Management of Deep Caries

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Management of Deep Caries
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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
bacteria
food
tooth
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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 ).

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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

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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
  .

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• 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.

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Management of deep caries

• The objective is to focus on the
• Diagnosis
• ttt modalities

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Treatment Modalities

• The results of diagnosis

Pulp Exposure
No exposure
Indirect pulp capping
Vital (traumatic)exposure
Non-vital (carious) exposure
Conventional cavity preparation
and restoration
Direct pulp capping
RCT

• Recent advances of caries removal
  carisolv
  
  Smartprep instrument

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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.

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• 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

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• 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.

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• 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

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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

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• Direct Pulp Capping Techniques

Calcium Hydroxide Technique
Total etch technique
hemostasis
hemostasis
Disinfect cavity
Disinfect cavity
primers
CaOH
Resin modifieed glass ionomer
adhesives
IRM
Resin modifieed glass ionomer
Restoration
Restoration
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• Calcium Hydroxide Technique
• 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.

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• The area is then air dried
• 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.
• The calcium hydroxide should then be covered with
  a resin-modified glass ionomer extended onto
  dentin.
• A permanent restoration is placed, with a dentin
  bonding system used to seal the margins of the
  restoration.

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• 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.

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• Total Etch Technique
• Enamel and dentin are etched with 32 phosphoric
  acid for 15 seconds.
• The acid is rinsed off and the preparation is
  lightly dried.
• The entire preparation , including enamel, dentin
  and pulpal tissue , is treated with a dentin
  bonding system.
• 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.
• The restoration is subsequently completed in
  conventional fashion.

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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.

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• Carisolv gel consists of two carboxymethylcellulo
  se 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

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• 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

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A soft caries lesion
Gel application. Let gel slide onto the lesion.
Wait 30 seconds.
Re-applied gel stays clear. Cavity is hard with a
probe.
The lesion is gently scraped with a star
instrument
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The gel is removed with a dry pellet
Complete caries removal is checked with an
explorer

The cavity is cleaned with wet pellets
Finished cavity
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Advantages of carisolv

• The patients perceive the method as much more
  comfortable than drilling and anaesthetics are
  seldom needed.
• Saves time
• Avoids removal of unnecessary healthy dental
  tissues

Action of excavator. Healthy dentine is also
removed.
Selective removal of softened dentine caries with
the Carisolv instrument. Healthy dentine is not
affected.
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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.

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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.

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• 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.

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Thank you