Management of Deep Carious Lesions and Caries Control Restoration

Dr. Basil Yousif

Infected and Affected Dentin

Infected dentin is the outer layer of carious dentin where bacteria are present and the collagen is irreversibly denatured. It is soft and not remineralizable and must be removed. Affected dentin is the inner layer of carious dentin where no bacteria are present, the collagen is reversibly denatured and remineralizable and should be preserved.

To distinguish clinically between these two layers, the operator traditionally observes the degree of discoloration and tests the hardness by explorer. Bacterial acids precede the bacteria in dentin caries

Firm, dry discolored or not-: affected or minimally infected Soft wet dentin discolored or not- , infected A clinical description of exactly where infected dentin stops and affected dentin begins is practically impossible.

Removal of carious dentin:

depends primarily on tactile sensation. Color differences can not be used as a reliable index for complete caries removal In rapidly advancing lesions, the softened dentin show little or no color change while more slowly advancing lesions have more discoloration.

Dentin that appears leathery, peels off in small flakes, or can be judiciously penetrated by a sharp explorer should be removed. Further excavation uncover harder and harder dentin

Evaluate the excavated area with a sharp explorer In slowly progressing caries, you may end with sclerotic dentin which is the ideal final excavation-. Classical Caries Excavation: To hear the ring of a sharp probe on a hard dentin floor

DEJ should be stain free

Methods of removal deep caries:

Spoon Excavator: requires sharp instrument and great skills

A slow-speed handpiece with a large round bur A high-speed handpiece using a round bur operated just above stall-out speed

Chemical Caries Detection

1% acid red 52 ( acid rhodamine B) Does it stain the irreversibly carious infected dentin only or both infected and affected???? Some studies reported that these dyes does not discretely discriminate the infected from affected tissues

These dyes do not stain bacteria but instead stain the organic matrix of less mineralized dentin. Chemical caries detection may provide a more conservative tooth preparation

Removal of all caries initially, regardless of the size of the lesion and pulp exposure possibility. OR seal the deepest layers of carious dentin assuming that is affected and remineralizable dentin

Indirect Pulp Capping

In asymptomatic teeth that have deep lesions where complete excavation of softened dentin is anticipated to produce pulpal exposure, the softened dentin nearest the pulp may be left

Medicate this dentin with calcium hydroxide Calcium hydroxide promotes reparative dentin bridges Such repair usually occur in 6 to 8 weeks and may be evident radiographically in 10 12 weeks.

Technique:

Partial removal of the soft caries: leave the deepest dentin that seems to expose the pulp if excavated. Ca(OH)2 is applied and then you have to : Re-opened after 8-10 weeks for further Excavation Or place the definitive restoration over the Ca(OH)2 in the same visit.

The object is to arrest the lesion and allow the formation of tertiary dentin Proper sealing is essential Most of studies results showed minimal remaining bacteria and less exposure than single excavation technique.

Why Re-Enter?
To be sure there is no exposure and removes the remaining (minimally) infected dentin further excavationTo verify that remineralization has occurred

Why not Re-enter? Remineralization will occur and any remaining bacteria become inviable Reentry into the excavated area may produce additional pulpal irritation.

The success rate: varied between 74% and 92% Prognosis is better young permanent teeth The patient should be informed that the treatment is a compromise

Deep Carious Lesion

Complete

excavation Pulp protection Definitive Restoration

Incomplete excavation Leave the deepest soft dentin and Place Ca(OH)2
Dont re-enter Soft dentin will remineralized and any remaining bacteria will become inviable

Re-enter For further excavation and verification if remineralization has occurred or not

Current Policy:

Complete excavation of the carious dentin. If pulp exposure has occurred, do direct pulp capping.

Direct Pulp Capping

Is a technique for treating a pulp exposure with a material that seals over the exposure site and promotes reparative dentin formation. If the exposure site is the result of removing softened dentin overlying the pulp, termed a carious pulpal exposure

If the pulp exposure occurs in an area of normal dentin usually as a result of operator error or misjudgment instrument or bur-, termed a mechanical pulpal exposure In both conditions, direct pulp capping is considered only when the tooth is symptomless at the time of operation, with no history of irreversible pulpitis and with normal pulp response.

Types of Pulp Exposure

Mechanical Trumatic Carious

Factors that improve the prognosis of direct pulp capping procedure: Type of exposure No lingered or spontaneous pain Normal vitality tests No tenderness to percussion Small exposure, less than 0.5 mm in diameter

Controllable bleeding Clean, uncontaminated field: rubber dam must be placed before proceeding in cavity preparation The exposure was relatively atraumatic

Clinical Procedures:

Rubber Dam placement. Complete excavation of the soft dentin Hemorrhage indicates an exposure The bleeding should be controlled using a sterile cottong pellet and any dentin chips should be washed away with copious irrigation with sterile saline

Do not blow the exposure dry with air syringe. Dry it with cotton pellete. Saliva contamination must be avoided. Cover the exposure with a hard setting calcium hydroxide cement Place a layer of resin-modified galss ionomer lining material or IRM

Continuing vitality test should be done over a long period of time Radiographic follow up also should be considered for dentin bridge formation

Materials used for DPC:

Calcium Hydroxide:

- The material of choice for a direct pulp capping technique in general practice (may be due to its antibacterial action). - It cause superficial necrosis of the pulp, followed by dentine bridge formation beneath the layer of coagulative necrosis

Clacium hydroxide acts as an initiator rather that as a substrate for repair. Mineralization of the dentin bridge is by calcium ions from the blood stream and not those from the calcium hydroxide material. Calcium hydroxide has been associated with internal root resorption when used as a pulp dressing following pulpotomy in deciduous teeth.

Direct pulp capping is contraindicated in deciduous teeth

Resin bonding agents

Mineral Trioxide Aggregate: Current research on these two materials showed a success rates equal or better than calcium hydroxide but further studies is required.

Studies on germ-free animals have shown that healing of traumatically exposed pulp occurs irrespective of the pulp capping agent It has been suggested that the action of calcium hydroxide is due to its antibacterial activity.

Partial Pulpotomy (Cvek technique).

Cvek have suggested that deep carious exposures be opened up so that 1 to 3 mm of exposed pulp can be removed (partial pulpotomy).

The aim is to remove any infected pulp tissue and to remove any dentin chips inadvertently pushed into the pulp tissue cause severe inflammatory reaction.

Caries Control Restoration:

Part of Control phase of operative treatment

When numerous acute lesions are present, the practitioner should treat these without delay in one or two appointments with the caries control procedures. Thus the rate of the carious process is significantly reduced, potential pulpal irritation is minimized, and the patient is in a healthier and more comfortable state.

It is an intermediate operative procedure in which the carious process is stopped by quick removal of the soft caries and the teeth is restored with a temporary restorative material.

Indications of Caries Control Restorations:

1. Acute (rapidly progressing) caries: lesions that have progressed at least half the distance from the DEJ to the pulp (Usually indicated in patients with high risk for caries????) 2. Teeth with questionable pulpal prognosis 3. Inadequate available time

Objectives:

Remove the decay from all of the advanced carious lesions (adverse pulpal sequelae are soon likely to occur). Remove the nidus of caries infection in the patients mouth Place appropriate pulpal medication, and restore the lesions with IRM.

Operative Technique:
1. Anesthesia 2. R.D isolation

3. Caries removal: - Initial opening of the tooth with a large carbide bur - Excavation of the soft caries, Retaining unsupported enamel is permissible

4.

Medication and Placement of IRM. If a long interval is anticipated between the caries control procedures and the permanent restoration , amalgam as a temporary restoration- can be used

5. It is usually accompanied with plaque control , dietary control, antimicrobial treatment. 6. Reevaluation for pulp health and gingival health as marker of plaque control effectiveness

7. When to replace IRM with a definitive restoration? After the condition is stabilized, Good pulpal health

Further antimicrobial treatment dietary reassessment is indicated

and