9. Dental Cariology.pptx

DENTAL CARIES AND ITS
MANAGEMENT
Dr. Irari

Introduction
 Dental caries is a disease that is
common to all dentate individuals.
 For dental caries to occur, a bacterial
biofilm has to accumulate on a tooth
surface.
 The bacteria within the biofilm
metabolize dietary sugar substrates
producing acids which, over time,
demineralize the tooth tissue.

Bacteria responsible for dental
caries
 Streptococcus mutans
 Lactobacilli
 Others?

Aetiology of dental caries.
 The carious process is dynamic in
nature.
 The initiation and progression of
dental caries are dependent on a
number of factors:
◦ Dietary habits
◦ Fluoride intake
◦ Quality and quantity of saliva

 From the earliest stage, continued
demineralization is not inevitable; the
lesion may be arrested by disrupting
the plaque biofilm.
 On the other hand, not all lesions may
remineralize following improved OH or
use of fluoride.
 Therefore, the primary goal should be
prevention of caries.

Dynamic nature of dental
caries

How to describe caries
 Based on site:
◦ Occlusal
◦ Smooth surface caries
◦ Pit and fissure caries
◦ Proximal
◦ Adjacent to a restoration
 Based on origin:
◦ Primary
◦ Secondary/ caries adjacent to a restoration (CAR)
 Hard tissue involved:
◦ Enamel
◦ Dentine
◦ Root dentine and cementum (root caries)
 Stage of disease (according to ICDAS):
◦ Early (incipient) decay
◦ Established decay
◦ Severe decay
 Arrested caries: active disease progression is halted.

Caries detection and diagnosis:
clinical examination
 When examining teeth for the
presence of caries, all surfaces must
be clean.
 The examination must be carried out
under adequate lighting. Why?
 The tooth or teeth in question must be
examined wet and dry.

Caries detection and diagnosis:
clinical examination
 When light illuminates a sound tooth, the light
can either be transmitted, or it can undergo
refraction or reflection.
 The porosities created in enamel during the
carious process are normally filled with water
(refractive index = 1.33) which has a refractive
index close to enamel (1.66). In this situation little
light scattering occurs. If the lesion is dried and
the water is replaced with air which has a lower
refractive index (1.0), the larger difference in
refractive indices between enamel and air results
in greater light scattering, enabling easier
recognition of the white spot lesion.

Refraction of light in a carious
lesion

Clinical examination of carious
teeth
 A lesion that needs to be dried to
enable its diagnosis is less severe
than one that is seen even on a wet
surface.

Radiographic diagnosis
 Bitewing radiographs
 Periapical radiographs

Other diagnostic aids
 Diagnodent pen –
detects fluoresence
from bacterial
porphyrins
 Caries indicating
solutions.
 Please read more on
these.

Remember!!
 Diagnosis of caries is primarily by visual and
clinical examination.
 Be careful when using a sharp explorer as
this may cause cavitation within incipient
(early and small) lesions. May cause more
harm than good!
 Radiographs are used as a diagnostic aid to
confirm the presence or extent of a lesion.
 Decay that is less than 2mm into dentine may
be difficult to diagnose using a radiograph.

Caries risk assessment
 Caries risk is a prediction as to whether a
patient is likely to develop new caries in the
future.
 Caries risk can change throughout a patient's
life and a dentist can have a positive impact
on reducing this risk.
 Events in a patient's life can also have a
negative effect on caries risk; for example, an
elderly patient may be placed on medication
which causes a dry mouth. In addition, this
patient may require a removable partial
prosthesis which will complicate oral hygiene
procedures.

Management of the high caries
risk patient
 Patients may be assessed as either
low, moderate or high caries risk
cases.
 In a patient with high caries risk
requiring extensive and advanced
restorations, an assessment should be
made to establish the main risk factors
and how to manage them.

Management of the high caries
risk patient
 Following this, stabilization of active
lesions (e.g. with Glass ionomer
restorations) is carried out. Elimination of
other plaque retentive factors should
then take place (e.g. replacement of
poorly contoured restorations and
dentures).
 A further risk assessment should then be
undertaken before advanced restorations
are placed.

Caries risk factors
 Past caries experience
 Oral hygiene
 Diet
 Fluoride
 Saliva

Past caries experience
 A strong predictor of future caries is past
caries experience.
 A dental history and chart are important
to assess dental attendance, how often
restorations and re-restoration have
been required, and whether teeth have
been lost due to caries.
 A clinical and radiographic examination
will reveal the presence of any new
carious lesions.

Oral hygiene
 OH is directly related to the amount of
plaque present.
 Plaque = biofilm = cariogenic bacteria
 Plaque indices e.g. Silness and Löe
help in determining the amount and
distribution of plaque (level or oral
hygiene).

Silness and Löe plaque index
 0 = No plaque visible
 1 = Plaque visible on a probe
 2 = Plaque visible with the naked eye
 3 = Plaque visible all around tooth.

Oral hygiene
 Guidance must be given to patients with poor
oral hygiene and high plaque scores (also
calculus).
 Use disclosing tablets or solution.
 Demonstrate proper tooth brushing technique,
preferably using patient’s own toothbrush.
Discuss use of interdental aids such as dental
floss or interdental brushes.
 Advise patients with bridges to use superfloss for
cleaning beneath pontics and connectors.

Diet
 Once sugar is consumed, the bacteria
within the biofilm are able to produce
acid, resulting in a rapid fall in plaque
pH.
 When this falls below a critical pH
(around pH 5.5), the plaque fluid
becomes undersaturated with respect
to tooth mineral, and demineralization
of the tooth occurs.

Diet
 It may take some time for the pH and
plaque fluid mineral saturation to return
to resting levels.
 A subsequent sugar snack may cause
another dip in pH. Frequent sugar
intakes may keep the biofilm
undersaturated with respect to tooth
mineral and below the critical pH for
several hours each day. Sticky, sugary
foods may also remain around the teeth
for prolonged periods of time and have a
similar effect.

Diet charts/ diet diary
 In a caries risk assessment, the
patient’s diet needs to be evaluated.
This enables the practitioner to
provide realistic and achievable
advice.
 The diet chart/diary should include two
working or school days and one non-
working day. Why?

Diet diary
 The diet diary can then be used to
highlight the dietary sugar content,
including any hidden sugars as well as
the frequency of sugar consumption.

Sunday Monday Tuesday
Breakfast Mug of tea, 2
sugars
Weetabix
Mug of tea, 2
sugars
White bread
with jam and
margarine
Mug of tea, 2
sugars
Cake
Mid-morning
snack
Tea, 2 sugars
Mandazi
Tea, 2 sugars
Cookies
Chewing gum Chewing gum
Lunch Rice/ beef,
Fanta orange
Maize + beans Ugali managu
Early evening Tea, 2 sugars
White bread
Cappuccino, 2
sugars
Café latte, 2
sugars
Dinner Ugali + tilapia
+ maziwa lala,
2 sugars
Pilau Chapati +
beans
Late night Drinking
chocolate, 2
sugars
Coke Tea, 2 sugars

Fluoride
 Information on use of topical fluoride
(e.g. use of toothpastes) should be
gathered from the patient.
 For lower caries risk individuals, frequent
tooth brushing with a fluoridated
toothpaste is sufficient.
 For high caries risk individuals,
supplemental fluoride should be
considered e.g. fluoride varnishes and
mouthwashes, or high dose fluoride
toothpastes such as Duraphat.

Fluoride: mode of action
 Application of fluoride in high doses
leads to the formation of calcium
fluoride which is relatively soluble and
acts as a fluoride reservoir, protecting
against further carious attack by
inhibition of tooth mineral dissolution
when the local pH falls.

Saliva: important constituents
and functions

Xerostomia
 Can be a side effect of medications such
as antihypertensives, diuretics,
antidepressants, antipsychotics,
antispasmodics and some
antihistamines.
 Other causes of dry mouth include
autoimmune diseases such as Sjögren's
syndrome, diabetes, radiotherapy to the
head and neck, and the use of
recreational drugs such as caffeine,
alcohol and amfetamines.

Xerostomia
 Hyposalivation or xerostomia is a
major risk factor for caries.
 Patients may such on sweets to try
and stimulate saliva flow.

The restorative cycle of a
tooth
 The restorative cycle refers to the
common practice of restoring teeth.
Each restoration on the tooth has a
lifespan. At replacement, succeeding
restoration is usually larger in size.
 A significant proportion of dental
treatment is dedicated to the
replacement of failed restorations with
secondary caries.

The restorative cycle and
secondary caries
 The appearance of caries, following
restoration of a tooth, illustrates the
continued high caries risk of the
patient and also shows that restoration
alone does not change this.

Clinical example of the
restorative cycle

Past dental history- restorative
cycle 46,47 2008-2015

Proximal caries with cavitation

Summary of Rx planning for high
caries risk patient
Early caries detection and risk assessment are
important, aid in prevention of new disease.
 Provide emergency treatment first (endo or
extractions).
 Assessment of risk factors.
 Preventive advice based on specific risk
factors.
 Stabilization of disease. Provisional
restorations.
 Definitive restorations.
 Completion of endodontic treatment.
 Reassessment of caries risk and compliance
to treatment plan. Re-evaluation of risk

Online resources
 International Caries
Detection and
Assessment
system (ICDAS)
www.icdas.org

Reference
Diagrams and sections of text from
Advanced Operative Dentistry: A
practical approach.
Ricketts & Bartlett (2013).
Elsevier publications

CLINICAL REQUIREMENTS
 5 Class I restorations
 2 Class III/ IV/ V
 1 complete denture
 1 full coverage crown/ post & core
 Endodontics -

9. Dental Cariology.pptx

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