Dental Caries

Diagnosis and Treatment Options

Dental CariesInfectious , multifactorial disease.Characterized by the loss of mineral contents of the calcified tissue.Presents in a spectrum of presentation.Lesion status: incipient/cavitated; active/inactive

Subclinical

Incipient lesion

Cavitated lesion(Irreversible tooth Morbidity)

Demineralization

Remineralization

Demineralization

Remineralization

Treatment Options

Traditional - detection of caries lesion followed by immediate restoration.Current management philosophy - treatment decision should be based on the status of the lesion (incipient vs cavitated, active vs inactive), and other patient’s factors (age, frequency of visit, oral hygiene status, dental IQ, motivation, risk factor).Non-surgical management (remineralization) of the disease should be part of the treatment plan.

Examples of Treatment Options

Cavitated, active - surgical (restoration)Non-cavitated, active - surgical or non-surgical (remineralization)Cavitated, inactive - surgical (stress bearing area) or non-surgical (non stress bearing area)Non-cavitated, inactive - non-surgical

Dilemma of Caries Diagnosis

No reliable objective diagnostic technique to differentiate between incipient lesion and cavitated lesion.No reliable objective diagnostic technique to differentiate between active and inactive caries lesion

Diagnosis and Treatment Options

Based on location

Pits and fissuresSmooth surfacesProximal surfacesRoot cariesSecondary caries

Enamel

Dentin

Pits and Fissures Caries

Demineralization around the wall and bottom of the pits (incipient lesion)

Once demineralization reach the DEJ, it begins spreading laterally

Start infecting the underlying dentin (surgical intervention indicated)

Diagnosis of Pits and Fissures Caries - Traditional Method

Using an explorer to probe into the pit/fissure - a feel of “catch” or a “stick” indicate the presence of caries at the bottom of the pit/fissure

Problem with the Traditional MethodEven at the stage where surgical treatment is indicated, the occlusal enamel may still be intactThe “catch” or “stick” you feel when you use your explorer to probe into an intact pits is a result of the “wedging effect”

Possible Result of Probing into an Incipient Lesion

Diagnosis of Pits and Fissures Caries - Current Method

Use an explorer to remove plaque and food debris from the fissure orificeUnder good lighting, isolation (dry) and magnification; visually inspect for any damage to the enamel Look for any subtle color changes around the pits and fissures

Diagnosis of Pits and Fissures Caries - Current Method

Enamel is low in opacity, thus any changes in color (e.g. caries dentin) in the underlying dentin will show through the enamelLook for a gray shadow or opaque area around the pits and fissures - a “halo”Ignore the color change within the pits and fissures Bitwing radiographs may be helpful in diagnosing deep lesion

Current Problems Relating to the Diagnosis of Pits and Fissure Caries

Uneven diagnostic conclusion among dentistsNo reliable objective diagnostic technique to differentiate between incipient lesion and cavitated lesion.No reliable objective diagnostic technique to differentiate between active and inactive caries lesion

New TechnologiesNew quantitative diagnostic system e.g. DIAGNOdent

Laser FluorescenceJ Dent 2002;30:129-134Specificity higher for visualSensitivity higher for DIAGNOdent

• Frequeucy-Domain Infrared Photothermal Radiometry and Modulated Laser Luminescence. Jeon RJ et al. Caries Res 2004;38:497-513

Treatment OptionsConclusive evidence of the presence of cavitated lesion

Bitewing radiographs

Definitive “halo” around the pits and fissures

Cavitated enamel

SURGICAL

Treatment Options

Presence of questionable cavitated lesionHeavily stained pits and fissuresQuestionable halo

Sealants or restore with composite

Consider patient’s age and caries risk status

Treatment Options

Deep pits and fissures

Sealants in young or caries active or prone patients

Treatment Options - Surgical

Lesion specific restoration should be the primary option.Material specific restoration can be considered if unable to isolate or for economic reason.

Important Research

Mertz-Fairhurst EJ et.al. JADA 1998;129:410-412

Large occlusal lesions were treated with acid etch composite restorations, leaving soft, demineralized

dentin both at the DEJ and in the base of the cavity. The teeth were followed over 10 years.

There were no report of failed restoration, pulpitis or pulp death.

Empirical Evidence

Sealing caries may not work.It will work if you can maintain a complete and absolute seal of the enamel.However, a complete seal is very difficult to achieve.Beside pits and fissures, there may be micro cracks on the enamel.

Proximal Caries - Diagnosis

Bitewing radiographs

Trans-illumination - placing the mirror or light source on the lingual side of anterior teeth and directing light through the teeth. Lesion will show through as a dark area

Opacity or color change under the marginal ridge (under dry and clean environment)

Radiographic Diagnosis of Proximal Caries

Triangular shaped

radiolucency - gingival to the

proximal contact area -

pointing towards DEJ

Radiographic Diagnosis of Proximal Caries

Triangular radiolucency- point end short of DEJ

Point end right at DEJ

Radiolucency in dentin

Treatment Options

Radiolucency in dentin

SURGICAL INTERVENTION

Treatment Options

Triangular radiolucency point ended right at DEJ

SURGICAL OR NON-SURGICAL -Should depend on caries status/activities and other patient’s factors

Treatment Options

Triangular radiolucency point - ended short of DEJ

NON-SURGINCAL MANAGEMENT

Treatment Options - Current philosophy

Unless there are clear evidence of radiolucency in dentin, all decision to initiate surgical intervention should take into consideration of patient’s caries risk status and other patient’s factors.

Reason: these lesions may be arrested lesions or potentially can be converted from active to arrested lesion using various non-surgical management techniques.

Longitudinal Radiographic Data on a Patient (mesial of #3)

1984

1987

1995

2003

Inactive , Cavitated Lesion

Treatment Option - Surgical

Small lesionLesion specific restoration should be your primary choice; material specific restoration if unable to isolate or for economic reason

Treatment Option - Surgical

Medium/large lesionDirect Restoration - lesion specific vs material specificIndirect Restoration - should only be considered if patient’s caries status become more stable

Current Problems Relating to the Diagnosis of Proximal Caries

Incipient lesion = triangular radiolucency point short of DEJCavitated lesion = triangular radiolucency point at or past DEJDisagreement among dentist in exactly where the point end, and when should surgical intervention indicated

Current Problems Relating to the Diagnosis of Proximal Caries

No reliable objective diagnostic technique to differentiate between active and inactive caries lesionBest evidence: longitudinal radiographic data on the patientSupporting evidence: patient’s caries risk and other patient’s factors

Future

Quantitative data on the exact amount of mineral loss (incipient vs cavitated) - e.g. technology use in diagnosing pits and fissure caries (DIAGNOdent)Better understanding in the differences between active and arrested lesion - e.g. qualitative and quantitative differences in the mineral contents; microbiological differences?Active Arrested

Time?

Smooth Surface Caries - Diagnosis

Dry, clean, magnified

Plaque covered surface Cleaned surface

Diagnosis of Smooth Surface CariesIncipient

(chalky white, brown, black)

Cavitated

Diagnosis of Smooth Surface Caries

Active (Matte, white)

Arrested (Shiny, white, brown)

Treatment Options

• Incipient, active• Incipient, arrested• Cavitated, arrested

• NON-SURGICAL (control measures depends on the caries status of the patient)

• SURGICAL (patient has esthetic concern)

Treatment Options

Cavitated, active (matte surface)

SURGICAL

Problem with Treatment Option

No objective diagnostic tool to differentiate between active and arrested lesion. Thus sometime it may be difficult to decide when to initiate surgical intervention.

Treatment Options

CompositeRMGI - patient with very high caries potentialAmalgam

Root Caries

Supragingival caries lesion located at CEJDiagnostic criteria similar to smooth surface lesionTreatment options similar to smooth surface lesion (1st preference = RMGI)

Because of the decrease in the incidence of dental caries (primary caries) in most industrialized countries; maintenance of previously inserted restoration has become the major workload in a typical dental practice.

THUS

Evaluation of existing restorations is becoming the main focus of the subjective and objective examination of your patient. How you are handling the findings is what’s going to define your treatment or your practice philosophy.

Disease Trend in Dental Office

Existing Restoration - Clinical Status

Secondary CariesMarginal Integrity

marginal defectoverhangopen margin

Contourproximal contactaxial contourocclusion

Biomechanical Form

restoration fracturetooth fracture

Estheticpatient’s esthetic concern

Secondary Caries

Carious lesion located at the margin of a restoration

It is the most common reason for replacing an existing restoration

Secondary Caries

Diagnosis of Secondary Caries

Diagnosis should NOTNOT be based on using a sharp explorer and trying to get a “stick” at the margin of a restoration

Tools used for diagnosis are based on the location of the margin

Diagnosis of Secondary Caries

Visually Accessible AreaPrimary Diagnostic

Tool

Visual

Dry, clean, magnified, properly illuminated

Diagnosis of Secondary Caries

Visually Inaccessible Area

Tools

Tactile&

Bitewings Radiograph

Common Mistakes in Diagnosing Secondary Caries

Use of a sharp explorer and probe in to a defect, using a “stick” as the diagnostic criteria for the presence of secondary cariesAn uniform radiolucent line around a composite restoration - may be due to the presence of a thick layer of adhesive resin. Radiographic burnout at CEJ

Secondary Caries - Treatment Options

Surgical

ReasonsMost of the time when the lesions are detected, they are frank cavitated lesion.These lesions are more likely to be active lesion (time frame of the development of the disease)These lesions are in a very retentive area (limited ability for non-surgical management techniques to work; similar to pits and fissure caries)

Secondary Caries - Treatment Options

Direct vs indirectFinancialPatient’s caries status, oral hygiene status, dental IQ, motivation, risk factors