Prof. Asaad Javaid MCPS, MDS College of Dentistry Ha’il University, Saudi Arabia

University of Ha’il

Treating caries or cavities??

Learning Objectives Describe diff. b/w old & new caries definition Differentiate b/w caries disease and lesion Mention current caries treatment strategies

Caries - old definition A disease which irreversibly damages the mineralized tissues of a tooth

Logical treatment Surgical removal of irreversibly damaged tissue and restoring it with a synthetic material

Consequences of a restoration A small restoration turns into larger one

Why did it happen?

It happened Because cavity (caries lesion) was treated but the caries disease was not

Caries disease & cavity / lesion Caries lesion (Cavity) An invisible process during which bacteria in the mouth produce acids that destroy the surfaces of teeth Needs diagnosis through saliva and bacterial tests If the disease stays untreated, it can demineralize hard tooth tissues to the point that a visible lesion (cavity) forms

New definition It is a multifactorial infectious disease of calcified tooth tissues characterized by alternating process of demineralization and remineralization

New definition reveals An infectious disease Saliva plays a significant role Remineralization may be induced Cariogenic diet plays a role

Caries – an infectious disease The cariogenic bacteria are Streptococcus Mutans Streptococcus Sobrinus Lactobacilli

Do we ever assess bacterial count in patient’s mouth?

Role of Saliva Saliva pH Viscosity Quantity – flow rate Buffering capacity

Do we get any of these tests done for caries patients?

Remineralization It may be induced through Application of fluoride varnish Application of fluoride gel Use of fluoride mouth washes Chewing Xylitol containing gums

Remineralization

Do we employ any of these therapeutic agents?

Cariogenic diet Fermentable dietary carbohydrates lower the pH of saliva and plaque causing caries activity in a mouth

Do we analyze patients’ diet?

Drill therapy Conventional drill and fill method is still being followed

How should caries be treated?

Caries Risk Assessment (CRA) Management

CRA Various CRA tools (CAT) are available

Low risk patients No cavitated lesions May have inactive white spots (smooth, shiny) Bacteria MS levels low Diet normal, sugar levels low Normal Saliva levels Low DMFT

At risk patients One or more cavitated lesions May have white spot lesions (active/inactive) Bacterial MS levels very high Sugar intake very high Saliva levels low (xerostomia) High DMF

Surprising rock !!

Patient At risk

Management Pain control Infection control Definitive restorations Dietary counselling Salivary flow Monitoring

Pain control When patient comes with pain, do the needful to remove pain

Infection control Bacterial count Activity of carious lesion Therapeutic restoration Therapeutic agents

Bacterial count Perform a Mutans Streptococci / Lactobacilli count test Bacterial levels over 100,000 CFU indicate a caries active status Level of under 100,000 CFU should be achieved before placing any definitive restoration

Activity of lesion Caries activity can be evaluated by examining the texture and appearance of white spot lesions and cavitated lesions

Lesion texture Active lesion Inactive lesion White Chalky Porous Rough Brown to black Shiny Smooth Hard

No treatment No treatment is required for inactive lesions

Therapeutic restoration Place Interim Therapeutic Restoration (ITR) to restore and prevent the progression of dental caries prior to definitive restoration in active cavitated lesions

ITR technique Remove caries using hand/rotary instrument Minimize the leakage of the restoration with maximum caries removal from the periphery (DEJ) of the lesion

Contd---- Restore the tooth with GIC or resin-modified GIC Follow-up care with topical fluorides and oral hygiene instruction improves the treatment outcome as GIC has fluoride releasing and recharging ability

GIC recharging Prescribe Fluoride mouth rinses X 2 times a day Fluoride tooth brushing X 2 times a day

Therapeutic agents Prescribe mouth rinsing with ½ oz (15 ml) Chlorhexidine (CHX) before bed for 2-3 weeks CHX varnishes are also available for topical application to control ms

Definitive restoration Once the Mutans Streptococcus / Lactobacilli count is reduced to level less than 100,000 CFU, place definitive restoration

Remineralization protocols Non cavitated lesions

Non- cavitated lesions Smooth surface caries not extending greater than 1/3 of the way through the dentin, are treated with a remineralization protocol

Induction of remineralization Prescribe: Fluoride rinse (.05%) X 2 times a day 2 sticks of Xylitol gum for 5 minutes 3 times/day after meals

Contd--- Apply low concentration 0.2 - 1.1% NaF gel 1% fluoride gel can be used, 5 minutes twice per day for 3 days 0.2% gel can be used 5 minutes daily for two weeks Application is repeated every 6 months

Contd---- Apply high concentration Fluoride varnish at intervals of 3-6 months

Non- cavitated lesions Pit and fissure caries (non-cavitated) not extending greater than 1/3 of the way through the dentin, are treated with a fluoride releasing fissure sealant CHX and other treatments as mentioned earlier

Root caries Like other caries –risk patients, ms levels must be controlled as mentioned previously In the early stages (non-cavitated), a remineralization protocol can be employed In deeper, cavitated lesions use glass ionomers for restoration

Dietary counselling Stress diet compliance

Salivary flow Stress measures to maintain normal salivary flow

Monitoring Recall the patient every 3-4 months to monitor for the first year

Summary In past: Caries treatment was directed towards treating carious lesion (cavities) Current strategy: Treatment should be directed towards treating caries disease

Questions ?