management of deep caries .

1. MANAGEMENT OF DEEP
CARIES
DONE BY.,
B. GLADSON SELVAKUMAR
CRI.,
CSI CDSR

2. Dental caries is an infectious micro-biologic
disease of the teeth that results in localized
dissolution & destruction of the calcified
tissues. requiring restorative intervention &
even extraction..
Definition :

3. Etiology
food bacteri
a
tooth

4. Dentin Caries
Affected & Infected Dentin:
In operative procedures, it is convenient to term
dentin as either..
Affected dentin: is softened, demineralized dentin
that is not yet invaded by bacteria  inner carious
dentin ( does not requires removal ). OR
Infected dentin:  outer carious dentin & Bacterial
plaque is both softened & contaminated with
bacteria ( requires removal ).

6. Caries Detecting Die
 Caries detection solutions have been
used by clinicians to distinguish between
affected and infected dentin.
 These are protein dyes that stain
denatured callagen of carious dentine

7. Response to dental caries
In the earliest stages of exposure to
microorganisms, there is an effort to seal the
tubules. This is accomplished by increased
calcification. The result is a visible change
known as transparent dentin or dentinal
sclerosis .

8. In addition, pulpal odontoblasts, stimulated by
the advancing carious lesion, will rapidly deposit
dentin. The dentinal tubules in this new dentin
are irregular, making them less permeable this
type of dentin is known as : irregular dentin ,
reparative dentin , secondary dentin or
tertiary dentin . Dentinal sclerosis and
reparative dentin may be successful deterrents
if the carious lesion progresses slowly.

9. The objective is to focus on the:
 Diagnosis
 ttt modalities
Management of deep caries

10. Treatment Modalities
The results of diagnosis :
No exposure Pulp Exposure
Indirect pulp
capping
Non-vital
(carious)
exposure
 Recent advances of caries removal :
carisolv
Smartprep instrument
Vital
(traumatic)
exposure
Direct pulp capping
Conventional
cavity
preparation
and restoration RCT

11. DENTIN THICKNESS
 We must remember that no material
can provide better protection for the pulp
than dentin.
 The remaining dentin thickness, from
the depth of cavity preparation to the
pulp, is the most important factor in
protecting the pulp from insult.

12. Remaining dentin
thickness
 Shallow cavity depth
– Preparation 0.5 mm into dentin (ideal
depth)
 Moderate cavity depth
– Remaining dentin over pulp of at least
1-2 mm
 Deep cavity depth
– Depth of preparation with less than 1.0
mm of remaining dentin over pulp

13. Remaining dentin
thickness
o The studies have shown that 0.5 mm
thickness of dentin reduces the effect of
toxic substances on the pulp by 75%,
1.0mm thickness of dentin reduces the
effect of toxins by 90%,little if any pulpal
reaction occurs when there is a
remaining dentinal thickness of 2mm or
more
 It helps us to make a decision
concerning the use of bases and liners.

14. Reactionary dentin deposition
 Reactionary dentin deposition was observed
beneath cavities with a RDT above 0.5 mm as well
as beneath cavities with a RDT below 0.25 mm.
 However, maximal reactionary dentin appeared to
be beneath cavities with an RDT between 0.5 to
0.25 mm.
 The area of reactionary repair was also influenced
by the choice of restoration material
(from greatest to least: calcium hydroxide, composite,
resin-modified glass ionomer [RMGI] cement, and
zinc oxide-eugenol).
o Odontoblast numbers were maintained beneath
cavities with a RDT above 0.25 mm.

15. Decision making in the use
of sealers, liners and/or
bases
 Remaining dentin thickness in tooth
preparation.
 Thermal conductivity of restorative
material
 Presence or absence of pulpal symptoms-
pain to stimuli
– Thermal
– Sweets (osmotic
changes)
– Duration of symptom
– Spontaneous pain

16. Decision making in the use
of sealers, liners and/or
bases
 Cavity sealers: protective coating on the cavity walls
creating a barrier to leakage – Resin bonding
systems (i.e.OptiBond Solo)
 Cavity liners: cement or resin coating of minimal
thickness (less than 0.5 mm) placed as a barrier to
bacteria or to provide a therapeutic effect (pulpal
sedative or antimicrobial effect). Applied to cavity
walls adjacent to pulp ( calcium hydroxide
liners:Life,Dycal;glass-ionomer liners:VitreBond;
Jonosit,)
 Cavity bases: placed to replace missing dentin,
placed in thicknesses of 0.5-1 mm; these are :glass-
ionomers:
VitreBond, Fuji IILC, modified glass-ionomers:
Jonosit; zinc-phosphate cements, carboxylate
cements

17. Calcium hydroxide
 Calcium hydroxide has been used as a lining material
since the 1920s.
 Because of the basic pH of about 11, calcium hydroxide
is both antibacterial and can neutralize the acidic
bacterial byproducts.
 The high pH creates an environment conducive to the
formation of reparative dentin.
 In addition, calcium hydroxide has the capacity to
mobilize growth factors from the dentin matrix, causing
the formation of new dentin.
 Calcium hydroxide is an ideal lining material for the
very deep cavity preparation and also continues to
represent an option for both the indirect and direct pulp
capping.

18. Merits of calcium hydroxide
cement over adhesive cements
 Adhesive resins can be acidic and
cause pulpal irritation.
 Many dentin bonding agents and resin-
reinforced glass ionomers are actually
detrimental to the pulpal tissues.
 In contrast, calcium hydroxide has been
shown to provide a significantly
improved potential for pulpal repair
compared to adhesive resins

19. Demerits of calcium hydroxide
 Unfortunately, the self-setting calcium hydroxide
liners are highly soluble and subject to dissolution
over time.
 Traditional calcium hydroxide liners are easily lost
during acid etching.
 Dentin bonding agents that contain water, acetone,
or alcohol can also detrimentally affect the properties
of calcium hydroxide.
 A hermetic seal of the cavity may stabilize the lesion
and arrest caries progression.
 Therefore, when a restoration of composite resin is
planned, glass ionomer cement should line the
cavity preparation, sealing over the calcium
hydroxide material, if used.

20. Resin modified GIC
 Restorative materials that exhibit antimicrobial benefits are
useful in minimal intervention and other types of dentistry.
 Some studies show that RMGIs were about equal to
conventional calcium hydroxide liners.
 Remaining softened, demineralized dentin covered by glass
ionomer becomes remineralized, presumably under the
influence of the fluoride release and the presence of calcium
and phosphate ions from the cement.
 This phenomenon is also referred to as the “healing of affected
dentin.”
 However, in other studies, RMGIs were found to cause the
greatest reduction in odontoblast numbers.
 It is frequently recommend that a thin liner of calcium hydroxide
be applied to the cavity floor of deep preparations before RMGI
is placed.
 This appears to provide improved pulpal protection from injury
and bacterial microleakage.

21. Mineral trioxide aggregate (MTA
 In recent years, mineral trioxide aggregate (MTA) preparations
have been introduced (ProRoot MTA [DENTSPLY Tulsa Dental
Specialties]).
 These silicate cements are antibacterial, biocompatible, have a
high pH, and are able to aid in the release of bioactive dentin
matrix proteins.
 MTA is a powder consisting of fine hydrophilic particles of
tricalcium silicate, tricalcium aluminate, tricalcium oxide, and
silicate oxide.
 It also contains small amounts of other mineral oxides, which
modify its chemical and physical properties.
 Hydration of the powder results in formation of colloidal gel with
a pH value equal to 12.5 (similar to calcium hydroxide) that
solidifies to form a strong impermeable hard solid barrier in
approximately 3 to 4 hours.
 It is hypothesized that the tricalcium oxide reacts with tissue
fluids to form calcium hydroxide.

22. Merits and demerits of MTA
 The material has a low solubility and a radiopacity slightly
greater than that of dentin.
 Because it has low compressive strength, it should not be
placed in functional areas.
 Another significant disadvantage for the restorative dentist is
that the setting times may take several hours. As a result, 2-
step procedures are frequently necessary, requiring interim
restorations.
 As previously discussed, recent evidence indicates that an
indirect pulp cap should be performed in a single treatment
appointment.
 Any immediate restoration will require coverage with a layer
of RMGI cement.
 MTA is an excellent material for direct vital pulp exposures
and numerous endodontic applications.
 The material has good long-term sealing capabilities, and
some studies show greater success than conventional
calcium hydroxide.

23. Biodentine
 Biodentine is a relatively more user-friendly material for the
restorative dentist as compared to traditional MTA preparations.
 Biodentine is an active biosilicate material useful in direct and
indirect pulp capping, and it also has endodontic applications.
 In addition, it is different from the usual MTA formulations. The
manufacturing process of the active biosilicate technology
eliminates the metal impurities.
 The setting reaction is a hydration of tricalcium silicate, which
produces a calcium-silicate gel and calcium hydroxide.
 In contact with phosphate ions, it creates precipitates that
resemble hydroxyapatite.
 “An evaluation of the dentin-Biodentine interface demonstrated
an increase in the carbonate content of interfacial dentin, which
suggested intertubular diffusion and mineral tags of Biodentine
hydration products creating a hybrid zone.”
 Biodentine resists microleakage similar to RMGI cements21
and also has an antibacterial effect.

24.  Biodentine reaches a final set in about 10 to 12
minutes.
 This is much faster than the time required for
MTA and also demonstrates higher compressive
strength.
 Therefore, it can serve as an excellent interim
restoration.
 As of yet, the manufacturer recommends the
material be used in a 2-step procedure.
 At a subsequent appointment, the clinician cuts
the ideal cavity preparation, leaving the
Biodentine as a liner or a dentin substitute base
under the definitive restorative material

25. TheraCal LC
 TheraCal LC, another recently introduced
material, is in simplistic chemical terms, a
material that offers the pulpal/dentin benefits
of both calcium hydroxide and RMGI in one
product.
 The material demonstrates strong physical
properties with low water solubility and can be
light-cured up to a thickness of 1.0 mm.
 TheraCal LC is FDA approved as an apatite
stimulating liner with the ability to induce
apatite crystal formation, similar to
commercially available self-curing MTA
products.

26.  Dentinal fluid absorbed by TheraCal LC results in a
sustained release of calcium and hydroxide ions.
 Calcium is necessary for rapid apatite stimulation, and
hydroxide ions are required for providing an “alkalinizing
effect” for wound healing propagation.
 TheraCal LC is intended for use as an internally placed
pulpal protectant liner over both occlusal and axial dentin.
 When performing a direct pulp cap, use of a rubber dam to
reduce bacterial contamination, apex development, and
control of pulpal hemorrhage are among the essential
factors for success.
 This material will appeal to the clinician who wants the
ease of placement of conventional calcium hydroxide liners
along with the biological benefits of the newer calcium
silicates.
 TheraCal LC allows for the one-step indirect pulp cap.

27. Indirect Pulp Capping
When caries is thought to extend close to,
or into the pulp, excavation of the pulpal
caries can be stopped at soft affected but not
infected dentine (affected dentine could be
remineralised if the acid production was
halted). Medication is then applied over the
pulpal dentine prior to placement of the
definitive restoration.

28. Medication is left for 6 – 8 weeks .
During this waiting period :
 The carious process is arrested
 Soft caries hardened
 A protective layer of reparative dentine is laid
down

29. However the difficulty with this tecnique is
knowing:
 how rapid the carious process has been
 how much tertiary dentine has been
formed
 knowing exactly when to stop excavating to
avoid pulp exposure.

30. Materials used for indirect pulp capping :
 Calcium Hydroxide
Although CaOH is the most commonly used it
has been argued that its effect occurs only in
case of its direct contact with pulp tissues .
Therefore a material with better sealing ability
should be used .
 Zinc oxide and Eugenol
 Recently adhesive resin has been used

32. Direct Pulp Capping
Technique for treating a pulp
exposure with a material that
seals over the exposure site &
promotes reparative dentin
formation..
Requirements of direct pulp
capping:
 Asymptomatic vital tooth
 Pin-point exposure (0.5mm or
less in diameter)
 Non-hemorrhagic or easily
controlled.
 Dry, sterile filed
 Non-carious atraumatic
exposure

33. Direct Pulp Capping Techniques
Calcium Hydroxide
Technique
Total etch technique
hemostasis hemostasis
Disinfect cavity Disinfect cavity
CaOH primers
Resin modifieed glass ionomer adhesives
IRM Resin modifieed glass ionomer
Restoration
Restoration

34. Calcium Hydroxide Technique:
1. Bleeding must be controlled.
This control may be achieved by :
 Washing the area with sterile saline and drying
it with either paper points or cotton pellets,
 Using cotton pellets soaked with hydrogen
peroxide or 5.25% sodium hypochlorite, OR
 Using a hemostatic agent .
If bleeding fails to stop after two or three
attempts, then endodontic therapy should be
considered.
 A disinfectant should be placed on the cavity
floor.

35. 2. The area is then air dried
3. Calcium Hydroxide is placed directly in contact
with pulp tissue. This step is very important, for
the better the contact of the calcium hydroxide
dressing with the pulpal wound, the better the
healing.
4. The calcium hydroxide should then be covered
with a resin-modified glass ionomer extended
onto dentin.
5. A permanent restoration is placed, with a
dentin bonding system used to seal the
margins of the restoration.

36. An alternative is to place a zinc oxide-eugenol
restoration over the calcium hydroxide cap.
Zinc oxide-eugenol provides an excellent seal
and, with its anti-microbial properties, makes
for a very good temporary restoration.
After three months, assuming pulp vitality and
no symptoms, the zinc oxide-eugenol can be
removed and a more permanent sealed
restoration placed.

37. Total Etch Technique :
1. Enamel and dentin are etched with 32% phosphoric
acid for 15 seconds.
2. The acid is rinsed off and the preparation is lightly dried.
3. The entire preparation , including enamel, dentin and
pulpal tissue , is treated with a dentin bonding system.
4. Adhesive resin is applied onto the enamel, dentin and
pulpal tissue and light cured, and a thin layer of resin-
modified glass ionomer is also applied over and around
the exposure site ( mechanically protect the perforation
from intrusion of the restorative material during packing
or condensation) and then cured.
5. The restoration is subsequently completed in
conventional fashion.

38. Chemo-mechanical caries
removal
 An alternative to mechanical means of
caries removal .
 The need for local anesthetic is reduced
or eliminated.
 It is an effective alternative means of
caries removal because it brings
together atraumatic measures and
bacterostatic/bactericidal action.
 Chemicals used can be in the form of
liquid (Caridex ) or gel (Carisolv).

39. Caridex
 Caridex was developed by C.M.Habib
from a formula N-monochloroglycine
and amino butyric acid and is called as
GK 101 E.
 It gained FDA approval in 1984.
 It was initially introduced in US market in
1985.
 The system involved the intermittent
appilication of preheated N-monochloro
DL 2 aminobutyric acid to the carious

40. CARIDEX
 The solution was claimed to cause
disruption of collagen in the carious
dentin and facilitating its removal.
 The mechanism of softening involved
chlorination of remaining partially
degraded dentinal collagen and tha
conversion of hydroxyproline to pyrrole
-2- carboxylic acid which initially
disrupted altered collagen fibres in the
caries.

41. Disadvantages:
-Expensive
-large quantity required
-solution has to be heated
-short self life
-hand instuments were optimum.

42. Carisolv
Carisolv™ is a chemo-mechanical method
for minimally invasive caries removal .
The system comprises :
 a gel that selectively attacks denatured
collagen in the carious dentine, thus making
the carious dentine softer.
 a set of specially designed
instruments used for
removal of the
softened material.

43. Carisolv gel consists of two
carboxymethylcellulose based gels:
 a red gel containing :
amino acids (glutamic acid, leucine and lysine),
NaCl
NaOH
Erythrosine (added in order to make the gel
visible during use ).
 and a second containing sodium hypochlorite

44.  The two gels are thoroughly mixed in equal
parts at room temperature before use . The
solution has a pH 11.
 The positively and negatively charged groups
on the amino acids become chlorinated and
further disrupt the collagen crosslinkage in the
matrix of the carious dentine.
 The gel is then applied onto the exposed
carious dentine and left for 30 to 60 seconds
then the softened dentine is gently but firmly
abraded away leaving a hard, caries-free cavity
.

45. A soft caries lesion Gel application. Let gel slide onto the
lesion. Wait 30 seconds.
The lesion is gently scraped with
a star instrument
Re-applied gel stays clear. Cavity
is hard with a probe.

46. The gel is removed with a
dry pellet
Complete caries removal is
checked with an explorer
The cavity is cleaned with
wet pellets
Finished cavity

47. Advantages of carisolv
 The patients perceive the
method as much more
comfortable than drilling and
anaesthetics are seldom
needed.
 Saves time
 Avoids removal of unnecessary
healthy dental tissues
Action of excavator. Healthy dentine is also removed.
Selective removal of softened dentine caries with the Carisolv™
instrument. Healthy dentine is not affected.

49. Papain gel
 IN 2003 a research project in brazil led to a
new formula to universalise the use of
chemo –mechanical method for caries
removal and promote its use in public health.
 the new formula was commercially known as
papacarie.
 It basically consists of
papaine,chloramine,toluidine
blue,salts,thickening vehicle which together
are responsible for its bactericide
,bacterostatic and anti inflammatory
properties.

50. Smartprep instrument
 The SMARTPREPTM Instrument is a polymer
instrument that safely and effectively remove
decayed dentin, leaving healthy dentin intact.
 It is a self-limiting instrument and is not hard
enough to penetrate healthy dentin. As it gently
removes decay and contacts the healthy dentin,
the instrument's edges become rounded and
unable to cut healthy tooth structure.
 A high-speed carbide bur is first used to gain
access to the decay. After access has been
created, the SMARTPREPTM Instrument is
used in a slow speed handpiece (500-800 rpm)
to complete caries removal.
 They are single-patient-use rotary instruments.

52. Advantages :
 Conserve healthy tooth structure,
 Virtually no risk of inadvertent pulp
exposure,
 Reduce the need for anesthesia and
allow for same-visit cavity preparations
on multiple quadrants,
 Designed to reduce post-operative
sensitivity.

53. The restorative treatment doesn't
cure the caries process, so
identifying & eliminating the
causative factors for caries must
be the primary focus, in addition
to the restorative repair of
damage caused by caries.