Presentation on theme: "Early Caries Detection and Treatment"— Presentation transcript:
1Early Caries Detection and Treatment J Good BDS MFD(RCSI) PGCHETSeptember 2011
2Learning Outcomes Following this lecture you should be able to: discuss the carious processdescribe how to recognise ‘early carious lesions’ and ways of detecting themdiscuss the principals involved in the management of early carious lesions
3The Carious ProcessFour factors are necessary to produce dental caries:?
4Dental caries is:a disease of the calcified tissues of the teethcaused by the action of micro-organisms on fermentable carbohydratescharacterised by demineralisation of the mineral portion of enamel and dentine followed by disintegration of their organic material
5In its early stages the disease can be arrested since it is possible for remineralization to occur ALSOThis disease is not inevitable as it can be completely prevented by relatively simple measures
6Susceptible SitesSites on the tooth surface which favour plaque retention and stagnation are particularly prone to decay:
8Approximal enamel smooth surfaces just cervical to the contact point.
9Enamel of the cervical margin of the tooth just coronal to the gingival margin
10Where perio disease has resulted in gingival recession
11The margins of restorations, particularly those that are deficient or overhanging
12Tooth surfaces adjacent to dentures and bridges which increase the areas where stagnation can occur.
13Why is diagnosis of caries in its ‘early stages’ important. The carious process can be modified by preventive treatment so that the lesion does not progressIf caries can be diagnosed at the stage of a ‘white spot lesion’ the balance can be tipped in favour of arrest by:?
14What is the POINT OF NO RETURN When a cavity is actually presentA hole in the dental tissues is not expected to calcify up from the base
15How can dental caries be diagnosed in its ‘EARLY STAGES’ Sharp eyesGood lighting with clean, dry teethIsolate teeth with cotton wool rolls, slow suction & buccal pad.QuestionWith what type of probe should you check for caries?
16Interproximally on anterior teeth: Operating light is reflected through the contact point with the dental mirrorCarious lesion appears as a dark shadow following the outline of the decay
17Interproximally on posterior Teeth: Stronger light source is required eg fibre-optic light with beam reduced to 0.5mm diam. (FOTI)Small diam. reduces glare and therefore reduces loss of detailUseful technique where you want to avoid radiation eg pregnancy or where teeth would appear overlapped on x-ray due to crowding.
19Good bitewing radiographs are also essential in diagnosis A film holder is used so that the x-ray beam passes at right-angles to the long axis of the tooth and tangentially through the contact area
20Tooth separation Uses orthodontic separating elastics After a few days the teeth are separated and presence of a cavity can be assessed by:Direct visionGentle probing with blunt probeElastomer impression material
21Occlusal CariesDirect vision – discolouration, cavitation and the grey appearance of enamel undermined by cariesBitewing radiographs – will only show more advanced lesionsCaries DyesElectronic caries monitors - can be used to help diagnose occlusal caries
22Work using the principal of electrical resistance since intact enamel is a good insulator During the carious process, moisture filled porosities act as conductive pathways causing the resistance to fallThese measurements may be repeated at recall appointments and comparative readings may indicate whether a region is growing or not.
23Diagnosing ‘AT RISK’ patients Caries is a reversible processIf the dentist can diagnose the process early then the patient can be advised on instituting preventive measures to tip the balance in favour of arrestDiagnosis is more than simply recording the decalcified areas, their location and their appearance
24The dentist needs to know whether the patient is likely to develop new cavities and/or whether existing cavities are likely to progress.To help make these decisions a Caries Risk Assessment should be carried out.What would this involve?
25Caries ManagementOnce caries has been diagnosed, the dentist must decide how the process should be treated:Use preventive measures to attempt to arrest the processORSurgically remove and replace the damaged tissues and prevent recurrence
26Prevention On smooth surfaces: Dietary advice Use of fluoride Improve plaque controlREASSESS
27Pits and Fissures:Difficult to diagnose in early stages so Fissure Sealing susceptible teeth as soon after eruption as possible is often the choice
28Indications for FS High caries risk Stagnating plaque Newly erupting molars(Stained and decalcified deep fissure patterns)
29Isolation Very important Cotton wool rolls Slow suction Buccal pads Rubber dam
30Clean occlusal surface with a wet prophy brush Then wash and dry using 3-in-1
34Apply FSNote the use of the ball-ended burnisher
35Light Cure Note orange protective shield should be in place!!! 470nm wavelength light for 20 secs
36Check the occlusionClear unfilled resins – will adjust with occlusion unless excessive material has been usedWhite filled resins – need to be adjusted at chairside for the patient
37Indications for Preventative Resin Restoration (PRR) High caries riskStained and decalcified deep fissure patternsMore than 2 other carious lesions in the mouthEnamel biopsy shows that lesion is confined to enamel
38Procedure for PRRFollow similar steps as for a Fissure SealantBUTAfter the prophy brush is used, the stained enamel must be removed using a tapered diamond bur in the fast handpiece.Any decay is then removed using a round bur in the slow handpiece.
39The tooth surface can then be restored using one of the following options: Flowable compositeGI and flowable compositeCompositeamalgam
40Approximal SurfacesA lesion limited to the enamel on B/W radiograph should be treated preventively:Diet adviceFluoridePlaque control
41Unless the caries risk is very high, time is on the patient’s side: Research has shown that progression of a lesion through enamel, if it occurs, can be very slow, taking 2-6years before it is evident in dentine radiographicallyRef – Pitts, N.B. (1983). Monitoring of caries progression in permanent and primary approximal enamel by bitewing radiography. A review. Community Dent. Oral Epidemiol., 11,
43Radiographically just through enamel and into dentine: In a young patient or high- & medium-risk patients – advice is to treat operativelyIn a low-risk patient – treat preventively.Show the patient the radiograph and suggest that it should be repeated in 6 months.
44Root Caries:Early diagnosis very important as advanced lesions can be difficult to manageMeticulous plaque controlDietary controlUse of topical fluoride (as a varnish &/or mouthwash)
45Diet Advice No snacking between meals Aim for 2-3 sugar attacks per dayNever sugar before bedAvoid fizzy drinks but if not possible then chose diet varietyEach patient is an individual and will require specific advice
46Cariostatic Mechanisms of Fluoride Post-eruption - inhibits demineralization and promotes remineralizationDepending on its pH and concentration, fluoride can also exert a bacteriocidal or antienzymatic effect.Pre-eruption – may alter morphology making fissures more self-cleansing.
47Modes of Fluoride Application Patient may be receiving fluorinated water or taking fluoride tablets.These facts would be important to know before prescribing any further fluoride treatment – WHY?
48Topical application of Fluoride falls into 2 categories: Frequent-use, low-concentration preparations i.e. Toothpastes and mouthrinsesPeriodic-use, high-concentration preparations i.e. fluoride varnishes, gels and prophylactic pastes
49Toothpastes ( ppm F)Mouthrinses – daily ?% NaFweekly ?% NaFNaF varnish (Duraphat) ?%Fpainted on in the surgeryAPF gel ?%F – swabbed onto the tooth surface or applied in closely fitting traysProphylaxis paste ?%F – applied in surgery with a rubber cup
50Plaque Control Toothbrushing Dental floss/tape Woodsticks Interdental brushesSingle tufted brushes
51Current Toothbrushing Advice Brush twice daily with fluoridated toothpaste containing at least 1,350ppm fluorideBrush last thing at night and on 1 other occasionSpit out after brushing and do not rinse
52SummaryIt is important to recognise early carious lesions as they are reversibleBe aware of the different techniques used to help identify these lesionsPreventive management is the treatment of choice: diet analysiseffective plaque removalappropriate use of Fluoride