Treatment of dental caries as an infectious disease

RATIONALE Incipient enamel caries is caused by specific microorganisms Streptoccus mutans plus sucrose reduces the pH in the plaque to a critical level of 5.0-5.5, which can overcome the buffering capacity of saliva and result in demineralization of enamel

RATIONALE Incipient enamel caries is caused by specific microorganisms High bacterial counts are the result of the patient’s diet, and be reduced by altering the diet. A high Strep mutans count generally indicates large and/or frequent ingestion of sucrose.

RATIONALE Incipient enamel caries is caused by specific microorganisms A high lactobacillus count generally indicates a high proportion of carbohydrates in the patient’s diet. A normal saliva flow rate (1-2 ml/minute) and buffering capacity (5-7pH) discourages demineralization and encourages remineralization; a low flow rate (0.7 ml/minute or less) and buffering capacity (<4pH) will encourage demineralization and caries activity

RATIONALE A diet diary can indicate dietary intake, and dietary counseling may result in an altered diet that will decrease caries activity. Lactobacillus counts are significantly higher in patients with open caries lesions; restoration of these lesions will produce a dramatic drop in the count.

RATIONALE Caries begins as a subsurface lesion which can be remineralized as long as the surface remains intact. Supersaturated salivary calcium and phosphates in the presence of fluoride can slowly remineralize demineralized enamel. Remineralized enamel is more resistant to subsequent demineralization than original intact enamel

RATIONALE The effect of oral hygiene/plaque control on caries activity is controversial. Oral hygiene is much less important than diet, but complete plaque removal daily will reduce caries on exposed tooth surface

RATIONALE Various anti-microbial mouthwashes will reduce certain cariogenic microorganisms, but may also interfere with the normal oral flora and allow overgrowth of undesirable organisms. For example, Chlorohexadine Gluconate mouthwashes may reduce Strep. Mutans counts, but will not reach organisms in deep lesions. Deep lesions should therefore be eliminated with caries control restorations before instituting anti-microbial therapy.

RATIONALE Fluoride applied in various ways (systemic, clinical and home) decreases cariogenic organisms and promotes remineralization.

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

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

Treatment planning for restorative dentistry (high caries risk ) The restorative treatment must be coordinated with all the means utilized in the Caries Risk Management Program (diet, oral hygiene, fluoride, antimicrobials, saliva stimulation, ect.)

Treatment planning for restorative dentistry ( high caries risk ) Early elimination of all dentinal caries is very important in eliminating the source of Strep. Mutans. Caries control restorations may be necessary to accomplish this quickly.

Treatment planning for restorative dentistry ( high caries risk ) Types of lesions and choice of treatment: Routine use should be made of fluoride application to cavity preparations and fluoride-releasing liners, bases and restorative materials.

Types of lesions and choice of treatment ( high caries risk ) Smooth surface incipient caries; Sticky pits and fissures Sticky pits and fissures with incipient caries Small and moderate lesions Deep lesions Root caries

Types of lesions and choice of treatment ( high caries risk ) Smooth surface incipient caries: Reminerlize with clinical topical fluoride applications and home application of fluoride by various means ; toothpaste, rinses, brush-on gels, custom tray-applied gels, ect. Sticky pits and fissures: Pit and fissure selants

Types of lesions and choice of treatment ( high caries risk ) Sticky pits and fissures with incipient caries Preventive resin/sealants (Remove caries, place composite in the cavity and cover all with sealant) Definitive amalgam restorations Small and moderate lesions Definitive amalgam, composite or glass ionomer restorations

Types of lesions and choice of treatment ( high caries risk ) Deep lesion: Caries control restorations with ZnO-eugenol, glass ionomer or amalgam, and the definitive resotrations after caries activity has decreased Root caries: Fluoride applications Glass ionomer restoration

Treatment planning for restorative dentistry ( high caries risk ) Routine use should be made of fluoride application to cavity preparations and fluoride releasing liners, bases and restorative materials

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

A previous history of caries, demonstrated by numerous restoration, especially with recurrent caries. Numerous large carious lesion, especially those with depth greater than width.

Unpigmented demineralized areas on smooth surfaces, often on the lingual third. Lesions on the lingual surfaces indicate an even higher risk. Recent incidence of new lesions on recall examinations. Patients requiring extensive reconstructive procedure

Patients (especially the elderly) with root caries. Patients that report a history of a physical condition, medical treatment (especially radiation therapy), medication and dietary changes that would influence saliva or oral flora History of continued high quantity intake of carbonated beverages

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

DX ACTIVE INACTIVE COLOR LIGHT DARK CONSISTENCY MUSHY FIRM MOISTURE WET DRY SYMPTOM SENSITIVE NONE SHAPE DEPTH>WIDTH WIDTH>DEPTH

Caries control restoration The goal is elimination of the source of cariogenic organisms by removal of caries from all deep lesions and placement of temporary restorations early in the treatment. This is very important in effecting reversal of the active caries process.

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

Caries Control Restoration Pulpal response to the restorative treatment can be observed and endodontic treatment instituted if necessary before planning definitive restoration.

Caries Control Restoration The restoration protects the pulp against further insult and promotes healing of the lesion by remineralization of affected dentin and stimulation of reparative dentin.

Caries Control Restoration Patient comfort and mastication are quickly improved by decreasing sensitivity from open cavities, food impaction, ect. Occlusal and proximal stability is maintained.

Caries Control Restoration Restorative materials used for caries control restoration. CaOH is bacteriocidal and stimulates reparative dentin Reinforced Zinc Oxide-eugenol is obtundant, reducing pain and sensitivity; it is bacteriocidal to organisms deep in the cavity, and it seals margins well for several months, preventing ingress of nutrients to the organisms. Strength is fair.

Caries Control Restoration Restorative materials used for caries control restoration. Glass ionomer-bonds to tooth structure for improved retention, it release fluoride which reduces organisms and promotes remineralization, has good marginal seal, fair strength, and is esthetically pleasing. Amalgam has excellent strength, maintains occlusal and proximal relationships, fair marginal seal, best for long term temporary

Caries Control Restoration Similar restorations can be used to quickly restore deep lesions for emergency patients when time is limited. Caries control restorations should be left in place until caries activity tests indicate a significant decrease in caries activity. Definitive restorations can then be placed with a promise of much greater longevity.

Caries Control Restoration Indirect pulp capping is often done in conjunction with caries control restorations. Pulp must show radiographic and clinical signs and symptoms of vitality. All caries is removed at the periphery, establishing a sound DEJ.

Caries Control Restoration

Caries Control Restoration Indirect pulp capping is often done in conjunction with caries control restorations. All infected dentin is excavated with large round burs and excavators, being careful not to expose the pulp. Basic fuchsin effectively identifies infected dentin. A small amount of firm caries (affected dentin) is left over sites of potential exposure.

Caries Control Restoration Indirect pulp capping is often done in conjunction with caries control restorations. Calcium hydroxide liner is placed in the deepest areas. The high pH of the CaOH will neutralize acid, kill bacteria and stimulate formation of restorative dentin. The rein-forced ZOE, glass ionomer or amalgam restoration is placed

Caries Control Restoration Indirect pulp capping is often done in conjunction with caries control restorations. After 6-8 weeks the entire restoration is removed, any remaining caries is removed and a definitive restoration is planned.

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