Transcript Management of the Early Carious Lesion

Early Caries
Detection and Treatment
J Good BDS MFD(RCSI) PGCHET
September 2011
Learning Outcomes
Following this lecture you should be able to:
• discuss the carious process
• describe how to recognise ‘early carious
lesions’ and ways of detecting them
• discuss the principals involved in the
management of early carious lesions
The Carious Process
Four factors are necessary to produce
dental caries:
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Dental caries is:
• a disease of the calcified tissues of the
teeth
• caused by the action of micro-organisms
on fermentable carbohydrates
• characterised by demineralisation of the
mineral portion of enamel and dentine
followed by disintegration of their organic
material
In its early stages the disease can be
arrested since it is possible for
remineralization to occur
ALSO
This disease is not inevitable as it can be
completely prevented by relatively
simple measures
Susceptible Sites
Sites on the tooth surface which favour
plaque retention and stagnation are
particularly prone to decay:
Pits and Fissures
Approximal enamel smooth surfaces
just cervical to the contact point.
Enamel of the cervical margin of the tooth just coronal to
the gingival margin
Where perio disease has resulted in
gingival recession
The margins of restorations, particularly those that
are deficient or overhanging
• Tooth surfaces adjacent to dentures and
bridges which increase the areas where
stagnation can occur.
Why is diagnosis of caries in its ‘early
stages’ important.
• The carious process can be modified by
preventive treatment so that the lesion
does not progress
If caries can be diagnosed at the stage of
a ‘white spot lesion’ the balance can be
tipped in favour of arrest by:
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What is the
POINT OF NO RETURN
• When a cavity is actually present
• A hole in the dental tissues is not expected
to calcify up from the base
How can dental caries be diagnosed in its
‘EARLY STAGES’
• Sharp eyes
• Good lighting with clean, dry teeth
• Isolate teeth with cotton wool rolls, slow
suction & buccal pad.
Question
With what type of probe should you check
for caries?
Interproximally on anterior teeth:
• Operating light is reflected through the
contact point with the dental mirror
• Carious lesion appears as a dark shadow
following the outline of the decay
Interproximally on posterior Teeth:
• Stronger light source is required eg fibreoptic light with beam reduced to 0.5mm
diam. (FOTI)
• Small diam. reduces glare and therefore
reduces loss of detail
• Useful technique where you want to avoid
radiation eg pregnancy or where teeth
would appear overlapped on x-ray due to
crowding.
FOTI
• Good bitewing radiographs are also
essential in diagnosis
• A film holder is used so that the x-ray
beam passes at right-angles to the long
axis of the tooth and tangentially through
the contact area
Tooth separation
Uses orthodontic separating elastics
After a few days the teeth are separated and
presence of a cavity can be assessed by:
• Direct vision
• Gentle probing with blunt probe
• Elastomer impression material
Occlusal Caries
• Direct vision – discolouration, cavitation
and the grey appearance of enamel
undermined by caries
• Bitewing radiographs – will only show
more advanced lesions
• Caries Dyes
• Electronic caries monitors - can be used
to help diagnose occlusal caries
• Work using the principal of electrical
resistance since intact enamel is a good
insulator
• During the carious process, moisture filled
porosities act as conductive pathways
causing the resistance to fall
• These measurements may be repeated at
recall appointments and comparative
readings may indicate whether a region is
growing or not.
Diagnosing ‘AT RISK’ patients
• Caries is a reversible process
• If the dentist can diagnose the process
early then the patient can be advised on
instituting preventive measures to tip the
balance in favour of arrest
• Diagnosis is more than simply recording
the decalcified areas, their location and
their appearance
• The dentist needs to know whether the
patient is likely to develop new cavities
and/or whether existing cavities are likely
to progress.
• To help make these decisions a Caries
Risk Assessment should be carried out.
What would this involve?
Caries Management
Once caries has been diagnosed, the
dentist must decide how the process
should be treated:
• Use preventive measures to attempt to
arrest the process
OR
• Surgically remove and replace the
damaged tissues and prevent recurrence
Prevention
On smooth surfaces:
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Dietary advice
Use of fluoride
Improve plaque control
REASSESS
Pits and Fissures:
Difficult to diagnose in early stages so
Fissure Sealing susceptible teeth as soon
after eruption as possible is often the
choice
Indications for FS
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High caries risk
Stagnating plaque
Newly erupting molars
(Stained and decalcified deep fissure
patterns)
Isolation
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Very important
Cotton wool rolls
Slow suction
Buccal pads
Rubber dam
Clean occlusal surface with a wet
prophy brush
Then wash and dry using 3-in-1
Etch for 20secs with 37%
Orthophosphoric Acid
Wash for 10 secs
and then
dry with 3-in-1
Note – ‘frosted’ appearance of enamel
Apply FS
• Note the use of the ball-ended burnisher
Light Cure
• Note orange protective shield should be in
place!!!
• 470nm wavelength light for 20 secs
Check the occlusion
• Clear unfilled resins – will adjust with
occlusion unless excessive material has
been used
• White filled resins – need to be adjusted at
chairside for the patient
Indications for Preventative
Resin Restoration (PRR)
• High caries risk
• Stained and decalcified deep fissure
patterns
• More than 2 other carious lesions in the
mouth
• Enamel biopsy shows that lesion is
confined to enamel
Procedure for PRR
Follow similar steps as for a Fissure Sealant
BUT
After the prophy brush is used, the stained
enamel must be removed using a tapered
diamond bur in the fast handpiece.
Any decay is then removed using a round bur
in the slow handpiece.
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The tooth surface can then be restored
using one of the following options:
Flowable composite
GI and flowable composite
Composite
amalgam
Approximal Surfaces
A lesion limited to the enamel on B/W
radiograph should be treated preventively:
• Diet advice
• Fluoride
• Plaque control
Unless the caries risk is very high,
time is on the patient’s side:
• Research has shown that progression of a
lesion through enamel, if it occurs, can be
very slow, taking 2-6years before it is
evident in dentine radiographically
Ref – Pitts, N.B. (1983). Monitoring of caries progression in permanent and primary
approximal enamel by bitewing radiography. A review. Community Dent. Oral
Epidemiol., 11, 228-35.
Radiographically just through enamel and
into dentine:
In a young patient or high- & medium-risk
patients – advice is to treat operatively
In a low-risk patient – treat preventively.
Show the patient the radiograph and
suggest that it should be repeated in 6
months.
Root Caries:
• Early diagnosis very important as
advanced lesions can be difficult to
manage
• Meticulous plaque control
• Dietary control
• Use of topical fluoride (as a varnish &/or
mouthwash)
Diet Advice
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No snacking between meals
Aim for 2-3 sugar attacks per day
Never sugar before bed
Avoid fizzy drinks but if not possible then
chose diet variety
Each patient is an individual and will require
specific advice
Cariostatic Mechanisms of Fluoride
• Post-eruption - inhibits demineralization
and promotes remineralization
• Depending on its pH and concentration,
fluoride can also exert a bacteriocidal or
antienzymatic effect.
• Pre-eruption – may alter morphology
making fissures more self-cleansing.
Modes of Fluoride Application
Patient may be receiving fluorinated water
or taking fluoride tablets.
These facts would be important to know
before prescribing any further fluoride
treatment – WHY?
Topical application of Fluoride
falls into 2 categories:
• Frequent-use, low-concentration
preparations i.e. Toothpastes and
mouthrinses
• Periodic-use, high-concentration
preparations i.e. fluoride varnishes, gels
and prophylactic pastes
• Toothpastes (525 -1450ppm F)
• Mouthrinses – daily ?% NaF
weekly ?% NaF
• NaF varnish (Duraphat) ?%F
painted on in the surgery
• APF gel ?%F – swabbed onto the tooth
surface or applied in closely fitting trays
• Prophylaxis paste ?%F – applied in
surgery with a rubber cup
Plaque Control
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Toothbrushing
Dental floss/tape
Woodsticks
Interdental brushes
Single tufted brushes
Current Toothbrushing Advice
• Brush twice daily with fluoridated
toothpaste containing at least 1,350ppm
fluoride
• Brush last thing at night and on 1 other
occasion
• Spit out after brushing and do not rinse
Summary
• It is important to recognise early carious
lesions as they are reversible
• Be aware of the different techniques used
to help identify these lesions
• Preventive management is the treatment
of choice: diet analysis
effective plaque removal
appropriate use of Fluoride