Caries notes

Caries

Carious lesion in enamel consists of four zones:

1. Translucent zone
2. Body of the lesion, represent area of demineralization
3. Surface zone
4. Dark zone, represent area of remineralization
Uncavitated enamel lesion is in a dynamic balance between demineralisation and
remineralization  depends on the oral environment

Carious dentin lesion consists of four zones, but clinically divided into two:
1. Infected layer
a. seriously denatured with high levels of bacterial invasion
b. not capable of repair
2. Affected layer
a. capable of repair should the caries be arrested

Carious lesions are only significantly infected once the carious lesion extends into the
middle third of dentine and that infection levels increase markedly once a lesion has
cavitated

Key to the progression of caries is the presence of a cariogenic dental plaque or biofilm on
the tooth surface

caries balance concept states that the progression or reversal of dental caries is determined
by the balance between pathological factors and caries protective factors.

Presently, there is no way of knowing from a one off examination whether a carious lesion is
progressing, regressing or remaining stable
Caries risk assessment valid at a patient level, these tools cannot predict caries activity at
the individual tooth or surface level, with sufficient reliability

Colonisation of MS in the oral cavity of children is the result of transmission of these

organisms from the child’s primary caregiver
- Factors influencing colonisation include frequent sugar exposure in the infants and
habits that allowed salivary transfer from mother/caregiver to infants
- Maternal factors, such as high levels of MS, poor oral hygiene, low socioeconomic
status and frequent snacking increase the risk of bacterial transmission to her infant
- Effective perinatal program should institute practices such as therapeutic
interventions and lifestyle modification counselling both during pre- and post-
partum to reduce maternal MS and lactobacilli levels
-

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Caries notes

Caries detection

Ideal tool for detection of the initial lesion, the ‘gold standard,’ has not yet been identified
(high-level evidence)

Conventional and validated tools for detecting early carious lesions include visual and tactile
examination and radiography (bitewings). ~ good specificity but moderate sensitivity,
relatively operator-dependent
Combination of clinical examination and bitewing radiographs allows diagnoses with
improved sensitivity and specificity

Systematised diagnostic procedures contains 3 stages:

1. The detection of a lesion
2. Evaluation of its severity (depth)
3. Level of activity
Diagnosis consists of deciding, for each surface of a tooth:
• Lesion present – yes/no
• Lesion stage – initial/moderate (risk of irreversible pulpal disease low)/advanced
(riskof irreversible pulpal disease high)
• Lesion activity – active/arrested (soft/hard for dentine and rough/smooth for
enamel)
• • For primary teeth, what is the risk of the lesion causing pain/sepsis before the
tooth exfoliates.

Evaluation of individual caries risk (Age group, health state and use of medications, lifestyle,
oral hygiene, nutrition and use of fluorides) cannot be separated from the actual diagnosis
of carious lesions  categorise a patient as being at low or high risk of caries for the correct
choice of preventive, interceptive, or therapeutic care

New diagnostic tools developed recently are not 100% reliable, but could aid in sensitivity
for detection when combined with conventional technique
- The most prominent include transillumination (Diagno.cam, Kavo®) and fluorescence
systems (DIAGNOdent, Kavo®; CS 1600 Kodak; VistaCam iX, DürrDental®; SoproLife,
Acteon®)
- Technologies, particularly those based on fluorescence, may assist in raising the
awareness and motivation of patients

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Caries notes

Caries classification

ICDAS
ICDAS permit is the identification and recording of enamel caries as well as the traditional
recording of dentinal caries, promoting a preventive philosophy to care from the outset

More clinically relevant:

lesion stage as follows:
• Initial – may be non cavitated, with no dentine involvement, or limited to the outer
1/3rd dentine. Risk of irreversible pulpal disease extremely low
• Moderate – lesion extends to the middle 1/3rd of dentine, and radiographically a
clear band of dentine of normal radiodensity separates the lesion from the dental
pulp. Risk of irreversible pulpal disease low
• Advanced – the lesion involves the inner 1/3rd of dentine, and radiographically
encroaches on the pulp. Risk of irreversible pulpal disease high.
Lesion activity:
- Active enamel lesion will feel slightly rough to a steel instrument drawn gently over
the surface
- Arrested enamel lesion will feel smooth
- Active dentinal caries will feel soft
- Arresting dental caries feels harder and is drier
- Arrested dentinal caries will be hard
- Colour is not a reliable indicator
- Gold standard diagnostic test for an arrested lesion is it does not progress over time

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Caries notes

Caries management
Caries management cycle should manages caries at the patient and tooth level
Aim: preserve tooth tissue whenever possible
Achieved by:
- Patient assessment
- Clinical assessment, including dental history, biofilm status and staging of the carious
lesions present
- Synthesis of findings and diagnosis

Shift in the orientation of dentistry towards ‘patient self-care’

- Dentists help their patients assume responsibility for achieving and maintaining their
own oral health, and that of their children

Innes and Manton, 2017

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Caries notes

International Caries Consensus Collaboration (ICCC) guideline on removal of carious tissue:

- Preserve non-demineralised and remineralisable tissue
- Achieve an adequate seal by placing the peripheral restoration onto sound dentine
and/or enamel, thus controlling the carious lesion and inactivating remaining bacteria
- Avoid discomfort/pain and dental anxiety as both impact significantly on
treatment/care planning and outcomes. Methods that are less likely to lead to dental
anxiety are preferable
- Maintain pulpal health by preserving residual dentine (avoiding unnecessary pulpal
irritation/insult) and preventing pulp exposure, that is, leave soft dentine in proximity to
the pulp if required
- Maximise longevity of the restoration by removing enough soft dentine to place a
durable restoration of sufficient bulk and resilience

Soft, decomposed dentine should be removed and the firm, demineralised dentine left
behind (ICCC)
Soft dentine
- tissue that will deform when a hard instrument is pressed onto it and can easily be
scooped up (hand excavator) with little force being required
Firm dentine
- Tissue that is physically resistant to hand excavation and some pressure needs to be
exerted through an instrument to lift it’
 in order to avoid pulpal exposure in deep cavities, it is better to leave some soft dentine
over the floor of the cavity

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Caries notes

Prevention

The first step in preventing the development of ECC is to provide perinatal oral healthcare to
expectant mothers as soon as possible

Infants and parents (caregivers) will benefit from an early infant oral health visit and the
establishment of a ‘dental home’.

Dental home
- The ongoing relationship between the dentist and the patient where accessible and
coordinated oral healthcare can be delivered comprehensively while actively
involving family participation

Infant oral health visit consists of a six-step protocol:

1. Caries risk assessment
2. Proper positioning of the child (knee-to-knee exam)
Used with children aged six months to three years, or up to age five with children
who have special healthcare needs
3. Age appropriate tooth brushing prophylaxis
4. Clinical examination of the child’s oral cavity and dentition
5. Fluoride varnish treatment
6. Assignment of risk, anticipatory guidance and counselling
o Providing information on oral hygiene, growth and development issues (that is,
teething, digit or dummy habits), oral habits, diet and nutrition and injury
prevention
o Following brief motivational interviewing (counselling), the parent/caregiver is
asked to select two self-management goals or recommendations as their
assignments before the next re-evaluation dental visit

A. Sealants
Sealants are used
o Preventively (stopping the initiation of caries)
o Therapeutically (arresting the progression of either enamel or dentine caries)
 One in ten lesions will progress under therapeutic sealants

Protocols for placing resin sealants:

1. Provided there are not significant amounts of plaque present there is no need to
clean the tooth surface as the acid etching will remove the plaque present
2. The surface should be etched for 2,030 seconds with 35% phosphoric acid
3. This is followed by washing for 20 seconds and drying until the surface appears
frosted
4. The resin is then applied with an instrument rather than a brush as this reduces the
risk of air bubbles and makes the resin easier to control (in the author’s experience)
5. Although autopolymerising materials are available most operators opt for the
advantages of the demand set of light cured materials
6. The sealant is then checked for adequacy and retention

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Caries notes

surface of the lower first premolar is very caries resistant because of its morphology and
therefore sealants are rarely indicated for these teeth

Evidence is clearly in favour of sealing non-cavitated occlusal carious lesions, even those
with radioluncencies extending up to a third into dentine

Read JC 7 (Caries detection and sealants for more detail regarding sealant)

Meta-analysis (Bagherian and Sarraf, 2018)

Flowable composite as fissure sealants had a slightly significant positive effect on retention
rates compared with the use of conventional resin-based sealants

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Caries notes

B. ART
Aims:
- Preventing the development of carious lesions and of stopping their progression into
dentine
- To restore dentine carious lesions in a minimally invasive way

consists of two components:

- Preventive (ART sealant)
Use HVGIC, which is placed over carious lesion- prone pits and fissures under finger
pressure. Hand instruments (such as an excavator and an applier-carver) are used for
adjusting the bite and removing excess material
- Restorative (ART restoration) component
Removal of soft, completely demineralised (decomposed) carious tissue with hand
instruments
Cavity is then cleaned and restored with an adhesive dental material (HVGIC) that
simultaneously seal the remaining pit and fissure

review shows that removal of decomposed dentine is most adequately achieved through
the use of a chemo-mechanical gel, but this method takes a relatively long time
- The next most effective method is using a sharp metal hand excavator
- The rotating metal dental drill has a tendency to over-prepare the cavity. So as
ceramic material bur.
- Laser tend to under-prepare

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Caries notes

ART restoration
- ART using high-viscosity glass-ionomer can safely be used in single-surface cavities in
both primary and permanent posterior teeth
- ART using high-viscosity glass-ionomer cannot be routinely used in multiple- surface
cavities in primary posterior teeth
- Insufficient information is available for conclusions about ART restorations in
multiple-surfaces in permanent posterior teeth, and in anterior teeth in both
dentitions
- The ART restoration criteria, used in most ART studies, are more stringent than other
assessment criteria, such as the United States Public Health Services (USPHS) and the
FDI criteria, and lead to lower survival result reports than would be obtained if these
criteria were used

Protocol for ART restoration

1. Isolate the tooth with cotton wool rolls. Keep the treatment area free from saliva.
2. With an explorer, gently remove plaque and food debris from the deepest parts of
the available pits and fissures.
3. Wash the pits and fissures, using wet cotton wool pellets.
4. Assess the extent of the carious lesion.
5. Enlarge the entrance of the cavity if it is found to be too small, using an Enamel
Access Cutter or dental hatchet.
6. Break only very thin enamel that might fracture when the restoration is in place,
using a hatchet.
7. Remove the carious dentine with hand excavators in a scooping movement, starting
at the dentine-enamel junction and ending at the floor of the cavity. Leaving a little
decomposed dentine behind is permitted if it is difficult to remove or if the child
becomes impatient.
8. Clean the cavity with a wet cotton pellet(s) followed by a dry one.
9. Ensure that the fissures which run into the cavity are free from debris. Remove
debris with a sharp probe.
10. Ensure that the enamel that forms the cavity opening is free from demineralization
(as far as possible).
11. Place 2 drops of liquid on the mixing pad. The first one, positioned in the corner of
the pad, usually contains air bubbles and is, therefore, used for conditioning.
Without releasing pressure, move the bottle to the centre of the pad and place a
second drop there. This one should not contain air bubbles and will be used for
mixing.
12. Condition the cavity and adjacent pits and fissures with diluted (15–20%) polyacrylic
acid by passing a moist cotton pellet, dipped in the conditioner, around the dentine
and enamel in the cavity for some 10–15 seconds. Bottled dentine conditioner is also
availabe.
13. Ensure that the pellet touches the cavity walls. This is not always easy in small
cavities. Use pellets appropriate to the size of the cavity. A disposable brush can also
be used.
14. Wash with a wet cotton pellet(s) for some 5 seconds. Repeating this is necessary.
15. Dry with cotton pellet(s) (do not use the air syringe). The cavity will look shiny. Keep
this situation uncontaminated by saliva and/or blood.

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Caries notes

16. Ensure proper isolation. Perhaps replace cotton rolls.

17. Mix the GIC according to the manufacturer’s instructions. Only accept a properly
mixed GIC; no runny or dry mixture is acceptable. Encapsulated GIC can also be used.
18. Insert the GIC material into the cavity with the applier/carver instrument. Push the
GIC into the corner(s) of the cavity (in case of an enamel overhang) with the round
end of the medium excavator. Insert a second portion of GIC and press it into place
with the round end of the large excavator. Fill the adjacent pits and fissures but DO
NOT overfill much, as the excess has to be removed.
19. Rub some petroleum jelly over your index finger (very thin layer), place the finger
over the tooth surface and press for 20 seconds.
20. Remove the visible GIC excess with the carver end of the applier/carver instrument.
21. Check the occlusion with articulation paper.
22. Wait until the material has set a bit and then adjust the bite with a medium-sized
excavator and/or carver instrument.
23. Remove petroleum jelly-covered top layer of the GIC with a large excavator and/or
carver instrument. Ensure a smooth GIC-onto-enamel junction. Use the round end of
the small and/or large excavator to achieve this.
24. Protect the restoration with a thin layer of petroleum jelly again.
25. Remove the cotton wool rolls.
26. Ask the patient not to eat for at least one hour.

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Caries notes

Hall technique

Raise in occlusion
- Child patients usually don’t seem to concerned about this matter, although they
might be uncomfortable at first, but they accommodate to the disruption of their
occlusion quite quickly
- And there is no problems with TMJ as well
- Right after the placement, the mean increase in OVD is 1.1 mm, usually it decreases
the next day
- And by 2 weeks, it already reduced to 0.3 mm
- The compensations seems to be (although not completely) be from the intrusion of
the tooth with crown and some from the opposing tooth

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Caries notes

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