operative

Deep carious lesion management

What is caries?

- According to Specific plaque hypothesis: it is caused by specific

bacteria only “mutans”
NB. after studies, it was discovered that not only
mutans that contribute to the formation of dental
caries
- According to Non-specific plaque hypothesis: carious
lesions develop when bacteria reaches specific count
- Ecologic plaque hypothesis: caries is a disease, that
occurs due to ecologic shift within dental biofilm environment driven
by frequent access to fermentable dietary carbohydrates which
leads to a move from balanced population (from low -> high
cariogenicity)

Oral microbes,
fermentable CHO,
Plaque, acids

remineralization demineralization

Salivary and therapeutic

components

- Caries is a dynamic process (demineralization and

remineralization), that’s why active and arrested zones are
developed.
- Carious lesion= signs and symptoms of disease, such as white
lesions, cavitation, pits and fissures.

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Dental caries management Vs. Caries lesion management:

⇒ Dental caries management: control disease at patient
level, through preventive and non-invasive methods
⇒ Carious lesion management: control of symptoms of a
disease at tooth level
Dental caries management:
- more conservative -> more biological and medical approach of
treatment (not surgical), As a single restorative material will never
be able to replace the function of both enamel & dentin.
- Aim
⇒ Control disease
⇒ Prevent lesion from becoming clinically manifest
⇒ Prevent the advancement of clinically detectable lesion
Why do we remove caries tissue?
- To retain the tooth and the vitality of pulp.
Carious lesion:
⇒ Caries infected dentin (CID) (outer: towards the
source)
⇒ Caries affected dentin (CAD) (inner)
CID:
ü Highly infected
ü Highly demineralized
ü Denaturated collagen fibrils
ü Non sensitive (no dentinal tubules nor their nerve endings) and
thus sometimes even probing or excavation doesn’t cause pain.
ü Non remineralizable
NB. Collagen is very important for remineralization.

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CAD
ü Slightly infected
ü Partially demineralized
ü Collagen fibrils retain their structure & crosslinking (coating that
allows remineralization)
ü Sensitive
ü Remineralizable
How to differentiate between CID and CAD? (clinically)
1. Color: not valid criteria
2. Moisture: not valid criteria when experience is not high (can’t
differentiate between Moist “affected” and wet “infected”)
3. Caries detecting dyes: for CID only, but it also stains
hypomineralized structures (such as DEJ), so it requires
experience to differentiate between:
⇒ Highly stained areas -> caries
⇒ Lightly stained areas -> DEJ
To avoid overcutting
NB. Caries detecting dies contain carcinogenic components and
thus their use is limited
4. Texture and hardness: divided into zones
The most superficial zone à ↑ bacterial necrotic zone

↓ minerals (nearly 0)
As we go down à ↓ minerals and slightly infected. contaminated
zone

demineralized
zone

trancluecent
zone

sound dentin

teriary dentin
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Dentin layers seen during excavation:

1. Soft dentin:
- most superficial, after we remove the necrotic layer
- represents CID
- Clinically:
-> probe go deeper and dentin deform
-> Excavation require no forces
-> Removed as flakes.
2. Firm dentin:
- represents CAD
- clinically:
-> probe doesn’t go deeper
-> Excavation requires pressure
-> Removed as debris/powder
3. Leathery dentin:
- transition between Soft and firm dentin.
4. Hard dentin:
- not excavated (may break excavator)
- Crying dentin sound when probed.

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Why do we restore carious lesions?

1. Aid plaque control and thereby manage caries activity at this
specific location (if the lesion was removed, but undermined
enamel was left and no restoration was placed to seal the cavity
-> bacterial accumulation occurs leading to recurrent caries)
2. Protect the pulp-dentin complex and arrest the lesion by sealing
it (If caries process continues -> pulpal inflammation)
3. Restore the function, form, and aesthetics of the tooth

Guiding principles of carious tissue removal

1. Avoid anxiety and pain
2. Preservation of dental tissues:
- Not applicable with amalgam restoration
- Adhesive restorations are more conservative (I only remove
the defect) I don’t need any retentive means as I rely mainly
on adhesion.

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- Tooth restoration cycle:

Carious lesion

Early invasion treatment

Fracture of adjacent
carious lesion

Restorative re-treatment

Second re-treatment,
now using crown
Root canal treatment

Endodontic retreatment

Extraction

3. Provision of sound cavity margins to achieve an adequate

peripheral seal (golden rule)
Sound enamel and dentin in the margins forming a tight seal in all
walls (mesial, distal, buccal, lingual and gingival, but axial/pulpal I
may compromise) in this case any remaining bacteria will die after
the placement of restoration
4. Maintenance of pulpal health and avoidance of pulp exposure
5. Maximizing the longevity of the restoration

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Priorities during restoration of carious lesion

1. Preserving healthy and remineralizable tissues
2. Restorative seal
3. Maintaining pulpal health
Try to be conservative: if removal of soft dentin may cause pulp
exposure then leave it
4. Restoration success:
Sound dentin is the best for bonding and mechanical properties
No 3 and 4 are opposite:
Deep lesions: the lesions that extends radiographically to early 1/3 or
¼ of dentin and in this case we are concerned with pulp vitality
Shallow or moderately deep lesions we are concerned with restoration
longevity
Before we manage deep carious lesions:
1. History form the patient: any signs and symptoms indicating
irreversible pulpitis (the patient should not complain of pain, the
main complain should be sensitivity or food impaction)
2. Clinical inspection: swelling, pain on percussion, tenderness or
mobility.
3. x-ray: to know the depth of lesion, and the presence of dentin
bridge separating caries from pulp
è bitewing radiographs are mainly used for caries detection
while, periapical radiographs are used to check for any
periapical radiolucency

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Strategies for carious lesion removal

1. Non-selective removal to hard dentin (complete caries
excavation):
- Less conservative
- Only hard dentin is left so that demineralized
dentin is completely removed
- Needs high experience, skills and luck to avoid
pulp exposure. However, sometimes exposure
occurs (main disadvantage)
- This is considered overtreatment and no longer advocated
2. Selective removal to firm dentin
- Used with shallow or moderate lesion
- Leaves leathery or firm dentin pulpally while the
peripheral cavity margins are left hard
3. Selective removal to soft dentin (1 steps partial
caries removal)
- soft carious tissue is left over the pulp to avoid exposure and
stress to the pulp thereby promoting pulpal health, while
peripheral enamel and dentin are prepared to hard dentin to
allow tight seal and placement of durable restoration
- it’s indicated in the deep carious lesions which
extend to the inner third of quarter of the dentin
- selective removal to soft dentin reduces the risk
of pulpal exposure significantly as compared with
nonselective removal to hard or selective removal
to firm dentin
- we remove as much as possible of soft dentin until we feel that
pulp shadow/ pulp horns are near, to keep the smallest amount
possible of bacteria leading to inactivation of bacteria by time
as there is a peripheral seal then follow up the case

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Peripheral seal concept of selective removal to soft dentin

- Maintenance of pulp vitality after restoration by adhesive
methods
- Elimination of dentinal infections by deactivating, sealing, or
removing bacteria
- Conservation of dental tooth structure for long term biomimetic
function
- Treatment goal:
1. Create a peripheral seal zone of enamel, DEJ and normal
superficial dentin near the DEJ (I should leave at least 1.5-
2mm dentin band below DEJ)
2. Leave the inner carious dentin (affected dentin) inside the
peripheral seal zone
3. Remove highly infected outer carious dentin inside of the
peripheral seal zone without exposing the pulp, small areas of
circumpulpal outer carious dentin are left to prevent exposure
4. Seal in and deactivate any remaining bacteria left inside the
peripheral seal zone
5. Use adhesive restorative technique that will maximize the
bond strength of the peripheral seal zone and the inner carious
affected dentin inside the peripheral seal zone

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Disadvantages:
1. We can’t rely on x-ray to monitor the case (follow up): In
radiographs a radiolucent area appears below the restoration, and
after 6monthsthe same radiolucent zone appears so I can’t
decide whether this area increased or decreased
NB. Recently subtraction radiography was designed to solve the
problem of monitoring (not available yet)
2. Patient education about his case is important as not to think that
the caries was left due to improper treatment
3. Non reliable adhesion: due to presence of soft dentin in axial wall
4. Soft dentin acts as a cushion while the restoration is rigid so
when load falls, stresses are concentrated on the walls leading to
fracture or failure of adhesive joint causing leakage,
discoloration or sensitivity
4. Stepwise carious tissue removal (2 steps partial caries removal):
- This strategy is carried in two steps:
⇒ In the first step, soft dentin is left over the
pulp and peripheral dentin is prepared to hard
dentin to provide complete and durable seal. A
provisional restoration (control restoration) is
then placed (6-12 months) to allow changes in
dentin and pulp to take place (formation of
reparative dentin, dentin becomes dryer and
harder “soft dentin is wet by time it loses its
moisture”, dentin color becomes darker “similar
to arrested caries concept”)
⇒ In the second step, the provisional restoration is removed and
the soft dentin is removed to reach the leathery dentin which
will be left on the pulpal side of the preparation (may be
omitted to avoid the risk of pulp exposure)

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Disadvantages:
- Leakage: if control restoration breaks and the patient doesn’t come
(in the first step I remove as much as I can from soft dentin to
allow for bulk of restoration 2.5-3 mm)
- Patient compliance: the patient may miss the follow up appointment
- Risk of pulp exposure during the second step
Control restoration:
- Aim:
1. Change cavity condition to inactivate the bacteria and arrest the
lesion (clinically: dryer harder and darker)
2. Stimulation of pulp to deposit tertiary dentin
- which material?
glass ionomer
1. Seal through bonding to dentinal tissues
2. Biocompatible
3. Enhance remineralization by fluoride release
How can you analyze your treatment?
1. Pulp vitality
2. Presence or absence of pain
3. Presence or absence of apical radiolucency
Notes:
The selection between step wise and selective caries removal?
- According to compliance of the patient (not very important)
- Depth of the lesion: as in extremely deep lesions, stepwise
excavation is the technique of choice
Extremely deep lesion = more than ¾ thickness of dentin is carious

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Pulp capping:
1. Indirect pulp capping:
A liner is placed on caries affected dentin
(firm dentin) = selective removal to firm
dentin technique
2. Direct pulp capping
Placement of a dressing on exposed pulp that seems clinically
healthy or with reversible pulpitis, to maintain its vitality
Factors affecting success of direct pulp capping
1. Accidental or due to caries progression:
- Accidental: as the exposure may be due to trauma, crown
preparation (over reduction)
- caries exposure during excavation, in this case all the infected
dentin should be removed
2. Age:
- pulp capping is better at young ages due to higher healing
power
3. Size of the exposure site:
- the smaller the better
4. Material used:
- the restorative material should be of good durability and
sealing and thus composite is better than glass ionomer in this
case (glass ionomer is used as a control restoration)
5. Isolation:
- the best conditions for pulp capping is complete isolation and
the usage of sterile instruments
6. Occlusal or proximal:
- Occlusal exposure site is better, as in case of proximal
exposure site there is a direct communication with the
external environment.

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Materials used in direct pulp capping

1. Calcium hydroxide:
⇒ Gold standard:
• The material has a well-known success rate
(proved its success)
• A bench mark: any material is compared to it
⇒ Disadvantages:
- no adhesion to dentin
- dissolution leaving gaps/voids leading to fracture of the
restoration placed on top of it or bacterial
ingress.
- tunnel defects are seen in the formed dentin
bridge (facilitates re-entry of bacteria)
⇒ Mode of action: it’s highly alkaline, causing local
necrosis of pulp (in the most superficial area),
which causes the pulp to react by dentin formation (by UMCs
and odontoblasts)
⇒ May causes obliteration of the pulp chamber
2. Silicate (hydraulic) cements:
- Requires water for setting
- Mineral trioxide aggregate (MTA):
⇒ Dicalcium silicate, tricalcium silicate and tricalcium aluminate
⇒ Advantages:
- Good reparative dentin-forming
ability
- Excellent sealing
- Antibacterial

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⇒ It’s highly alkaline and its reaction produces calcium

hydroxide, so what’s new?
ü With calcium hydroxide there is no full setting leading to
continuous release of calcium hydroxide
ü While with MTA complete setting occurs, which means that
the release of calcium hydroxide is not continuous and thus
decreasing the dissolution
⇒ Drawbacks:
1. Long setting time: 4-24 hours, which requires the placement
of a wet cotton on top of it then sealing the cavity by
temporary restoration and then another visit is made to
place the final restoration
2. Difficult handling
3. Solubility
4. Color: greyish color (1st generation)
5. cost
⇒ Types:
• Grey MTA (GMTA): contains iron
• White MTA: no iron, but bismuth oxides (metal used to
make the material radio opaque) causes discoloration. But at
lower extent than grey MTA

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- Biodentin (Septodont, France):

⇒ Powder: tri and Dicalcium silicate and calcium
carbonate (filler to improve the strength)
⇒ Liquid: calcium chloride (to speed up the setting time) in an
aqueous solution with an admixture of polycarboxylate
⇒ Initial setting after 12 minutes of application up to 85 minutes
(final setting)
⇒ Stimulates reparative dentin formation
⇒ Better mechanical properties than Ca(OH) and MTA, and thus can
be used as a control restoration up to 6 months
⇒ Can be applied in bulk
⇒ Color: removed iron and bismuth oxides, and added zirconium
oxides as radio opacifiers which causes no discoloration
⇒ Adhesion: highly alkaline -> caustic action on collagen -> roughness
leading to micromechanical interlocking + calcium release leading
to chemical bonding
⇒ Its main disadvantage is the high cost
⇒ Supplied in the form of capsules (placed in the amalgamator for
30 seconds before use).
- Theracal LC (Bisco, USA):
⇒ Light cured mineral trioxide aggregate (MTA)-filled,
resin modified (RM) calcium silicate cement
⇒ Polymerizable methacrylate monomers, included in
order to achieve a bond to composite resins and dentin
⇒ Disadvantages:
ü The presence of a resinous material in contact with the pulp
leads to irritation (cytotoxicity = destroys odontoblasts)
ü After setting of resin network, no minerals/ions can reach the
pulp
⇒ Not used as a control restoration

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NB. The pulp capping material is not completely removed before the
application of the final restoration to avoid re-exposure, as the
formation of dentin bridge is not always guaranteed and sometimes
even if formed it’s would be very thin (it takes 30-130 days and
sometimes 6 months for reparative dentin to form)
Is pulp capping successful?
The success rates of pulp capping seem to grow every day.
However, it depends on the experience of the operator and
the other factors which can’t always be guaranteed:
⇒ If bleeding on pulp stops then pulp capping is done, if
not it’s an indication of inflammation and thus no pulp
Capping
⇒ Whether the pulp exposure occurred when the tooth is isolated
or not
Aiding tools in caries excavation: (removal of infected dentin)
1. Rotary tools:
- Conventional round burs:
⇒ Tungsten-carbide or carbon steel
⇒ Direction: Periphery to center
⇒ High efficiency, but tendency to over-excavate
- Polymeric burs:
⇒ Self-limiting concept,
⇒ Made of PEKK (polyether-ketone-ketone), whose hardness is
higher than caries infected dentin (can remove it) but lower
than the carried affected dentin (can’t remove
it), when it comes in contact with firm/sound
dentin -> blunting and thus doesn’t remove soft
dentin (tendency for under excavation)

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- Ceramic burs:
⇒ CeraBurs (Komet-Brasseler, Germany)
⇒ Alumina-yttria stabilized zirconia
⇒ No significant difference between the ceramic
and conventional tungsten-carbide burs (tendency
for over excavation)
2. Caries disclosing dyes:
- 0.5% basic fuchsin in a propylene glycol base:
⇒ claim to stain exclusively the top, irreversibly destroyed
carious layer, enabling differentiation from what could be left
in the cavity.
⇒ tendency to over staining more than the infected dentin
(hypomineralized areas such as DEJ may be
lightly stained)
⇒ concerns about its carcinogenicity
- 1% acid-red solution (Caries Detector, Kuraray
Tokyo Japan)
⇒ staining of dentin clinically judged as “sound”,
with a 30% false positive diagnosis of residual
caries (possibility of over excavation)
⇒ time consuming
⇒ slightly stained tissue should not be removed
- 1% acid-red in propylene glycol base:
⇒ 1% acid-red dye in a polypropylene glycol base (Caries Check,
Nippon Shika Yahuhin, Japan)
⇒ higher molecular weight of polypropylene glycol (300MW)
makes it more caries specific more than propylene glycol-based
dye

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3. chemo-mechanical excavation:
- sodium hypochlorite-based agents:
• Caridex (National Patent Medical Products, USA)
⇒ Sodium hypochlorite solution buffered with an amino acid
containing mixture of amino butyric acid, sodium chloride and
sodium hydroxide
⇒ Questionable efficacy
⇒ Disadvantages: Specific apparatus, short shelf life, longer
treatment time, and higher treatment cost
• Carisolv (MediTeam Dental, Sweden)
⇒ 0.5% w/v sodium hypochlorite, 0.1M of an amino acid mixture
(glutamic acid, leucine and lysine), and water
⇒ applied in the form of gel placed in a syringe
which is transparent, when placed on the lesion
(infected dentin), leading to its pealing and thus
the gel becomes turbid , then a non-cutting
instrument is used to remove the pealed part, then reply and
so on until totally clear.
⇒ residual bacteria specially at DEJ due to accessibility (if
undermined enamel was not removed)
- Enzyme-based agents:
⇒ Papacarie (Formula and Acao, Sao Paulo, Brazil)
⇒ Papain enzyme and chloramine
⇒ The main action depends on the presence of the papain
enzyme, the chloramine was added to enhance removal of
denaturated tissues (collagen)

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- Biosolv (SFC-V, SFC-VIII, 3M ESPE, Sheefeld, germany)

⇒ Experimental
⇒ Pepsin in a phosphoric acid/sodium biphosphate buffer
⇒ Phosphoric acid dissolves the inorganic component of carious
dentin, while it at the same time gives pepsin access to the
organic part of the carious
⇒ May affect sound dentin also, and thus not used
4. air abrasion excavation:
⇒ air abrasion systems for cavity preparation
use the kinetic energy of abrasion particles to
cut tooth structure
⇒ the major drawback of air abrasion excavation
of carious dentin is that sound dentin is more
efficiently removed than carious dentin
⇒ may lead to under excavation in some areas and over
excavation in another areas
⇒ biomass to selectively dissolve the denaturated collagen
5. fluorescence aided caries excavation (FACE)
⇒ differentiation between infected and affected carious dentin
⇒ based on the fact that several oral microorganisms produce
orange-red fluorophores as by-products of
their metabolism (porphyrins), infected carious
tissue will fluoresce especially in the red
fraction of the visible spectrum due to the
presence of porphyrins
6. laser:
⇒ still under study
⇒ does it affect sound enamel and dentin and whether its energy
affect the pulp.
⇒ So still not widely used

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