIES
SHALLOW LESIONS
MODERATE LESIONS
DEEP LESIONS
Management of caries
Determined by the thickness
of remaining dentine
MANAGEMENT OF SHALLOW
LESIONS
Caries within enamel (R1 and R2 lesions)
Use adhesive materials
OUTLINE FORM
EXTENSION
FOR
PREVENTION
OUTLINE FORM
CONSERVATION
OF
TOOTH STRUCTURE
COMPOSITE
RESTORATIONS
Shallow-Just into enamel or
dentine
etch, prime, adhesive,
CR
AMALGAM RESTORATIONS
1 mm into dentine - AR
Proximal caries treatment decision
making
Post . Tooth
Clinical Dx
Not
cavitated
Proximal
surface
Cavitated
Predict’n / obs’n
Caries
unlikely/
no progress
Caries likely/
progress
Treatment
No treatment
Anti-microbial /
F-
Rest’n & antimicro
/ F-
MANAGEMENT OF
DENTAL CARIES
“Only when bite wings
show that the carious
lesion has intruded well
into dentine”
Anusavice
MANAGEMENT OF PROXIMAL CARIES
Root caries
Active, progressing root caries shows little
discolouration and is primarily detected by
the presence of softness and cavitation.
Darker discolouration: more remineralization
GLASS IONOMER CEMENT
RESTORATIONS
Shallow and
moderate - GIC
restoration
GLASS IONOMER CEMENT
RESTORATIONS
Deep cavity - > 2mm
into dentine
Ca(OH)2, GIC
restoration
GIC/CR SANDWICH
RESTORATIONS
Deep cavity - > 2mm
into dentine
Ca(OH)2, GIC
restoration,
CR
Management of root caries using
ozone
KaVo HealOzone
Converts oxygen to
ozone which is then
pumped through a
tube and a HP with a
special silicone cup
onto the tooth with
an air tight covering.
KaVo HealOzone
It takes about 20 secs before 99.9% of the
caries pathogens are eliminated. The ozone is
pumped away, broken down into oxygen again.
KaVo HealOzone
MANAGEMENT OF SECONDARY
CARIES
If the lesion is large or other indications
for redo such as loss of marginal
integrity, aesthetics etc are present,
replacement of the restoration is
necessary.
MANAGEMENT OF SECONDARY
CARIES
If the lesion is small, repair.
Management of rampant caries
Caries control-change flora of oral cavity
Oral hygiene instructions
Patient education and motivation
Diet counselling
Management of rampant caries
Caries control to decrease streptococcus
mutans colony
prevents pathogen
from occupying margins of new
restorations and may decrease potential
for 20 caries
MANAGEMENT OF MODERATE
CARIOUS LESIONS
Caries penetration involving up to half of
dentine thickness between dentinoenamel junction and the pulp (R3 lesion)
MANAGEMENT OF MODERATE
CARIOUS LESIONS
If cavity is 1 mm into dentine and you are
restoring with Composite resins:
Etch, prime, adhesive, CR
Or Amalgam:
-just place AR, no need for lining
MANAGEMENT OF MODERATE
CARIOUS LESIONS
Composite resins
1-2 mm into dentine
GIC lining, etch, adhesive, CR
Amalgam
2 mm into dentine - GIC lining, AR
MANAGEMENT OF DEEP
CARIOUS LESIONS
Caries penetration involving outer half of
dentine thickness between dentinoenamel junction and the pulp (R4 lesion).
May involve the pulp as well.
MANAGEMENT OF DEEP
CARIOUS LESIONS
AIM:Preservation of pulp vitality.
Only possible where pathological changes
within the pulp are deemed to be
reversible-a difficult assessment to
make since clinical signs and symptoms
correlate poorly with histological
findings.
Management of deep carious lesions
Success is dependent upon 4 factors:
1 Correct assessment of whether the pulp is
capable of being saved
2 Respect of the operator for pulp during
cavity prep
3 Control of micro-organisms at the base of
the cavity
4 Provision of a well-sealed restoration
G V BLACK
1896
STAGES OF CAVITY
PREPARATION
1 Access
2 Removal of superficial caries
3 Resistance form
4 Retention form
5 Convenience form
6 Margins
7 Removal of deep caries
8 Protection of cavity
Outline form
Rational cavity design principles
Peter R Hunt
J Esthetic Dent
1994;6(5)345-356
Rational cavity design principles
1 Gaining access to the body of the lesion
without being destructive.
2 Removal of tooth structure i.e. infected
and incapable of regeneration.
3 Avoiding the exposure of dentine
unaffected by the caries process.
4 Retaining and reinforcing sound but
undermined enamel.
Rational cavity design principles
5 Reducing the perimeter of the
restoration.
6 Keeping the margins of the restoration
away from the gingival.
7 Reducing occlusal stress on the final
restoration
References on modern cavity
preparation
1 Peter R Hunt. Rational Cavity Design Principles. J Esthet
Dent 1994;6(5):345-56.
2 Elderton RJ. New approaches to cavity design. Br Dent
J.1984;157:421-27.
3 Elderton RJ. Restorative dentistry:1 Current thinking on
cavity design. Dental Update 1984;13:113-122.
4 Mount Graham . The problems with modern operative
dentistry. ADA New Bulletin 1997 (July)No 246:40-41.
OUTLINE FORM
Outline form
iatrogenic form
R J Elderton
OUTLINE FORM
Extension for prevention
Extension for destruction
R J Elderton
OUTLINE FORM
EXTENT OF CAVITY
OUTLINE FORM
FACTORS TO CONSIDER:
1 Extent of caries
2 Accessibility
3 Type of restorative material
4 Alignment of teeth
5 Preservation of tooth structure
6 Minimizing perimeter of restorative
margin
ACCESS AND OUTLINE FORM
High speed bur used for establishing
outline form and access
REMOVAL OF SUPERFICIAL
CARIOUS DENTINE
To eliminate any infected carious tooth
structure and faulty restorations
RETENTION FORM
FORM OF CAVITY WHICH PREVENTS
REMOVAL OF THE RESTORATION ALONG
THE PATH OF INSERTION
RETENTION FORM
Factors to consider:
1 Extent of caries
2 Angulation cavity walls
3 Depth and width of cavity
4 Type of material
5 Auxillary retentive features
AUXILLARY RETENTIVE
FEATURES
1 Macro-mechanical retention
a) Grooves
b) Slots
c) Pins
d) Dovetails
AUXILLARY RETENTIVE
FEATURES
2
a)
b)
Micro-mechanical retention
Acid-etching
sandblasting
3
a)
Chemical retention
Dentine bonding systems
RESISTANCE FORM
Form which prevents displacement of the
restoration
RESISTANCE FORM
Factors to consider:
1
Type of restorative material
2
Depth of cavity
3
Angulation of cavity walls
CONVENIENCE FORM
FORM OF CAVITY WHICH
FACILITATES VISIBILITY FOR
COMPLETE CARIES REMOVAL AND
INSTRUMENTATION.
CONVENIENCE FORM
Factors to consider:
1 Extent of caries
2 Alignment of teeth
3 Location of tooth on the arch
REMOVAL OF DEEP CARIOUS
DENTINE
Remove peripheral carious dentine before
proceeding to the part nearest to the
pulp.
FINISHING OF MARGINS
To ensure optimal adaptation of
restorative material to the margins
Design of cavosurface margins should
complement the restorative material.
CLEANSING AND PROTECTION
OF CAVITY
1 Remove all loose debris with water spray
and dry cavity with airspray.
2 Cavity may require placement of liner
and/or bases
MANAGEMENT OF DEEP
CARIOUS LESIONS
1
Mx of deep caries in permanent teeth with
mature apices
2
Mx of carious exposures in permanent teeth
with mature apices
3
Mx of carious exposures in permanent teeth
with immature apices
4
Mx of mechanical exposures in permanent
teeth with mature and immature apices
MANAGEMENT OF DEEP
CARIOUS LESIONS
DIRECT PULP CAP
INDIRECT PULP CAP.
DIRECT PULP CAPPING
OBJECTIVE:
To facilitate the formation of a “dentine
bridge” to seal the healing pulp away from
the restorative material and harmful
bacteria.
DIRECT PULP CAPPING
Direct pulp cap refers to the technique
for treating a pulp exposure with Ca(OH)2
to stimulate dentine bridge (reparative
dentine) formation.
Sturdevant et al 1995
INDIRECT PULP CAPPING
DEFINITION
Procedure involving the removal of
infected dentine except for the
deepest, last small amount, which if
removed might expose the pulp.
Sturdevant et al 1995
INDIRECT PULP CAPPING
OBJECTIVE
To kill any bacteria remaining, encourage
remineralization of residual dentine and
the formation of reparative dentine.
Mx of deep caries in permanent teeth with
mature apices
Definition of Indirect Pulp Capping (IDPC)
Indirect Pulp Capping refers to the process whereby all
carious, infected demineralized dentine is removed in the
periphery of the preparation, leaving a small amount of
affected firm and leathery demineralized dentine
immediately over area of the pulp; pulpal exposure might
result if this dentine were excavated. A calcium
hydroxide lining material is then placed over the
remaining demineralized dentine, followed by a sealing
liner and restoration.
INDICATIONS FOR IDPC FOR PERMANENT TEETH WITH
MATURE APICES
Indirect Pulp Capping in permanent teeth with mature apices
should be considered when there is:
1
Radiographically evident, deep carious lesion encroaching on the
pulp (R3 lesion)
2
No history of spontaneous pain
3
Responds normally to thermal and electrical vitality tests. Any
pain elicited during pulp testing with hot or cold stimulus does
not linger after the tooth returns to mouth temperature.
4
The tooth has no observable periradicular pathosis
5
The patient/parents/guardians is/are informed that root canal
treatment will be necessary should IDPC fail.
Other considerations include :
-No extensive softened dentin remaining
-Rubber dam isolation of the tooth is uncompromised
-No complex restorations are to be planned for this
tooth eg FPD, precision attachments etc
Desirable Outcomes
- Radiographic evidence of reparative dentine
formation.
-Normal responsiveness to electrical and thermal
pulp tests
-Breakdown of periradicular tissues is absent.
-No signs and symptoms.
Instruments / Materials
Local anaesthetics and syringes / needles
Rubber dam isolation
Sterile slow speed carbide round burs
Pulp capping material – hard setting calcium
hydroxide, Dycal and a sterile applicator
Base materials – Restorative GIC material-Fuji IX
(for posterior restorations) or Fuji II LC (for both
anterior and posterior restorations)
Direct restorative materials – AR, CR, GIC
METHOD
1 Pretreatment evaluation of the tooth with deep carious
lesions potentially exposing dental pulp
2 Case discussion with supervisor
3 Patient communication on the potential pulp exposure and
recall patient 1, 3, 6 monthly and annually.
4 Administer local anesthesia
5 Isolation
6 PREPARATION
a Entry is made into the tooth in conventional manner
with a high speed bur
b Establish adequate access to the carious lesion
c Soft carious dentine and carious material extending
beyond the limits of the ideal preparation is removed
with the largest slow speed round bur or large spoon
excavator that will fit the area.
d The carious removal process should begin peripherally.
As the carious dentine is removed peripherally, the bur
is worked into the deeper areas. Often, it is
necessary to enlarge the occlusal opening to gain both
visual and mechanical access.
e.
Caries in areas involving potential exposures,
such as the axial and pulpal walls, should be
removed LAST. Use very gentle, feather light
strokes over the area of the demineralised
dentine to remove only the wet, soft and
amorphous carious dentine. Leave the firm and
leathery, demineralized dentine (also known as
the affected dentine) that gives some moderate
resistance to gentle scraping with spoon
excavator immediately overlying the pulp. This
layer is left because its removal would likely
expose the pulp.
At this stage, discuss with your supervisor .
f. After all the wet and soft amorphous caries has
been removed, the preparation is re-evaluated for
undermined enamel, resistance form and retention
form.
g All thin undermined enamel areas in load bearing
areas should be removed with the high speed bur
and an attempt made to re-establish lost retention
and resistance form.
h Any pulpal floor destruction beyond ideal depth
should be left alone and not smoothened.
7 LINING
Line the affected dentine with a layer of calcium
hydroxide paste (eg Dycal), followed
by a glass ionomer liner/base to seal the Dycal.
8 RESTORATION
a Direct Restorations
For direct restoration (eg Amalgam, composite, glass
ionomer), place the final restoration. If time does not
permit, a glass ionomer or reinforced zinc oxide-eugenol
provisional restoration should be placed and the patient
reappointed for the final restoration as soon as possible.
The indirect pulp capping liner SHOULD NOT be
disturbed at the subsequent restoration process.
b Indirect Restorations
For placement of indirect restorations such as
cast metal restorations, ceramic
inlays/onlys/crowns or bridge abutments, please
discuss with your supervisor whether indirect pulp
capping is indicated.
9. Vital pulp therapy form
Complete the above form
PRECAUTIONS
1 Use care in removing carious dentine near the pulp
to prevent accidental pulp exposure.
2 If a temporary restoration has been previously
placed over an indirect pulp capping liner and the
tooth is re-entered for restorative procedure, do
not remove the indirect pulp capping material.
3 Prior to excavation, use tactile exploration to
confirm that the dentine lacks hardness.
PULPAL EXPOSURES
2 types:
1 Carious pulp exposure
2 Mechanical pulp exposure
Summary of Ideal Treatment
Options for Pulpal Exposures
Carious Exposure
Tooth with
Mature apex
Tooth with
Immature apex
Mechanical
Exposure
RCT
DPC
DPC/IDPC
DPC
MANAGEMENT OF DEEP
CARIOUS LESIONS
Indirect and Direct Pulp Capping as well as
Pulpotomy have been widely considered
acceptable treatment approaches to Vital
Pulp Therapy.
MANAGEMENT OF DEEP
CARIOUS LESIONS
Objectives of Vital Pulp Therapy
1 To maintain the health of the dental pulp
2 To maintain the integrity of the periradicular
tissues
3 To allow continued crown and /or root
development in immature permanent teeth, if
applicable.
Carious exposures in permanent
teeth with MATURE APEX
Indications for Direct Pulp Capping
Direct Pulp Capping of carious exposures in
permanent teeth with mature apices is
controversial because of its unpredictable
outcome. Hence, Root Canal Treatment is
usually indicated when carious exposure
occurs.
Carious exposures in permanent
teeth with MATURE APEX
However, some patients may choose not to
undergo the recommended Root Canal
Treatment in view of financial and/or time
constraints. Under such circumstances, a
Direct Pulp Capping of carious exposures in
mature permanent teeth may be
considered, if the following conditions are
met:
Carious exposures in permanent
teeth with MATURE APEX
The patient does not have compromised healing
potential and is not immuno-compromised or at risk of
Subacute Bacterial Endocarditis
The tooth has no history of spontaneous pain
The tooth is responsive to electrical and thermal pulp
testers with no observable radiographic periapical
pathoses
Carious exposures in permanent
teeth with MATURE APEX
The tooth concerned does not require complex
restoration e.g. crown, bridge abutment and/or such
that the Direct Pulp Capping does not and will not
interfere with a multidisciplinary treatment plan
The patient is agreeable to comply with the proposed
recall program
The patient is informed of potential root canal therapy
or extraction should Pulp Capping fail
Carious exposures in permanent
teeth with MATURE APEX
Rubber dam isolation of the tooth is uncompromised
The pulp exposure permits direct placement of pulp
capping material onto vital pulp tissue
Haemostasis can be achieved
Adequate coronal seal can be maintained
Carious exposures in permanent
teeth with MATURE APEX
Desirable Outcome:
1
Normal response to electrical and thermal pulp
tests is maintained
2
Breakdown of periradicular tissues is prevented
3
Adverse clinical signs or symptoms are prevented
Carious exposures in permanent
teeth with MATURE APEX
Method
Pretreatment evaluation of the tooth with deep carious
lesion, potentially exposing dental pulp
Case discussion with supervisors, KIV initiation of Direct
Pulp Capping evaluation form upon confirmed pulp exposure
with supervisor’s approval
Patient communication regarding the potential for a pulp
exposure and its consequences
Local anaesthetic administration
Carious exposures in permanent
teeth with MATURE APEX
Rubber dam isolation
Disinfection of the field of operation using a cotton swab
soaked in 1% Sodium Hypochlorite / Milton’s solution prior to
commencement of caries excavation
Complete removal of caries with a slow speed round bur,
commencing from periphery towards the deepest site with
potential exposure
Change of bur to another sterile slow speed round bur at the
potential exposure site
Carious exposures in permanent
teeth with MATURE APEX
In the event of pulp exposure, disinfection of the exposure site
and simultaneous control of hemorrhage with the application of
cotton pellet soaked in 1% sodium hypochlorite / Milton’s solution
Dycal placement directly onto the vital pulp tissue at the
exposure site followed by a base of glass-ionomer cement, if the
final restoration will be an amalgam or composite
Placement of final restoration with Amalgam, Composite or GIC.
If a glass-ionomer final restoration is indicated, the cavity can be
restored with glass-ionomer cement directly over Dycal without
having to place a separate base layer of glass-ionomer cement
Carious exposures in permanent
teeth with MATURE APEX
The patient will have to be recalled at 1,3, 6 months and
thereafter bi-annually until the patient is deemed suitable
for discharge
The patient is considered suitable for discharge under the
following conditions:
Pulp capping has succeeded and all the treatment objectives
are achieved within 5 years
Pulp capping has failed and there are signs and symptoms and
the tooth will require either Root Canal Treatment or
extraction
Carious exposures in permanent
teeth with MATURE APEX
At each recall appointment, the evaluation
protocol enumerated in the Pulp Capping evaluation
form is to be strictly adhered to and this should
be countersigned by the supervisor
The Pulp Capping evaluation form is to be
submitted, upon graduation or discharge of the
patient from the recall program, through Nurse Ai
Chin [Clinic 2] or Nurse Pwa [Clinic 3] to the Dept
of Restorative Dentistry for analysis
Carious exposures in permanent
teeth with IMMATURE APICES
Indications for Indirect Pulp Capping or Direct Pulp Capping
with / without Partial Pulpotomy
Indirect or Direct Pulp Capping in permanent teeth with
immature apices is recommended so as to allow further crown /
root development, provided that:
1 The tooth has no observable periradicular pathosis
2 The patient/parents/guardians is/are informed that root
canal treatment will be necessary should Pulp Capping fail
Carious exposures in permanent
teeth with IMMATURE APICES
Desirable Outcomes
There is radiographic evidence of continued crown / root
development
Normal responsiveness to electrical and thermal pulp tests is
maintained
Breakdown of periradicular tissues is prevented
Adverse clinical signs or symptoms, including resorptive
defects are prevented
Carious exposures in permanent
teeth with IMMATURE APICES
Method
Pretreatment evaluation of the tooth with deep carious
lesions potentially exposing dental pulp
Case discussion with supervisor
Patient communication on the potential pulp exposure and
the recall program required
Local anaesthetic administration
Rubber dam isolation
Carious exposures in permanent
teeth with IMMATURE APICES
Disinfection of the field of operation using a cotton swab
soaked in 1% Sodium Hypochlorite / Milton’s solution
prior to commencement of caries excavation
Caries excavation with a slow speed round bur,
commencing from periphery towards the deepest site
with potential exposure
With supervisor’s approval, indirect pulp capping can be
considered if there is no history of spontaneous pain
Carious exposures in permanent
teeth with IMMATURE APICES
1st Visit
Bulk of caries is excavated leaving the ‘affected’ dentin
adjacent to the pulp
Disinfect the excavation site with cotton pellet wet with
1% sodium hypochlorite / Milton’s solution
Place Dycal directly onto the ‘affected’ dentin
Provide base of glass-ionomer cement, if the final
restoration will be an amalgam or composite
Carious exposures in permanent
teeth with IMMATURE APICES
Placement of final restoration with Amalgam,
Composite or GIC. If a glass-ionomer final
restoration is indicated, the cavity can be
restored with glass-ionomer cement directly
over Dycal without having to place a separate
base layer of glass-ionomer cement
Carious exposures in permanent
teeth with IMMATURE APICES
2nd Visit [6 months later] and thereafter
Clinical evaluation:
Remove restoration and residual caries
·
If there is no pulp exposure, restore with permanent
restoration
· If there is pulp exposure, consider Root Canal Treatment
if root development is achieved; if not, please refer to
and follow on with the next steps
Carious exposures in permanent
teeth with IMMATURE APICES
In the event of pulp exposure during caries excavation,
direct pulp capping is to be considered:
Disinfect the exposure site & hemorrhage control with
the application of cotton pellet soaked in 1% sodium
hypochlorite / Milton’s solution
Perform (Partial) pulpotomy 2mm or to the level of
hemostasis in case of uncontrolled hemorrhage upon
pressure application with cotton pellet
Pure Calcium Hydroxide paste placement directly onto the
vital pulp tissue at the exposure site followed by a
base.
Carious exposures in permanent
teeth with IMMATURE APICES
Immediate placement of final restoration
Composite or GIC over the base material
eg.
Amalgam,
The patient will have to be recalled at 1, 3, 6 months and
thereafter bi-annually until the patient is deemed suitable for
discharge
The patient is considered suitable for discharge under the
following conditions:
Pulp capping has succeeded and all the treatment objectives are
achieved within 5 years
Carious exposures in permanent
teeth with IMMATURE APICES
Pulp capping has failed and there are signs and symptoms
and the tooth will requirie either Root Canal Treatment
or extraction
At each recall appointment, the evaluation protocol
enumerated in the Pulp Capping evaluation form is to be
strictly adhered to and this should be countersigned by
the supervisor
The Pulp Capping evaluation form is to be submitted, upon
graduation or discharge of the patient from the recall
program, through Nurse Ai Chin [Clinic 2] or Nurse Pwa
[Clinic 3] to the Dept of Restorative Dentistry for
analysis
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Indications for Direct Pulp Capping
Direct Pulp Capping of mechanical exposures in permanent
teeth has good prognosis if all the following conditions are
met:
The tooth has no history of pain
The tooth is responsive to electrical and thermal pulp testers
with no observable radiographic periapical pathoses
The tooth must be caries free
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Rubber dam isolation of the tooth is uncompromised
The pulp exposure permits direct placement of pulp
capping material onto vital pulp tissue
Bleeding from the exposure can be controlled
Adequate coronal seal can be maintained
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Desired Outcomes
Normal responsiveness to electrical and thermal pulp
tests is maintained
Breakdown of periradicular supporting tissue is
prevented
Adverse clinical signs or symptoms are prevented
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Method:
Pretreatment evaluation including whether the tooth
concerned require complex restoration eg crown, bridge,
abutment and /or whether the pulp capping interferes with
a multidisciplinary treatment plan.
Patient communication regarding the pulp capping recall
program required and the potential root canal therapy or
extraction should pulp capping fail.
LA administration
Rubber dam isolation
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Disinfection the field of operation using a cotton swab soaked
in 1% Sodium Hypochlorite / Milton’s solution prior to
commencement of caries excavation
Operative procedures
In the event of pulp exposure, disinfection of the exposure
site and simultaneous control of hemorrhage with the
application of cotton pellet soaked in 1% sodium hypochlorite /
Milton’s solution
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Dycal placement directly onto the vital pulp tissue at the
exposure site followed by a base of glass-ionomer cement, if
the final restoration will be an amalgam or composite.
Placement of final restoration with Amalgam, Composite or GIC.
If a glass-ionomer final restoration is indicated, the cavity can
be restored with glass-ionomer cement directly over Dycal
without having to place a separate base layer of glass-ionomer
cement
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
Recall appointments are to be given at 1,3, 6 months and
thereafter bi-annually until the patient is deemed
suitable for discharge
The patient is considered suitable for discharge under
the following conditions:
Pulp capping has succeeded and all the treatment
objectives are achieved within 5 years
Pulp capping has failed and there are signs and symptoms
and the tooth will require either Root Canal Treatment or
extraction
Mechanical exposures in permanent teeth
(Mature and Immature Apices)
At each recall appointment, the evaluation protocol
enumerated in the Pulp Capping evaluation form is to be
strictly adhered to and this should be countersigned by
the supervisor
The Pulp Capping evaluation form is to be submitted, upon
graduation or discharge of the patient from the recall
program, through Nurse Ai Chin [Clinic 2] or Nurse Pwa
[Clinic 3] to the Dept of Restorative Dentistry for
analysis
Summary of Ideal Treatment
Options for Pulpal Exposures
Carious Exposure
Tooth with
Mature apex
Tooth with
Immature apex
Mechanical
Exposure
RCT
DPC
DPC/IDPC
DPC
FUNCTIONS
OF
LINERS AND BASES
LINERS
FUNCTIONS
1 Encourage dentinal bridge formation
2 Secondary dentine formation
3 Seals dentine
4 Prevents galvanism
LINERS
1 Calcium Hydroxide
2 Glass Ionomer Cement
LINERS AND BASES
Calcium Hydroxide
 anti-bacterial
 remineralization of softened dentine (IDPC)
 stimulate pulp to form hard tissue barrier
over exposed site due to the high pH of the
material (DPC)
 not strong enough to withstand condensing
forces, therefore, a base over it is necessary.
LINERS AND BASES
Corticosteroid/ anti-bacterial prep
Initially advocated as pulp capping agents
to treat painful pulps if signs and
symptoms of irreversible pulpitis is
present, the steroid component of these
agents will decrease the inflammation.
LINERS AND BASES
Paterson: ”…use of corticosteroid
preparation as pulp capping agents cannot
be supported.”
BASES
FUNCTIONS
1 Thermal insulation (metallic restorations)
2 Seals liner in
3 Seals dentinal tubules from bacteria,
bacterial toxins and chemicals.
4 Replaces lost dentine (CRs)
5 Decreases polymerization shrinkage of CRs
BASES
1 Glass Ionomer Cements
2 Zinc Phosphate Cements
3 Zinc Polycarboxylate Cements
4 Zinc Oxide Eugenol
5 Reinforced Zinc Oxide Eugenol
COMPOSITE
RESTORATIONS
Very deep - > 2 mm
into dentine
Ca(OH)2, GIC
lining, etch, adhesive,
CR
COMPOSITE & LC GLASS
IONOMER RESTORATIONS
For cavities which are deep and wide,
use incremental techniques for CR &
LC GIC placement.
AMALGAM RESTORATIONS
> 2 mm into dentine - Ca(OH)2, GIC lining,
AR
INLAYS
Line deepest part of cavity
and undercuts with Ca(OH)2
and/or GIC lining.
TREATMENT STRATEGIES FOR
CARIES
Exam findings
Normal
No lesion
Nonresto.treat
None
Rest. Treat.
None
Follow-up
1 yr clin.
Exam.
TREATMENT STRATEGIES FOR
CARIES
Exam findings
Arrested
caries
Nonresto.treat
None
Rest. Treat.
Treatment is
elective
Aestheticsrestore
defects
Follow-up
1 yr clinical
exam.
TREATMENT STRATEGIES FOR
CARIES
Exam findings
Incipient
enamel
lesions only
Nonresto.treat
Rest. Treat.
Limit substrate Seal pit & fiss
as indicated
Modify
microflora
Plaque disruption
Modify tooth
surface
Stim. saliva
flow
Follow-up
3 mth R/V.
Check Oral
flora, MS
count,
progression
of white
spot,
presence of
cavitations
TREATMENT STRATEGIES FOR
CARIES
Exam findings
Cavitated
lesions
Nonresto.treat
Limit substrate
Modify
microflora
Plaque disruption
Modify tooth
surface
Stim. saliva
flow
Rest. Treat.
Restore tooth
surfaces
Follow-up
3 mth R/V.
Check Oral
flora, MS
count,
Progression of
white spot,
Presence of
new cavitations,
Pulpal response
Patient education and motivation in the
prevention of dental caries must be
stressed.
Preventive and control of dental caries
must be the foremost objective of
operative dentistry.
Research efforts in understanding
carious process, maximizing the benefits
of fluoride use, and developing anticaries
vaccines should be continued.
Finally, the clinical
treatment of
cavitated, carious
teeth must be
accomplished
expeditiously and
judiciously.