Treatment of dental caries as an infectious disease

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Treatment of dental caries as an infectious
disease

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RATIONALE

• Incipient enamel caries is caused by specific
  microorganisms
• Streptoccus mutans plus sucrose reduces the pH in
  the plaque to a critical level of 5.0-5.5, which
  can overcome the buffering capacity of saliva and
  result in demineralization of enamel

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RATIONALE

• Incipient enamel caries is caused by specific
  microorganisms
• High bacterial counts are the result of the
  patients diet, and be reduced by altering the
  diet.
• A high Strep mutans count generally indicates
  large and/or frequent ingestion of sucrose.

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RATIONALE

• Incipient enamel caries is caused by specific
  microorganisms
• A high lactobacillus count generally indicates a
  high proportion of carbohydrates in the patients
  diet.
• A normal saliva flow rate (1-2 ml/minute) and
  buffering capacity (5-7pH) discourages
  demineralization and encourages remineralization
  a low flow rate (0.7 ml/minute or less) and
  buffering capacity (lt4pH) will encourage
  demineralization and caries activity

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RATIONALE

• A diet diary can indicate dietary intake, and
  dietary counseling may result in an altered diet
  that will decrease caries activity.
• Lactobacillus counts are significantly higher in
  patients with open caries lesions restoration of
  these lesions will produce a dramatic drop in the
  count.

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RATIONALE

• Caries begins as a subsurface lesion which can be
  remineralized as long as the surface remains
  intact.
• Supersaturated salivary calcium and phosphates in
  the presence of fluoride can slowly remineralize
  demineralized enamel.
• Remineralized enamel is more resistant to
  subsequent demineralization than original intact
  enamel

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RATIONALE

• The effect of oral hygiene/plaque control on
  caries activity is controversial. Oral hygiene is
  much less important than diet, but complete
  plaque removal daily will reduce caries on
  exposed tooth surface

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RATIONALE

• Various anti-microbial mouthwashes will reduce
  certain cariogenic microorganisms, but may also
  interfere with the normal oral flora and allow
  overgrowth of undesirable organisms. For example,
  Chlorohexadine Gluconate mouthwashes may reduce
  Strep. Mutans counts, but will not reach
  organisms in deep lesions. Deep lesions should
  therefore be eliminated with caries control
  restorations before instituting anti-microbial
  therapy.

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RATIONALE

• Fluoride applied in various ways (systemic,
  clinical and home) decreases cariogenic organisms
  and promotes remineralization.

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RATIONALE

• Vigorous treatment to a testable endpoint (the 4
  lab tests of saliva at recall) is preferable to
  vague, ineffective treatment ad infinitum.
  Patient are very discouraged when they follow the
  dentists advice and caries activity still
  continues.

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RATIONALE

• Not all patients require the same treatment
  some will be over-treated and some under-treated
  unless proper diagnosis and treatment is done. It
  is important to determine which patients have the
  signs, symptoms and history that are indications
  of high caries activity and need to be placed on
  a Caries Risk Management Program.

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Treatment planning for restorative dentistry
(high caries risk )

• The restorative treatment must be coordinated
  with all the means utilized in the Caries Risk
  Management Program (diet, oral hygiene, fluoride,
  antimicrobials, saliva stimulation, ect.)

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Treatment planning for restorative dentistry (
high caries risk )

• Early elimination of all dentinal caries is very
  important in eliminating the source of Strep.
  Mutans. Caries control restorations may be
  necessary to accomplish this quickly.

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Treatment planning for restorative dentistry (
high caries risk )

• Types of lesions and choice of treatment
• Routine use should be made of fluoride
  application to cavity preparations and
  fluoride-releasing liners, bases and restorative
  materials.

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Types of lesions and choice of treatment ( high
caries risk )

• Smooth surface incipient caries
• Sticky pits and fissures
• Sticky pits and fissures with incipient caries
• Small and moderate lesions
• Deep lesions
• Root caries

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Types of lesions and choice of treatment ( high
caries risk )

• Smooth surface incipient caries
• Reminerlize with clinical topical fluoride
  applications and home application of fluoride by
  various means toothpaste, rinses, brush-on
  gels, custom tray-applied gels, ect.
• Sticky pits and fissures
• Pit and fissure selants

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Types of lesions and choice of treatment ( high
caries risk )

• Sticky pits and fissures with incipient caries
• Preventive resin/sealants (Remove caries, place
  composite in the cavity and cover all with
  sealant)
• Definitive amalgam restorations
• Small and moderate lesions
• Definitive amalgam, composite or glass ionomer
  restorations

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Types of lesions and choice of treatment ( high
caries risk )

• Deep lesion
• Caries control restorations with ZnO-eugenol,
  glass ionomer or amalgam, and the definitive
  resotrations after caries activity has decreased
• Root caries
• Fluoride applications
• Glass ionomer restoration

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Treatment planning for restorative dentistry (
high caries risk )

• Routine use should be made of fluoride
  application to cavity preparations and fluoride
  releasing liners, bases and restorative materials

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The indication for placing of patients on a
Caries Risk Management Program
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• A previous history of caries, demonstrated by
  numerous restoration, especially with recurrent
  caries.
• Numerous large carious lesion, especially those
  with depth greater than width.

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• Unpigmented demineralized areas on smooth
  surfaces, often on the lingual third. Lesions on
  the lingual surfaces indicate an even higher
  risk.
• Recent incidence of new lesions on recall
  examinations.
• Patients requiring extensive reconstructive
  procedure

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• Patients (especially the elderly) with root
  caries.
• Patients that report a history of a physical
  condition, medical treatment (especially
  radiation therapy), medication and dietary
  changes that would influence saliva or oral flora
• History of continued high quantity intake of
  carbonated beverages

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• Patients with active caries-lesions that are
  unpigmented, of a soft consistency, moist,
  sensitive to Sweets, cold or excarvation, and
  with depth greater than width.

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DX ACTIVE INACTIVE
COLOR LIGHT DARK
CONSISTENCY MUSHY FIRM
MOISTURE WET DRY
SYMPTOM SENSITIVE NONE
SHAPE DEPTHgtWIDTH WIDTHgtDEPTH
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Caries control restoration

• The goal is elimination of the source of
  cariogenic organisms by removal of caries from
  all deep lesions and placement of temporary
  restorations early in the treatment. This is very
  important in effecting reversal of the active
  caries process.

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Caries Control Restoration

• Cavity preparation is done quickly without
  definitive cavity preparation. Undermined enamel
  be left to aid in retention of these treatment
  restorations, especially if restoratives are used
  that bond to tooth structure.

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Caries Control Restoration

• Pulpal response to the restorative treatment can
  be observed and endodontic treatment instituted
  if necessary before planning definitive
  restoration.

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Caries Control Restoration

• The restoration protects the pulp against further
  insult and promotes healing of the lesion by
  remineralization of affected dentin and
  stimulation of reparative dentin.

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Caries Control Restoration

• Patient comfort and mastication are quickly
  improved by decreasing sensitivity from open
  cavities, food impaction, ect. Occlusal and
  proximal stability is maintained.

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Caries Control Restoration

• Restorative materials used for caries control
  restoration.
• CaOH is bacteriocidal and stimulates reparative
  dentin
• Reinforced Zinc Oxide-eugenol is obtundant,
  reducing pain and sensitivity it is
  bacteriocidal to organisms deep in the cavity,
  and it seals margins well for several months,
  preventing ingress of nutrients to the organisms.
  Strength is fair.

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Caries Control Restoration

• Restorative materials used for caries control
  restoration.
• Glass ionomer-bonds to tooth structure for
  improved retention, it release fluoride which
  reduces organisms and promotes remineralization,
  has good marginal seal, fair strength, and is
  esthetically pleasing.
• Amalgam has excellent strength, maintains
  occlusal and proximal relationships, fair
  marginal seal, best for long term temporary

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Caries Control Restoration

• Similar restorations can be used to quickly
  restore deep lesions for emergency patients when
  time is limited.
• Caries control restorations should be left in
  place until caries activity tests indicate a
  significant decrease in caries activity.
  Definitive restorations can then be placed with
  a promise of much greater longevity.

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Caries Control Restoration

• Indirect pulp capping is often done in
  conjunction with caries control restorations.
• Pulp must show radiographic and clinical signs
  and symptoms of vitality.
• All caries is removed at the periphery,
  establishing a sound DEJ.

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Caries Control Restoration
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Caries Control Restoration

• Indirect pulp capping is often done in
  conjunction with caries control restorations.
• All infected dentin is excavated with large round
  burs and excavators, being careful not to expose
  the pulp. Basic fuchsin effectively identifies
  infected dentin.
• A small amount of firm caries (affected dentin)
  is left over sites of potential exposure.

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Caries Control Restoration

• Indirect pulp capping is often done in
  conjunction with caries control restorations.
• Calcium hydroxide liner is placed in the deepest
  areas. The high pH of the CaOH will neutralize
  acid, kill bacteria and stimulate formation of
  restorative dentin.
• The rein-forced ZOE, glass ionomer or amalgam
  restoration is placed

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Caries Control Restoration

• Indirect pulp capping is often done in
  conjunction with caries control restorations.
• After 6-8 weeks the entire restoration is
  removed, any remaining caries is removed and a
  definitive restoration is planned.

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