1. Diagnosis and Treatment Options
Dental Caries
Diagnosis and Treatment Options

2. Dental Caries Infectious , 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
Demineralization
Subclinical
Incipient lesion
Demineralization
Remineralization
Remineralization
Cavitated lesion
(Irreversible tooth Morbidity)

3. 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.

4. 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

5. 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

6. Diagnosis and Treatment Options Based on location
Pits and fissures
Smooth surfaces
Proximal surfaces
Root caries
Secondary caries

7. Pits and Fissures Caries
Demineralization around the wall and bottom of the pits (incipient lesion)
Enamel
Once demineralization reach the DEJ, it begins spreading laterally
Dentin
Start infecting the underlying dentin (surgical intervention indicated)

8. 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

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

10. Possible Result of Probing into an Incipient Lesion

11. Diagnosis of Pits and Fissures Caries - Current Method
Use an explorer to remove plaque and food debris from the fissure orifice
Under 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

12. 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 enamel
Look 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

13. Current Problems Relating to the Diagnosis of Pits and Fissure Caries
Uneven diagnostic conclusion among dentists
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

14. New Technologies New quantitative diagnostic system e.g. DIAGNOdent
Laser Fluorescence
J Dent 2002;30:
Specificity higher for visual
Sensitivity higher for DIAGNOdent
Frequeucy-Domain Infrared Photothermal Radiometry and Modulated Laser Luminescence. Jeon RJ et al. Caries Res 2004;38:

15. Conclusive evidence of the presence of cavitated lesion
Treatment Options
Conclusive evidence of the presence of cavitated lesion
Bitewing radiographs
Definitive “halo” around the pits and fissures
Cavitated enamel
SURGICAL

16. Treatment Options Sealants or restore with composite
Presence of questionable cavitated lesion
Heavily stained pits and fissures
Questionable halo
Sealants or restore with composite
Consider patient’s age and caries risk status

17. Sealants in young or caries active or prone patients
Treatment Options
Deep pits and fissures
Sealants in young or caries active or prone patients

18. 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.

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

20. 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.

21. 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)

22. Radiographic Diagnosis of Proximal Caries
Triangular shaped radiolucency - gingival to the proximal contact area - pointing towards DEJ

23. Radiographic Diagnosis of Proximal Caries
Triangular radiolucency- point end short of DEJ
Point end right at DEJ
Radiolucency in dentin

24. Radiolucency in dentin
Treatment Options
Radiolucency in dentin
SURGICAL INTERVENTION

25. Treatment Options Triangular radiolucency point ended right at DEJ
SURGICAL OR NON-SURGICAL -
Should depend on caries status/activities and other patient’s factors

26. Treatment Options Triangular radiolucency point - ended short of DEJ
NON-SURGINCAL MANAGEMENT

27. 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.

28. Longitudinal Radiographic Data on a Patient (mesial of #3)
1984
1995
2003
1987

29. Inactive , Cavitated Lesion

30. Treatment Option - Surgical
Small lesion
Lesion specific restoration should be your primary choice; material specific restoration if unable to isolate or for economic reason

31. Treatment Option - Surgical
Medium/large lesion
Direct Restoration - lesion specific vs material specific
Indirect Restoration - should only be considered if patient’s caries status become more stable

32. Current Problems Relating to the Diagnosis of Proximal Caries
Incipient lesion = triangular radiolucency point short of DEJ
Cavitated lesion = triangular radiolucency point at or past DEJ
Disagreement among dentist in exactly where the point end, and when should surgical intervention indicated

33. Current Problems Relating to the Diagnosis of Proximal Caries
No reliable objective diagnostic technique to differentiate between active and inactive caries lesion
Best evidence: longitudinal radiographic data on the patient
Supporting evidence: patient’s caries risk and other patient’s factors

34. 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?

35. Smooth Surface Caries - Diagnosis
Dry, clean, magnified
Plaque covered surface
Cleaned surface

36. Diagnosis of Smooth Surface Caries
Incipient (chalky white, brown, black)
Cavitated

37. Diagnosis of Smooth Surface Caries
Arrested (Shiny, white, brown)
Active (Matte, white)

38. SURGICAL (patient has esthetic concern)
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)

39. Cavitated, active (matte surface)
Treatment Options
Cavitated, active (matte surface)
SURGICAL

40. 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.

41. Treatment Options Composite
RMGI - patient with very high caries potential
Amalgam

42. Root Caries Supragingival caries lesion located at CEJ
Diagnostic criteria similar to smooth surface lesion
Treatment options similar to smooth surface lesion (1st preference = RMGI)

43. Disease Trend in Dental Office
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.

44. Existing Restoration - Clinical Status
Secondary Caries
Marginal Integrity
marginal defect
overhang
open margin
Contour
proximal contact
axial contour
occlusion
Biomechanical Form
restoration fracture
tooth fracture
Esthetic
patient’s esthetic concern

45. Secondary Caries Carious lesion located at the margin of a restoration
It is the most common reason for replacing an existing restoration

46. Secondary Caries

47. Diagnosis of Secondary Caries
Diagnosis should NOT 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

48. Diagnosis of Secondary Caries Visually Accessible Area
Primary Diagnostic Tool
Visual
Dry, clean, magnified, properly illuminated

49. Diagnosis of Secondary Caries Visually Inaccessible Area
Tools
Tactile
&
Bitewings Radiograph

50. 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 caries
An uniform radiolucent line around a composite restoration - may be due to the presence of a thick layer of adhesive resin.
Radiographic burnout at CEJ

51. Secondary Caries - Treatment Options
Surgical
Reasons
Most 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)

52. Secondary Caries - Treatment Options
Direct vs indirect
Financial
Patient’s caries status, oral hygiene status, dental IQ, motivation, risk factors