Surgical and Non-Surgical Management of Carious Lesions

Question 1

What are dental caries?

Answer 1

A disease where an ecologic shift within 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

What is a carious lesion?

Answer 2

The consequence and manifestation of the disease dental caries

Question 3

What should caries management be used to describe?

Answer 3

It should be limited to situations involving the control of the disease through preventive and non-invasive means. It describes actions taken at a patient level such as plaque control, fluoride application, dietary interventions, and behaviour change techniques. It aims to control the disease and prevent lesion formation or advancement.

Question 4

What does carious lesion management describe?

Answer 4

Any procedure that involves doing something to an established, non-cleansable carious lesion to stop its progression. This might involve removing non, some, or all of the carious tissues from a non-cleansable lesion.

Question 5

What is the aim of surgical caries management?

Answer 5

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

Question 6

What are the guiding principles of surgical caries management?

Answer 6

Preservation of dental tissues

Maintenance of pulpal health

Avoidance of pulp exposure

Avoidance of dental anxiety

Provision of sound cavity margins to achieve a peripheral seal

Question 7

How are infected and affected dentine different?

Answer 7

Bacteria are only present in infected dentine whereas 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 8

What are the different types of dentine in terms of disease progression?

Answer 8

Soft

Leathery

Firm

Hard

Question 9

What does soft dentine feel like?

Answer 9

Deforms when a hard instrument is pressed into it and can easily be scooped up with little force required

Question 10

What does leathery dentine feel like?

Answer 10

Does not deform when an instrument is pressed into it but still easily lifted without much force required, may be difficult to differentiate between leathery and firm dentine.

Question 11

What does firm dentine feel like?

Answer 11

Physically resistant to hand excavation some pressure needs to be exerted through an instrument to lift it

Question 12

What does Hard dentine feel like?

Answer 12

A pushing force needs to be used with a hard instrument to engage the dentine, only a sharp cutting edge or a bur will lift it. A scratchy sound or “cri dentinaire” can be heard when a straight probe is taken across the surface

Question 13

What are the methods of caries removal?

Answer 13

Non-selective removal to hard dentine

Selective removal to firm dentine

Selective removal to soft dentine

Stepwise caries removal

No caries removal

Question 14

How is non-selective caries removal done?

Answer 14

Aim is to remove soft carious tissue to reach hard dentine resembling healthy dentine in all parts of the cavity, including pulpally.

Formerly known as complete caries removal

Question 15

Where did non-selective removal of caries arise?

Answer 15

In GV Black’s manual of operative dentistry.

It is the traditional approach to restorative dentistry.

Debate over evidence for leaving caries behind.

Question 16

What is the issue of non-selective caries removal?

Answer 16

It is least conservative and has a higher risk of pulpal exposure.

Carious pulpal exposure significantly increases treatment burden.

Question 17

What is the aim of selective caries removal?

Answer 17

To leather/firm dentine: The aim is to excavate to leathery or firm dentine in the pulpal aspect of the cavity.

To soft dentine: Involves leaving soft carious dentine in the pulpal aspect of the cavity, but peripheral enamel and dentine should be hard at the end of excavation to allow the best adhesive seal.

Question 18

Why does selective caries removal work?

Answer 18

Bacteria are sealed under the restoration and they will start to die over time while also being separated from nutrient source

Question 19

What is stepwise caries removal?

Answer 19

This is a two-stage procedure where Stage 1 is selective removal to soft
dentine (and placement of a provisional restoration considered suitable to
last up to 12 months) and Stage 2 is selective removal to firm dentine 6-12
months later, with placement of a definitive restoration. It has also
previously been known as 2-step excavation

This is to allow time for pulpal defence against the carious insult.

Question 20

What is atraumatic restorative technique?

Answer 20

A technique that uses ART restorations and ART sealants that was originally described for use in community settings.

Question 21

How is the atraumatic restorative technique conducted?

Answer 21

1. 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 22

What are the limitations and contraindications of atraumatic restorative technique?

Answer 22

Seems easy but is very technique sensitive

ART also involves sealing of all remaining fissures.

Not recommended for use in occluso-proximal lesions

Not recommended for use in multi-surface lesions

Question 23

What is chemomechanical caries removal?

Answer 23

Works by softening only infected dentine so that it can be removed by hand instruments without having an effect on enamel and affected dentine.

By removing only inected dentine it allows for most conservative cavity preparation.

Question 24

What are the types of chemomechanical caries removal?

Answer 24

CMCR

Sodium hypochlorite-based

Enzyme-based

Question 25

How is sodium hypochlorite used for caries removal?

Answer 25

0.475% NaOCl and amino acids (L-glutamic acid, L-leucin, and L-lysine) come with a special hand instrument designed to facilitate removal of softened dentine only(also burs available)

Question 26

What ingredients are used for enzyme-based chemomechanical caries removal?

Answer 26

Papain extract Chloramine Toluidine blue Salts, preservative, thickener, stabilizers, deionized water

Question 27

How does enzyme-based chemomechanical caries removal work?

Answer 27

It breaks down collagen in caries-infected dentine only Also has antimicrobial effect Technique is the same as NaOCl-based gels

Question 28

Why is CMCR not popular if it is so effective and conservative?

Answer 28

Operative time is significantly longer than other techniques.

Question 29

What is used for laser caries removal?

Answer 29

Er:YAG laser with wavelength 2.94µm • Er,Cr:YSGG (Erbium-chromium:yttriumselenium-gallium-garnet) wavelength 2.78µm Water is used with the laser

Question 30

What are the advantages to laser caries removal?

Answer 30

Amount of laser energy can be modified based on what we want to remove Leaves enamel surface with etched appearance Does not cause cracking or surface charring as seen with high speed burs Leaves rough dentine surface with minimal smear layer Some laser manufacturers report analgesic effect claim that LA is often not needed (not confirmed) Restoration survival is reported to be similar to use of burs (no long-term follow up studies in both primary and permanent teeth)

Question 31

What are the disadvantages of laser caries removal?

Answer 31

Takes longer than use of a bur Lacks tactile feedback requiring use of a separate instrument or technique to determine the extent of caries removal Can be very noisy

Question 32

What is air abrasion? What are the features of it?

Answer 32

A stream of aluminum oxide is emitted under high pressure. Particle size usually 27.5µm Pressure 60-120psi

Question 33

What are the limitations of air abrasion?

Answer 33

Some doubt over health effects for clinicians and patients Aluminium oxide chosen over glass-based materials due to increased hardness and risk of silicosis Often used with water jet to help contain particle stream

Question 34

What does air abrasion do to teeth?

Answer 34

Due to the shape of the stream and nature of abrasive particles, air abrasion leaves rounded cavosurface margins and internal line angles Also leaves halo of abraded healthy enamel surrounding cavity outline Leaves roughened surface Can lead to occlusion of dentinal tubules

Question 35

What is air abrasion more effective for?

Answer 35

Abrasive power is more effective on hard surfaces than soft surfaces meaning more likely to remove healthy dentine than soft carious dentine and therefore is not suitable for selective caries removal techniques Provides no tactile feedback Bio-active glass compound has been tested in vitro and found to be more selective for carious enamel than alumina particles

Question 36

What are polymer burs useful for?

Answer 36

Designed to facilitate removal of carious dentine while limiting removal of healthy dentine Made of polymer compound with hardness between that of infected dentine and that of healthy dentine Single use as the bur wears away and loses cutting efficiency as it approaches the affected dentine.

Question 37

What are the advantages to using polymer burs?

Answer 37

Preserves the affected dentine Operating time may be longer but it is definitely more conservative

Question 38

How are polymer burs recommended to be used?

Answer 38

Recommended for use in deepest part of cavity rather than the entire cavity.

Question 39

What are the advantages of using sonics and ultrasonics for caries removal?

Answer 39

Ample visibility during cavity prep Easy removal of caries on hard-to reach places due to specific angled tips Lower chance of iatrogenic damage to neighbouring teeth Low noise level Better tolerated by patients

Question 40

What are the disadvantages to using sonics and ultrasonics for caries removal?

Answer 40

They are slower High cost of tips Little evidence to support use

Question 41

What are caries detector dyes used for?

Answer 41

Introduced to differentiate between different layers of carious dentine. Claimed to reduce the need for Local Analgesia

Question 42

What is fluorescence-aided caries excavation (FACE) used for?

Answer 42

Uses fluorescent light source and camera with special computer software to analyse camera feed.

Question 43

What is the hall technique?

Answer 43

Using stainless steel crown over a primary molar tooth with an active carious lesion without any local analgesia, caries removal, or tooth preparation. The idea is to seal the caries with the crown preventing them from progressing.

Question 44

What are the limitations for the hall technique?

Answer 44

Strict guidelines in place for indications/contraindications and technique. Pre-operative radiograph is mandatory Not intended as a replacement for SSC

Question 45

What is resin infiltration and resin sealing used for?

Answer 45

Management of proximal caries in enamel Less effective for lesions extending to the DEJ Less effective in primary teeth

Question 46

What is resin infiltration and sealing?

Answer 46

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 47

What is the aim of resin infiltration and sealing?

Answer 47

Aim to avoid significant loss of healthy tooth structure involved with traditional class 2 tooth preparation through the marginal ridge

Question 48

Which is more effective resin infiltration or sealing?

Answer 48

Both seem equally effective

Question 49

What is the aim of non-restorative cavity treatment?

Answer 49

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

Question 50

Where should non-restorative cavity treatment be used?

Answer 50

Mainly primary teeth

Question 51

How effective is non-restorative cavity treatment?

Answer 51

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 52

How is sodium fluoride varnish used?

Answer 52

22,600ppm (5%) Different concentration, indications and uses to other fluoride modalities Requires repeated applications Can be flossed into contacts for proximal lesions with good efficac

Question 53

How does sodium fluoride varnish work?

Answer 53

Multiple mechanisms of action involving remineralisation and interruption of bacterial metabolism

Question 54

How does silver diamine fluoride work?

Answer 54

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

Question 55

What are the limitations to using silver diamine fluoride?

Answer 55

More useful in smooth surface lesions and anterior teeth Leads to severe black staining Use in caries management is off licence use