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

3. University of Ha’il

4. Treating caries or cavities??

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

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

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

8. Consequences of a restoration
A small restoration turns into larger one

9. Why did it happen?

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

11. 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

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

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

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

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

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

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

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

19. Remineralization

20. Do we employ any of these therapeutic agents?

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

22. Do we analyze patients’ diet?

23. Drill therapy
Conventional drill and fill method is still being followed

24. How should caries be treated?

25. Caries Risk Assessment (CRA)
Management

26. CRA
Various CRA tools (CAT) are available

28. 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

29. 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

30. Surprising rock !!

31. Patient At risk

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

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

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

35. 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

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

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

38. No treatment
No treatment is required for inactive lesions

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

40. 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

41. 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

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

43. 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

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

45. Remineralization protocols
Non cavitated lesions

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

47. 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

48. 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

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

50. 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

51. 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

52. Dietary counselling
Stress diet compliance

53. Salivary flow
Stress measures to maintain normal salivary flow

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

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

56. Questions ?