Surgical and Non-surgical management of dental caries

Question 1

What are dental caries?

Answer 1

A disease where an ecological shift in the dental biofilm environment driven by frequent
access to fermentable dietary carbohydrates,
leads to a move from a balanced population of
microorganisms of low cariogenicity to a
microbiological population of high cariogenicity
(more aciduric and acidogenic) and to an
increased production of organic acids. This
promotes dental hard tissue net mineral loss
and results in a carious lesion.

Question 2

How is a carious lesion different to dental caries?

Answer 2

Lesion is the consequence and manifestation o=of the disease dental caries

Question 3

What is the aim of surgical caries management?

Answer 3

To retain the tooth and the health of its pulp for as long as possible

Question 4

What are the guiding principles of surgical caries management?

Answer 4

preservation of dental tissues
• maintenance of pulpal health
• avoidance of pulp exposure
• avoidance of dental anxiety (in children and adults alike)
• and provision of sound cavity margins to achieve a peripheral seal

Question 5

What is the difference between infected dentine and affected dentine?

Answer 5

Bacteria in infected dentine only
• Bacterial products extend into affected
dentine
• Bacterial products advance further into
dentine, causing odontoblastic
processes to recede, causing “dead
tracts” for bacteria to advance into
• Gradual breakdown of inorganic and
organic components of dentine lead to
changing hardness and colour of dentine

Question 6

How are soft, eathery, firm, and hard dentine different to each other?

Answer 6

Soft: deforms when a hard instrument is pressed into it and can easily be scopped up with little force

Leathery: Does not deformwhen

Question 7

What are the types of dentine removal?

Answer 7

Non-selective removal to hard dentine (Aim is to remove all soft-carious tissue to reach hard dentine resembling healthy dentine in all parts of the cavity including pulpally.)

Selective removal to firm dentine (excavate until the leathery and firm dentine. All unsupported enamel must be caries free. Need good peripheral seal, if restoration leaks this risks bacterial entry)

Selecting removal to soft dentine (Leaving soft carious dentine in the pulpal aspect of the cavity, DEJ is kept clean, and the peripheral enamel and dentine should be hard at the end of excavation to allow the best adhesive to be used)

Stepwise caries removal (2 stages; stage 1 is selective removal to soft dentine placing temporary filling and step 2 is selective restoration to firm dentine and placement of final restoration this is to allow dentine to repair with tertiary dentine)

No caries removal

Question 8

What is the effect of performing a restoration over active caries?

Answer 8

Sealing the bacteria does not kill the bacteria but it deprives the bacteria of nutrients so the lesion will not progress.

Question 9

What does knowing the fact that carious lesions dont progress if restored without leakage help with?

Answer 9

No need to replace a restoration if there is a radiolucency underneath the caries.

Question 10

What is the most important limitation with stepwise removal?

Answer 10

More than 1/3rd of patients were found not to attend the second appointment

Question 11

What is the atraumatic restorative technique?

Answer 11

Originally described for use in community settings.

This is a very specific technique (Probably most misused technique)

Question 12

How is ART performed?

Answer 12

Isolate with cotton wool
2. Clean the tooth surface with a wet
cotton pellet
3. Widen the entrance with a hand
instrument, e.g. hatchet
4. Remove caries with hand excavator
5. Provide pulpal protection if necessary
(setting calcium hydroxide liner)
6. Clean the occlusal surface with probe
and wet cotton pellet
7. Condition the cavity and occlusal
surface
8. Mix GIC
9. Insert GIC into cavity and slightly
overfill, also place over pits and fissures
10.Press Vaseline-coated, gloved finger
onto occlusal surface
11.Check the occlusion with articulating
paper
12.Remove excess material with a carver
13.Recheck and adjust the occlusion until
comfortable
14.Cover filling/sealant with Vaseline or
varnish
15.Instruct patient not to eat for at least
one hour

Question 13

Where is ART usually performed?

Answer 13

In a community setting

Question 14

When should ART be used?

Answer 14

Very technique sensitive

Involves sealing all remaining fissures

Can be considered for use in occlusal cavities

Not recommended for use in occluso-proximal lesions

Not recommended for use in multi-surface lesions

Question 15

What is chemomechanical caries removal?

Answer 15

Use of sodium-hypochlorite based gels or enzyme-based gels to soften the infected dentine so that it can be removed with a special hand instrument specifically designed to only remove the dentine.

Question 16

What are the limitations to using chemomechanical caries removal?

Answer 16

local anaesthesia is rarely required

NaOCl-based gels may affect microtensile bond strength (No difference seen with papacarie)

Generally considered to be effective and conservative

Regardless of chosen , operative time is significantly longer

Local analgesia is rarely required
• NaOCl-based gels may affect microtensile bond strength (no difference
seen with Papacarie)
• Generally considered to be effective and conservative
• Regardless of chosen agent, operative time is significantly longer than
other techniques
• CMCR not popular for this reason

Question 17

What lasers are used for laser caries removal?

Answer 17

2 types used:

Er:YAG (2.94 micrometer wavelength)

Er,Cr:YSGG

Question 18

What are the advantages to using a laser for caries removal?

Answer 18

Leaves enamel with etched appearance

Does not cause cracking or surface charring as seen with high

Question 19

What is air abrasion?

Answer 19

Emit stream of aluminium oxide particles under high pressure

Question 20

What is air abrasion?

Answer 20

Emit stream of aluminium oxide particles under high pressure

Question 21

What are the disadvantages to using air abrasion?

Answer 21

More effective on hard dentine compared to soft dentine.

Provides no tactile feedback

Bio-active glass compound has been tested in vitro and found to be more effective than silica.

Question 22

What are polymer burs used for?

Answer 22

Designed to facilitate to removal of carious dentine while limiting removal of healthy dentine.

Made of polymer compound with hardness between that of infected dentine and healthy dentine.

Question 23

What are caries detector dyes?

Answer 23

Introduced to differentiate between different layers of carious dentine, as
described by original authors: (i) softening, (ii) discolouration, (iii) bacterial
• For practical purposes, dye intended to differentiate between infected and
affected dentine
• Originally red Fuchsian dye used (discontinued due to carcinogenicity) in
propylene glycol carrier
• propylene glycol thought to only penetrate loosened collagen fibres with
broken intermolecular crosslinks
• 1.0% red acid dye, brilliant blue dye, polypropylene glycol carrier all
currently available
• Claimed to reduce the need for local analgesia

Question 24

What are the disadvantages to using red acid dye?

Answer 24

1.0% red acid dye appears to interact with lactic acid
produced by cariogenic bacteria, leading to staining of
only infected dentine

Further research showed that red acid dye also interacts in different ways as it tends to over-stain around the DEJ and close to the pulp due to differences in dentine mineral content (could lead to excess caries removal in these areas
(and potentially a pulp exposure))

Use relies on subjective determination of colour:

No objective measure leads to differences between practitioners and variations depending on lighting conditions

Dentine colour after caries detector dye and bacterial sampling reveals a poor correlation between colour and bacterial count

Manufacturers recommend removal until “pale pink” but this remains subjective

Some concerns of effect of dyes on dentine bond strength in vitro

Question 25

What is Fluorescence-Aided Caries Excavation?

Answer 25

FACE Uses fluorescent light source and camera with special computer software to analyse camera feed At certain wavelengths, fluorescence of dentine affected by dentine hardness Has been shown to leave minimal bacteria but remain more conservative than some other techniques BEWARE: do not confuse with quantitative light fluorescence used for caries detection (e.g. DIAGNOdent) - this has proven unreliable for determining extent of caries removal

Question 26

What is the Hall technique?

Answer 26

Involves placement of a stainless steel crown over a primary molar tooth with an active carious lesion without any local analgesia, caries removal or tooth preparation Has been described as the biggest discovery in paediatric dentistry in the last ten years, set to revolutionise children’s dentistry

Question 27

What are stainless steel crowns?

Answer 27

Preformed metal crowns. Come in a range of sized Pre-contoured Traditional preparation involves occlusal and proximal reductions under LA and rubber dam isolation

Question 28

How does the hall technique reduce the progression of caries?

Answer 28

Stainless steel crowns seal the carious lesion isolating the bacteria from their nutrients preventing them from growing and preventing the carious lesion from progressing. 92% success rate seen at 4 - 5 years.

Question 29

When should fissure sealants be used?

Answer 29

Traditionally it is used for prevention.

Question 30

How effective are fissure sealants at preventing progression of fissure sealants?

Answer 30

As long as the sealant remains intact the lesion will not progress even in dentine.

Question 31

What is resin inflitration and resin sealing used for?

Answer 31

Management of proximal caries in enamel: Aim to avoid significant loss of healthy tooth structure involved with traditional Class 2 tooth preparation through the marginal ridge

Question 32

What is the difference between infilltration and sealing in resing based restoration?

Answer 32

Infiltration: HCl etches and dehydrates enamel to open porous structure of carious enamel, infiltrates resin into the porous enamel Sealing: standard etch and resin bonding system used to cover lesion

Question 33

What are the indications and contra-indications for using resin infiltration and resin sealing?

Answer 33

Effective for proximal lesions in enamel: when placed under ideal conditions in permanent teeth Less effective for lesions extending to the DEJ Less effective in primary teeth Infiltration and sealing seem equally effective

Question 34

What is non-restorative cavity treatment and what does it aim to do?

Answer 34

AKA non-operative control of cavities Aim: use a high-speed handpiece to open a cavitated carious lesion to make it cleansable and allow for remineralisation of carious dentine and arrest of the lesion, thus preventing pain and discomfort or other sequelae of carious lesions. Intended for use in primary teeth Accompanied by special OHI to aid brushing perpendicular to the dental arch Usually accompanied by regular fluoride varnish applications

Question 35

How effective is non-restorative cavity treatment?

Answer 35

Often results in dentine sensitivity, lesion progression, food packing or eventual pain and infection May make restoration later more difficult due to removal of sound tooth structure Approx. 50% failure after 2 years

Question 36

What is sodium fluoride varnish and how is it used?

Answer 36

22,600ppm (5%) Different concentration, indications and uses to other fluoride modalities Requires repeated applications Multiple mechanisms of action involving remineralisation and interruption of bacterial metabolism Can be flossed into contacts for proximal lesions with good efficacy

Question 37

How does silver diamine fluoride varnish work?

Answer 37

SDF Two-fold mechanism of action: Fluoride uptake to form fluoroapatite crystals Silver forms silver phosphate, which interferes with biofilm formation and leads to cell death More useful in smooth surface lesions and anterior teeth Leads to severe black staining Use in caries management is off license use. (no approval for use in australia; only usable for dentine hypersensitivity)