Management of Deep Caries

Departemen Ilmu Konservasi Gigi

FKG USU
2023
 Pulp Dentin Complex and Caries

Dentin is a vital tissue containing

odontoblast processes, and
therefore dentin and pulp must be
considered as one unique
functional entity.
Pulp reactions to deep caries
lesions exhibit chronic inflammatory
exudates with
lymphocytes,macrophages and
plasma cells, and tertiary dentin
formation.
This is followed by atubular dentin
formation.
As the acute response settles, new
dentinal matrix can be laid down.
The combination of atubular dentin and
new dentinal matrix, also described as
reparative dentinogensis, is recognized
clinically as dentin bridge formation
following pulp capping procedures
However, it is important to
realize that tertiary dentin
per se cannot protect the
tooth from complete
destruction.
Pulp Dentine Complex Reaction
Due to Caries
 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 ).
Management of deep caries

The objective is to focus on the:

 Diagnosis

 Treatment
 The current operative
tradition
Nevertheless, current clinical practice is
immediately to perform operative
intervention in order to:
• remove softened, infected carious dentin
(because, according to present paradigms,
the infected tissue should be eliminated until
dentin that is hard to touch has been
obtained)
• extend the removal of enamel and
dentin to obtain a cavity suitable
for insertion of the restorative
material of choice
• apply some agents /protective materials ,
e.g. calcium hydroxide to protect the pulpo-
dentinal complex from:
– toxic effects of restorative materials
– microorganisms penetrating owing to
leakage at the tooth–restoration interface

– thermal fluctuations.
 Treatment
The results of diagnosis :

No exposure Pulp Exposure

Conventional Indirect Stepwise excavation

cavity preparation and pulp Vital Non-vital
restoration (carious)
•Iatrogenic
capping exposure
•Traumatic

Exposure

Direct pulp capping

RCT
 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 technique 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.
 Figure. The current clinical
practice of mechanical
excavation combines a
peripheral dentin excavation,
carried out using a round burr
(a, b), with elimination of the
centrally infected tissue using
an excavator (c, d). The probe
is used to assess clinical
consistency, and here dentin
that is hard to the touch has
not yet been obtained (e).
Note that the deeper and soft
carious dentin is a fragmented
tissue (f). An excavation close
to the pulp represents a risk,
because cracks along the
fragments may lead to pulp
exposure.
Stepwise Excavation
Stepwise Excavation
 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
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.
2. The area is then air dried
3. Pulp Protective Materials is placed directly in
contact with pulp tissue. This step is very
important, for the better the contact of the
material with the pulpal wound, the better the
healing.
4. A permanent restoration is placed, with a
dentin bonding system used to seal the
margins of the restoration.
Direct Pulp Capping VS Stepwise
Excavation
Pulp Protective Materials
Minimal Invasive in Caries Removal
 air abrasion
 Lasers
 polymer burs
 chemo-mechanical caries removal (carisolv
gel, caries detector dyes)
 ozone
Air Abrasion
Lasers
Polymer Burs
 Chemo-mechanical caries removal
chemo-mechanical caries removal 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.
 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 :
 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.
 Conclusion
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.
 References

1. Mount G.J., Hume W.R., Hien C., Mark S.W.

Preservation and restoration of tooth structure.
3rd edition., British: John Wiley&Sons Limited.
2016.
2. Torres C.R.G. Modern operative dentistry:
principle for clinical practice. Switzerland:
Springer Nature Switzerland AG; 2020