Management of Deep caries /certified fixed orthodontic courses by Indian dental academy

Definition :
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..

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Etiology

food bacteri
a

tooth


Dentine 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 ).


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


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 .


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.


Management of deep caries

The objective is to focus on the:
 Diagnosis

 ttt modalities


Treatment Modalities
The results of diagnosis :

No exposure Pulp Exposure

Conventional Indirect pulp Vital Non-vital
capping (traumatic) (carious)
exposure exposure
cavity
preparation
and restoration Direct pulp capping RCT
 Recent advances of caries removal :
carisolv
Smartprep instrument

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.


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


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.


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


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 www.indiandentalacademy.com

Direct Pulp Capping Techniques
Calcium Hydroxide Total etch technique
Technique

hemostasis hemostasis

Disinfect cavity Disinfect cavity

CaOH primers

Resin modifieed glass ionomer adhesives

IRM Resin modifieed glass ionomer

Restoration
Restoration

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. www.indiandentalacademy.com

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.


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.


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.


Chemo-mechanical caries removal
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.

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


 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

A soft caries lesion Gel application. Let gel slide onto the
lesion. Wait 30 seconds.

The lesion is gently scraped with Re-applied gel stays clear. Cavity
a star instrument is hard with a probe.

The gel is removed with a
Complete caries removal is
dry pellet
checked with an explorer

The cavity is cleaned with
Finished cavity
wet pellets

Advantages of carisolv

 The patients perceive the
method as much more
comfortable than drilling and
anaesthetics are seldom needed.
Action of excavator. Healthy dentine is also removed.

 Saves time

 Avoids removal of unnecessary
healthy dental tissues
Selective removal of softened dentine caries with the Carisolv™
instrument. Healthy dentine is not affected.


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.

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.


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.


Management of Deep caries /certified fixed orthodontic courses by Indian dental academy

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