Treatment of dental caries as an infectious disease

Treatment of dental caries Treatment of dental caries as an infectious diseaseas an infectious disease

가천의대 치의학교실가천의대 치의학교실

RATIONALERATIONALE

• Incipient enamel caries is caused by speIncipient enamel caries is caused by specific microorganismscific microorganisms– Streptoccus mutans plus sucroseStreptoccus mutans plus sucrose reduces t reduces t

he pH in the plaque to a he pH in the plaque to a critical level of 5.0-critical level of 5.0-5.55.5, which can overcome the buffering capa, which can overcome the buffering capacity of saliva and result in demineralization city of saliva and result in demineralization of enamelof enamel

RATIONALERATIONALE

• Incipient enamel caries is caused by speIncipient enamel caries is caused by specific microorganismscific microorganisms– High bacterial counts are the result of High bacterial counts are the result of the pthe p

atient’s dietatient’s diet, and be reduced by altering the , and be reduced by altering the diet.diet.

– A high Strep mutans count generally indicatA high Strep mutans count generally indicates large and/or es large and/or frequent ingestion of sucrosfrequent ingestion of sucrose. e.

RATIONALERATIONALE

• Incipient enamel caries is caused by speIncipient enamel caries is caused by specific microorganismscific microorganisms– A A high lactobacillushigh lactobacillus count generally indicate count generally indicate

s a s a high proportionhigh proportion of carbohydrates in the p of carbohydrates in the patient’s diet.atient’s diet.

– A normal saliva flow rate (1-2 ml/minute) anA normal saliva flow rate (1-2 ml/minute) and buffering capacity (5-7pH) discourages ded buffering capacity (5-7pH) discourages demineralization and encourages remineralizatmineralization and encourages remineralization; a ion; a low flow rate (0.7 ml/minute or less)low flow rate (0.7 ml/minute or less) and and buffering capacity (<4pH)buffering capacity (<4pH) will encourage will encourage demineralization and caries activitydemineralization and caries activity

RATIONALERATIONALE

• A diet diary can indicate dietary A diet diary can indicate dietary intake, and intake, and dietary counselingdietary counseling may may result in an altered diet that will result in an altered diet that will decrease caries activity.decrease caries activity.

• Lactobacillus counts are significantly Lactobacillus counts are significantly higher in patients with open caries higher in patients with open caries lesions; lesions; restoration of these lesions restoration of these lesions will produce a dramatic drop in the will produce a dramatic drop in the count.count.

RATIONALERATIONALE

• CariesCaries begins as a begins as a subsurface lesionsubsurface lesion whi which can be remineralized as long as the sch can be remineralized as long as the surface remains intact.urface remains intact.

• Supersaturated salivary Supersaturated salivary calciumcalcium and and phophosphatessphates in the presence of fluoride can s in the presence of fluoride can slowly remineralize demineralized enamel.lowly remineralize demineralized enamel.

• Remineralized enamel is more resistant tRemineralized enamel is more resistant to subsequent o subsequent demineralizationdemineralization than origi than original intact enamelnal intact enamel

RATIONALERATIONALE

• The effect of The effect of oral hygiene/plaque oral hygiene/plaque controlcontrol on caries activity is on caries activity is controversialcontroversial. Oral hygiene is much . Oral hygiene is much less importantless important than diet, but than diet, but complete plaque removal daily will complete plaque removal daily will reduce cariesreduce caries on exposed tooth on exposed tooth surfacesurface

RATIONALERATIONALE

• Various Various anti-microbial mouthwashesanti-microbial mouthwashes will r will reduce certain cariogenic microorganisms, educe certain cariogenic microorganisms, but may also but may also interfere with the normal orainterfere with the normal oral floral flora and and allow overgrowth of undesirable allow overgrowth of undesirable organismsorganisms. For example, Chlorohexadine . For example, Chlorohexadine Gluconate mouthwashes may reduce StreGluconate mouthwashes may reduce Strep. Mutans counts, but will not reach organp. Mutans counts, but will not reach organisms in deep lesions. isms in deep lesions. Deep lesionsDeep lesions shoul should therefore be eliminated with d therefore be eliminated with caries contrcaries control restorationsol restorations before instituting anti-micr before instituting anti-microbial therapy.obial therapy.

RATIONALERATIONALE

• Fluoride appliedFluoride applied in various ways (systemi in various ways (systemic, clinical and home) c, clinical and home) decreases cariogendecreases cariogenic organismsic organisms and promotes remineralizat and promotes remineralization.ion.

RATIONALERATIONALE

• Vigorous treatmentVigorous treatment to a testable to a testable endpoint (the 4 lab tests of saliva endpoint (the 4 lab tests of saliva at recall) is at recall) is preferable to vague, preferable to vague, ineffective treatment ad infinitum.ineffective treatment ad infinitum. Patient are very discouraged when Patient are very discouraged when they follow the dentist’s advice and they follow the dentist’s advice and caries activity still continues.caries activity still continues.

RATIONALERATIONALE

• Not all patients require the same Not all patients require the same treatmenttreatment – some will be over-treated – some will be over-treated and some under-treated unless and some under-treated unless proper proper diagnosis and treatment is donediagnosis and treatment is done. It is . It is important to determine which patients important to determine which patients have the have the signs, symptoms and historysigns, symptoms and history that are indications of high caries that are indications of high caries activity and need to be placed on a activity and need to be placed on a Caries Risk Management Program.Caries Risk Management Program.

Treatment planning for Treatment planning for restorative dentistry (high restorative dentistry (high caries risk )caries risk )

• The restorative treatment must be coordiThe restorative treatment must be coordinated with all the means utilized in the nated with all the means utilized in the CCaries Risk Management Programaries Risk Management Program (diet, or(diet, oral hygiene, fluoride, antimicrobials, salival hygiene, fluoride, antimicrobials, saliva stimulation, ect.)a stimulation, ect.)

Treatment planning for Treatment planning for restorative dentistry ( high restorative dentistry ( high caries risk )caries risk )

• Early elimination of all dentinal caries is Early elimination of all dentinal caries is very important in eliminating the source very important in eliminating the source of Strep. Mutans. of Strep. Mutans. Caries control restoratiCaries control restorations may be necessary to accomplish thions may be necessary to accomplish this quickly.s quickly.


• Types of lesions and choice of Types of lesions and choice of treatment:treatment:

• Routine use should be made of Routine use should be made of fluoride application to cavity fluoride application to cavity preparations and preparations and fluoride-releasing fluoride-releasing liners, bases and restorative liners, bases and restorative materials.materials.

Types of lesions and Types of lesions and choice of treatment ( high choice of treatment ( high caries risk )caries risk )

• Smooth surface incipient caries;Smooth surface incipient caries;• Sticky pits and fissuresSticky pits and fissures• Sticky pits and fissures with Sticky pits and fissures with

incipient cariesincipient caries• Small and moderate lesionsSmall and moderate lesions• Deep lesionsDeep lesions• Root cariesRoot caries


• Smooth surface incipient caries: Smooth surface incipient caries: – Reminerlize with clinical topical fluoride applReminerlize with clinical topical fluoride appl

ications and home application of fluoride by ications and home application of fluoride by various means ; toothpaste, rinses, brush-ovarious means ; toothpaste, rinses, brush-on gels, custom tray-applied gels, ect.n gels, custom tray-applied gels, ect.

• Sticky pits and fissures: Sticky pits and fissures: – Pit and fissure selantsPit and fissure selants


• Sticky pits and fissures with incipient carieSticky pits and fissures with incipient cariess– Preventive resin/sealants (Remove caries, placPreventive resin/sealants (Remove caries, plac

e composite in the cavity and cover all with see composite in the cavity and cover all with sealant)alant)

– Definitive amalgam restorationsDefinitive amalgam restorations• Small and moderate lesionsSmall and moderate lesions

– Definitive amalgam, composite or glass ionomDefinitive amalgam, composite or glass ionomer restorationser restorations


• Deep lesion:Deep lesion:– Caries control restorationsCaries control restorations with ZnO-eugeno with ZnO-eugeno

l, glass ionomer or amalgam, and the l, glass ionomer or amalgam, and the definitdefinitive resotrations after caries activity has decrive resotrations after caries activity has decreasedeased

• Root caries:Root caries:– Fluoride applicationsFluoride applications– Glass ionomer restorationGlass ionomer restoration


• Routine use should be made of Routine use should be made of fluoride application to cavity fluoride application to cavity preparationspreparations and fluoride releasing and fluoride releasing liners, bases and restorative liners, bases and restorative materialsmaterials

The indication for placing The indication for placing of patients on a Caries of patients on a Caries Risk Management ProgramRisk Management Program

• A previous history of caries,A previous history of caries, demonstrated by numerous demonstrated by numerous restoration, especially with restoration, especially with recurrent caries.recurrent caries.

• Numerous large carious lesion, Numerous large carious lesion, especially those with especially those with depth greater depth greater than width.than width.

• Unpigmented demineralized areas on smUnpigmented demineralized areas on smooth surfaces, often on the lingual third. ooth surfaces, often on the lingual third. Lesions on the lingual surfaces indicate Lesions on the lingual surfaces indicate an even higher risk.an even higher risk.

• Recent incidence of new lesions on recalRecent incidence of new lesions on recall examinations.l examinations.

• Patients requiring extensive reconstructivPatients requiring extensive reconstructive proceduree procedure

• Patients (especially the elderly) with Patients (especially the elderly) with root cariesroot caries..

• Patients that report a history of a Patients that report a history of a physical condition, medical treatment physical condition, medical treatment (especially radiation therapy), (especially radiation therapy), medication and dietary changes that medication and dietary changes that would would influence saliva or oral florainfluence saliva or oral flora

• History of continued History of continued high quantity high quantity intakeintake of carbonated beverages of carbonated beverages

• Patients with Patients with active caries-lesionsactive caries-lesions that a that are unpigmented, of a soft consistency, mre unpigmented, of a soft consistency, moist, sensitive to Sweets, cold or excarvaoist, sensitive to Sweets, cold or excarvation, and with depth greater than width. tion, and with depth greater than width.

DXDX ACTIVEACTIVE INACTIVEINACTIVE

COLORCOLOR LIGHTLIGHT DARKDARK

CONSISTENCONSISTENCYCY

MUSHYMUSHY FIRMFIRM

MOISTUREMOISTURE WETWET DRYDRY

SYMPTOMSYMPTOM SENSITIVESENSITIVE NONENONE

SHAPESHAPE DEPTH>WIDEPTH>WIDTHDTH

WIDTH>DEWIDTH>DEPTHPTH

Caries control restorationCaries control restoration

• The goal is elimination of the source of cThe goal is elimination of the source of cariogenic organisms by ariogenic organisms by removal of cariesremoval of caries from all deep lesions and from all deep lesions and placement of tplacement of temporary restorationsemporary restorations early in the treatm early in the treatment. This is ent. This is very importantvery important in effecting re in effecting reversal of the active caries process.versal of the active caries process.

Caries Control RestorationCaries Control Restoration

• Cavity preparation is done quickly Cavity preparation is done quickly without definitive cavity without definitive cavity preparation. preparation. Undermined enamel Undermined enamel be left to aid in retention of these be left to aid in retention of these treatment restorations,treatment restorations, especially if especially if restoratives are used that bond to restoratives are used that bond to tooth structure.tooth structure.


• Pulpal responsePulpal response to the restorative treatm to the restorative treatment can be observed and endodontic treaent can be observed and endodontic treatment instituted if necessary before plantment instituted if necessary before planning definitive restoration.ning definitive restoration.


• The restoration protects the pulp against The restoration protects the pulp against further further insult and promotes healing of thinsult and promotes healing of the lesione lesion by remineralization of affected d by remineralization of affected dentin and stimulation of reparative dentientin and stimulation of reparative dentin.n.


• Patient comfort and mastication are quicPatient comfort and mastication are quickly improved by decreasing sensitivity frokly improved by decreasing sensitivity from open cavities, food impaction, ectm open cavities, food impaction, ect. Oc. Occlusal and proximal stability is maintaineclusal and proximal stability is maintained.d.


• Restorative materials used for Restorative materials used for caries contrcaries control restoration.ol restoration.– CaOH is bacteriocidal and stimulates reparativCaOH is bacteriocidal and stimulates reparativ

e dentine dentin– Reinforced Zinc Oxide-eugenol is obtundant, reReinforced Zinc Oxide-eugenol is obtundant, re

ducing pain and sensitivity; it is bacteriocidal tducing pain and sensitivity; it is bacteriocidal to organisms deep in the cavity, and it seals mao organisms deep in the cavity, and it seals margins well for several months, rgins well for several months, preventing ingrespreventing ingress of nutrientss of nutrients to the organisms. Strength is fair. to the organisms. Strength is fair.


• Restorative materials used for Restorative materials used for caries concaries control restoration.trol restoration.– Glass ionomer-bondsGlass ionomer-bonds to tooth structure for i to tooth structure for i

mproved retention, it release fluoride which mproved retention, it release fluoride which reduces organisms and promotes remineralireduces organisms and promotes remineralization, has good marginal seal, fair strengtzation, has good marginal seal, fair strength, and is esthetically pleasing.h, and is esthetically pleasing.

– AmalgamAmalgam has excellent strength, maintains has excellent strength, maintains occlusal and proximal relationships, fair marocclusal and proximal relationships, fair marginal seal, best for long term temporaryginal seal, best for long term temporary


• Similar restorations can be used to Similar restorations can be used to quickly restore deep lesions for quickly restore deep lesions for emergency patientsemergency patients when time is limited. when time is limited.

• Caries control restorations should be left Caries control restorations should be left in place until in place until caries activity tests indicate caries activity tests indicate a significant decrease in caries activitya significant decrease in caries activity. . Definitive restorations can then be Definitive restorations can then be placed with a promise of much greater placed with a promise of much greater longevity.longevity.


• Indirect pulp cappingIndirect pulp capping is often done is often done in conjunction with caries control in conjunction with caries control restorations.restorations.– Pulp must show radiographic and Pulp must show radiographic and

clinical signs and symptoms of vitality.clinical signs and symptoms of vitality.– All caries is removed at the periphery, All caries is removed at the periphery,

establishing a sound DEJ.establishing a sound DEJ.



• Indirect pulp capping is often done in coIndirect pulp capping is often done in conjunction with caries control restorations.njunction with caries control restorations.– All infected dentin is excavatedAll infected dentin is excavated with large ro with large ro

und burs and excavators, being careful not tund burs and excavators, being careful not to expose the pulp. o expose the pulp. Basic fuchsinBasic fuchsin effectively i effectively identifies infected dentin.dentifies infected dentin.

– A small amount of firm caries (affected dentA small amount of firm caries (affected dentin) is in) is left over sites of potential exposure.left over sites of potential exposure.


• Indirect pulp cappingIndirect pulp capping is often done in co is often done in conjunction with caries control restorations.njunction with caries control restorations.– Calcium hydroxide liner is placed in the deeCalcium hydroxide liner is placed in the dee

pest areas. The high pH of the CaOH will nepest areas. The high pH of the CaOH will neutralize acid, kill bacteria and stimulate formutralize acid, kill bacteria and stimulate formation of restorative dentin.ation of restorative dentin.

– The rein-forced ZOE, glass ionomer or amalgThe rein-forced ZOE, glass ionomer or amalgam restoration is placedam restoration is placed


• Indirect pulp cappingIndirect pulp capping is often done is often done in conjunction with caries control in conjunction with caries control restorations.restorations.– After 6-8 weeksAfter 6-8 weeks the entire restoration the entire restoration

is removed, is removed, any remaining caries is any remaining caries is removed and a definitive restoration is removed and a definitive restoration is planned.planned.

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Treatment of dental caries as an infectious disease