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See all Premium member Presentation Transcript Slide 1: Dental caries classification, histology,diagnosis and management recent methods By Dr huma iftekhar Supervised by Dr ASHOK KUMAR Co supervised Dr AMIT kUMAR GARG Slide 2: “CARIES”derived from latin meaning rot or rotten It is an irreversible microbial disease of calcified tissue of teeth characterized by demineralization of inorganic portion and destruction of organic substance of tooth which often leads to cavitation Introduction Caries a brief history : Phase I(1700-early 1900’s) Cause was a mystery Caries-gangrene of tooth t/t was only amputation or extraction Caries a brief history Early history : Phase II(EARLY 1900-1970’s) Era of G V Black Fillings preferred over extraction GV Black Early history Slide 5: Phase III(present era) Caries not a gangrene Is a complex disease Etiology of caries : No universally accepted opinion Different theories have evolved through years of investigation and observation millers theory proteolytic theory proteolytic chelation theory Etiology of caries Slide 7: WD MILLER best known early investigator on dental caries According to him dental decay is chemicoparasitic process Assigned essential role to three factors oral microorganisms carbohydrate substrate acid which causes dissolution of tooth material Slide 8: MILLER AND HIS CHEMICOPARASITIC THEORY SUSCEPTIBLE HOST FERMENTABLE CARBOHYDRATE PLAQUE DEMINERELIZATION ACID PRODUCTION Slide 9: Proteolytic theory: proposed by gottileb & gottileb(1944) caries a proteolytic process caries due to yellowish pigmentatation produced by proteolytic organisms Proteolytic chelation theory: proposed by schatz at al(1955) implies simultaneous microbial degradation of organic components and dissolution of tooth minerals by the process of chelation Caries multifactorial infectious ds : microbial causes Sreptococcus mutans higher proportion required in dental plaque Posses adherence activity to tooth surface Produces extracellular polysacchride from sucrose Lactobacillus Progression of caries Acid tolerant causes dentinal caries Actinomyces viscosus Acidogenic &acid acid tolerant Produces root caries Caries multifactorial infectious ds Slide 11: Dependent on dietry sucrose Affects thickness and chemistry of plaque Slide 12: Driven by frequency of eating classification : Based on location: pit and fissure smooth surface root caries Based on severity: incipient occult Based on rate of progression: acute chronic recurrent arrested Based on treatment and restoration design(therapeutic classification by G V BLACK) classification Pathophysiology of caries : Caries causes damage by demineralization and dissolution of tooth structure Pathophysiology of caries Slide 15: sucrose +cariogenic plaque nutrients to organic acids lowering of ph(if below 5.5) dissolution of tooth mineral In caries active individual ph remains below 5.5 for 20-50 mins following single exposure to sucrose Caries risk assesment : Caries risk assesment Clinical characteristic of lesion : Clinical characteristic of lesion Sufficient thickness of anaerobic plaque has the potential to become cariogenic Large population of mutans streptococci along with sucrose rich diet produces extracellular polysacchride Anaerobic and acidic environment produces cavitation Surface cavitation along tooth surface : Surface cavitation along tooth surface Slide 19: The first indication of tooth decay are white spots on the enamel caused by the loss of calcium. If the demineralization process outruns the natural remineralisation process, the lesion grows and a cavity is formed. The bacteria may invade the pulp of tooth causing a consistent tooth pain, especially during the night. The bacteria may also produce an abscess, and eventually the tooth may be extracted by the dentist. First indication of tooth decay is white spot on enamel caused by loss of calcium If the demineralization process outruns the remineralization process lesion grows and cavity is formed Bacteria may invade pulp of tooth Causing consistant tooth pain The bacteria may eventually produce a abcess And eventually tooth can be extracted by dentist Cosequenses of caries G. v. black classification of cavities : G. v. black classification of cavities It represented a system of cavity design for restorations rather than carious lesion At that time it was thought that it is not possible to remineralize carious lesion In the absence to control the disease by any other means the margins of cavity were placed in self cleansing areas This led to initial cavity design being rather larger than necessary New classification of lesion of exposed tooth surface : New classification of lesion of exposed tooth surface Proposed in 1997 carious lesions occurs only on three sites on the crown & root which are areas subjected to plaque accumulation Site 1: pits fissures and enamel defects on occlusal surfaces of posterior teeth or other smooth surfaces Site 2: approximal enamel in relation to areas in contact with adjacent teeth Site 3: cervical one third of crown or on the exposed root surfaces Defining according to size and extent of lesion : Defining according to size and extent of lesion Communicating relationship between BLACKS & site ,size concept : Communicating relationship between BLACKS & site ,size concept Site 1: size 0,1,2,3,4-pit and fissure caries Cavity located on occlusal surface of posterior teeth or any simple enamel defect on smooth surface of any teeth Black class 1:smaller size 0 ,1 could not be performed so the black classification begins with site 1,size 2 Slide 25: Site 2:size 0,1,2,3,4- approximal lesion commencing in relation to contact area cavity located on approximal surface of any tooth (anterior or posterior) Blacks class II : lesions occuring between posterior teeth only. There was no equivalent of size 0 or 1 ,so blacks classification begins with size 2 site 2 Blacks class III : lesions occuring between anterior teeth only classified as size 2 site 2 Blacks class IV : extension of class III classified as site 2 size 4 Slide 26: Site 3 size 0,1,2,3,4- cervical lesions Lesions in cervical region around full circumference of tooth Blacks class V : does not recognize lesions on approximal surfaces erosive abrasive lesion or small carious cavity on buccal lingual surface is site 3 size 0 if restoration required then site 3 size 1 a larger carious lesion is site3 size 2 interproximal lesion will be site 3 size 3 site 3 size 4 is for complex lesion Slide 27: Dental Caries Enamel Caries Dentin Caries Cementum Caries (Root caries) Smooth surface caries Pit and fissure caries Clinical sites for caries initiation : Clinical sites for caries initiation Pits and fissures Rapidly colonized by bacteria Caries expands as it penetrates into enamel Entry site much smaller than actual lesion Affects greater area of DEJ Lesion is an inverted V with a narrow entrance and wider area of involvement near DEJ Slide 31: Smooth surface caries proximal surfaces particularly susceptible to caries coz of extra shelter provided to resistant plaque Lesions have broad area of origin and a pointed extension towards DEJ Cross section shows a V shaped lesion with a wide area of origin and the apex towards DEJ Enamel caries : Enamel caries histology of enamel Enamel composed of hydroxyapatite crystallites organised into long columnar rods Each rod starts at DEJ and extends to the surface of crown Enamel is able to act like a molecular sieve which explains why incipient lesions produces pulpal response Clinical characteristic of enamel caries : Clinical characteristic of enamel caries Incipient lesion chalky white when dried These areas of enamel lose their translucency because of extensive subsurface porosity caused by demineralization Softened chalky enamel that can be chipped away with explorer is a sign of active lesion Slide 36: Incipient caries of enamel can remineralize Noncavitated enamel lesions retain most of the original crystalline framework which serves as nucleating agent for remineralization Supersaturation of saliva with calcium and phosphate ions serves as driving force for remineralization process Remineralized lesions are intact but discoloured brown black spots Zones of incipient enamel caries : Zones of incipient enamel caries Translucent zone Deepest zone represents advancing front of lesion Name refers to structureless appearance Not always present Pore volume is ten times greater than normal enamel Slide 38: Dark zone Next deepest zone Does not transmit polarized light Small air or water filled pore makes the region opaque Pore volume is 2-4% Some say that its size is indication of remineralization that has recently occured Slide 39: Body of lesion Largest of the incipient lesion Has the largest pore volume 5% at periphery 25% at centre The interprismatic areas and striae of retzius provides access to the enamel rods which is attacked by bacteria Bacteria may be present in this zone Slide 40: Surface zone Relatively unaffected by carious attack Lower pore volume (less than 5%) Hypermineralized Slide 41: Translucent zone Dark zone Body of lesion Surface of lesion Striae of retzius Zones of enamel caries Dentinal caries : Dentinal caries Histology of dentine: Decay progresses slowly through enamel and quickly through dentine Enamel is approx.. 99% mineral whereas dentine is a living tissue with 30% organic content Salivary buffer are more potent at the enamel surface than deeper in dentine DEJ is least resistant to carious attack and allows lateral spread of caries Slide 44: Dentinal lesions are V shaped with base at DEJ and the apex directed pulpally Pulp dentine complex reacts to carious attack by attempting to initiate remineralization and blocking off open tubules In slowly advancing caries vital pulp repairs demineralized dentine by remineralization of intertubular dentine and by apposition of peritubular dentine Slide 45: CARIES OF DENTIN Begins with the natural spread of the process along the DEJ and rapid involvement of the dentinal tubules. The dentinal tubules act as tracts leading to the pulp (path for micro-organisms). Early Dentinal Changes: -initial penetration of the dentin by caries dentinal sclerosis, -calcification of dentinal tubules and sealing off from further penetration by micro-organisms, -more prominent in slow chronic caries. Dentinal sclerosis Initial penetration of dentine by caries produces dentinal sclerosis Sclerotic dentine formation occurs ahead of demineralization Function is to wall off the lesion by blocking the tubule Slide 46: Behind the transparent sclerotic zone, decalcification of dentin appears. In the earliest stages, when only few tubules are involved, microorganisms may be found penetrating the tubules Pioneer Bacteria. Behind the transparent sclerotic zone decalcification of dentine appears In earlier stages when only few tubules are involved microorganism may be found termed as PIONEER BACTERIA Slide 47: Advanced dentinal changes Decalcification and confluence of dentinal tubules Tiny liquifaction foci are formed These are filled with necrotic debris ,increases in size by expansion This expansion will bend the tubules leading their distortion Slide 48: Ground section Early dentinal carious lesion Body of enamel lesion Intact surface Infected dentine Decomposed dentine Dead tracts Zones of dentinal caries : Zones of dentinal caries Caries advancement in dentine proceeds through three stages (1) Weak organic acid demineralize dentine (2) Organic material of dentine particularly collagen degenerates and dissolves (3) Loss of structural integrity followed by invasion of bacteria Slide 50: Five different zones have been identified Normal dentine Subtransparent Transparent Turbid Infected Zones are more clearly distinguished in slowly advancing lesion Slide 51: NORMAL DENTINE Deepest area Dentinal tubules with smooth odontoblastic processes with no crystals in lumen No bacteria in tubules Stimulation of dentine produces sharp pain Slide 52: Subtransparent dentine Zone of demineralization of intertubular dentine and initial formation of very fine crystals in tubular lumen No bacteria Stimulation of dentine produces pain Dentine capable of remineralization Slide 53: Transparent dentine Softer than normal dentine Shows further loss of mineral from intertubular dentine and many large crystals in lumen of dentinal tubules No bacteria Collagen cross linking remains intact Intact collagen serves as template for remineralization Slide 54: Turbid dentine Zone of bacterial invasion Widening and distortion of dentinal tubules Collagen, irreversibly denatured Dentine beyond self repair Cannot be remineralized Must be removed before restoration Slide 55: Infected dentine Outermost zone Consists of decomposed dentine with bacteria Not recognizable Removal is essential Caries diagnosis : Identifying and preventing problems or treating them in eary stages is one of the most important things we can do for our patients Continuing education and integration of newer technologies allow us to do this and provides minimally invasive and tooth preserving treatment Caries diagnosis Diagnostic protocols : Conventional methods Alternative methods Diagnostic protocols Slide 58: Conventional methods Explorer & mouth mirror radiogragh visual examination Alternative methods : Digital radiogragphy DIAGNOdent QLF(quantitative light induce fluorescence) Electronic carrier monitor Fibreoptic transillumination Alternative methods Caries diagnosis methods : Widespread use of fluoride has created harder enamel surface more resistant to decay While it has reduced the overall incidence of decay it has made detection of caries in its early stage more difficult Caries diagnosis methods DIAGNnodent : We are proud to announce the acquisition of new high speed laser caries detector DIAGNodent uncovers decay by comparing fluorescence of healthy and decayed tooth Healthy tooth-no fluorescence decayed tooth-fluorescence increases in proportion to decay DIAGNnodent Slide 62: DIGNOdent as a means of caries detector If the enamel defect leading to decayed area is smaller than head of explorer used to detect cavities the decayed area may not be visible by our naked eye DIAGNodent uncovers hidden decay by comparing reflected flourescence of tooth structure against the establish baseline reading to establish decay Slide 63: Diagnodent Higher sensitivity and specificity than radiograph Influenced by staining of tooth Tool for monitoring mineral loss Digital imaging : Use of digital radiograph offers many advantages over traditional radiography Radiation exposure to patient is reduced Digital imaging Digital imaging cont… : Eliminates chemical processing Hazardous waste and lead foil eliminated Images can be transferred without loss of original quality Images can be used for substraction purpose,excellent method for tracking bone loss over time It can track hidden and small carious lesions Digital imaging cont… Quatitative light fluorescence : Enhances early detection of carious lesions Sensitivity with excellent repeatibility & reproducibility Quatitative light fluorescence QLF limitations : Only discern enamel demineralization Cannot differentiate decay, hypoplasia or unusual anatomic findings Cannot differentiate between enamel and dentine lesions Cannot differentiate between active and inactive lesions Sensitive to stains, deposits QLF limitations Fibre optic transillumination : Enamel lesions gray and opaque Dentinal lesions orange brown or bluish Useful as a adjunct Fibre optic transillumination Digital imaging fiberoptic transillumination : Has elevated traditional transillumination to more sophisticated method When teeth transilluminated area of demineralization scatter light and incipient lesions appear darker Differs from DIAGNodent ,has two handpiece one for smooth other for occlusal caries detection But.. It does not have the capability to determine the depth of the lesion Digital imaging fiberoptic transillumination Digital fibreoptic transillumination : Digital fibreoptic transillumination Safely and instantaneously creates high resolution image. Discovers or confirm presence of decay that cannot be seen radigraphically, visually or through explorer. Newer method of caries detection : “C”smart toothbrush modern toothbrush that will able to tell user whether they have developing caries It uses laser technology that collects reflected light from caries and is sent to the microcomputer chip in the toothbrush Newer method of caries detection Here is a question : Are these methods sole method of caries detection ANSWER NO They are only adjunct to visual examination and not complete substitute for the clinical judgement Here is a question Moving from mechanical to preventive model : Moving from mechanical to preventive model Prevention of dental caries : Preventive treatment methods are designed to Prevention of dental caries Limit tooth deminerelization Limit of pathogen growth Increase resistance Of tooth to deminerelization Oral hygiene Dietry modifications Antimicrobial agents Immunizations Saliva function Xylitol gums fluorides(systemic &topical) Pit and fissure sealants Preventive resin restoration Air abrasion : Oral hygiene Daily removal of plaque by tooth brushing,flossing &rinsing Floss purpose to remove plaque from proximal tooth surfaces Mechanical plaque removal changes the species composition of plaque &denies habitat to potential pathogens Slide 77: Dietry modifications Identify source of sucrose in diet and reduce the frequency of uptake Caries activity stimulated by frequency rather than quantity Sugar free foods for snacks may be advocated Substitution of alchohol based sugar Salivary functions : Saliva-natural defence against caries Protective properties of saliva clearance buffer properties antibacteril properties Xerostomia increases caries susceptibility Salivary stimulants ( gums,paraffin or salivary subsitute)to patient with impaired function Salivary functions Xylitol gums : Natural five carbon sugar Acts directly on bacteria Gets substituted for fructose in bacterial metabolism cycle Environmental shift favouring nonpathogenic bacteria Xylitol gums immunization : Caries vaccine primarily based on IgA immunoglobulin Certain limitations potential side effects concerns of possible reaction with cardiac tissues cost immunization Pit and fissure sealants : Specifically designed for caries prevention in pit and fissure areas coz fluorides more effective in prevention of smooth surface caries Three important preventive effects mechanical filling of pits and fissures with acid resistant resin Filled pits no longer habitat for s.mutans and other oral bacteria Render pits easy to clean Pit and fissure sealants Preventive resin restoration : Composite resin with overlying sealant application Consevative and esthetic More technique sensitive Accepted on a global basis as the technique of choice for minimally invasive treatment of incipient or small carious lesions in pit and fissure areas Preventive resin restoration Atraumatic restorative treatment : Minimal intervention technique for management of dental caries Glass ionomers cements are used They are fluoride releasing materials Valuable tool in fighting caries in those areas where the disease is rampant Atraumatic restorative treatment Air abrasion : Minimal intervention technology creates narrow preparations less expensively and more efficiently Uses 27micrometers aluminium oxide powder at pressure of 40-160psi Low viscosity flowable composite is used Greater patient comfort Air abrasion Slide 86: Air abrasion system not only diagnose but can be used to treat caries. When used with improved composite resin early treatment of decay can be done with small conservative restoration Fluoride exposure : In trace amount increase the resistance of tooth to demineralization Exerts anticaries effects by three mechanism Enhances precipitation of fluorapatite ,less soluble & more acid resistant Inhibits enzymatic glycosyltransferase prevents glucose from forming extracellular polysacchride reduces bacterial adhesion In high concentration directly toxic to oral microorganisms Fluoride exposure Management of pit &fissure caries : Diagnostic criteria Softening at the base of a pit and fissure Opacity surrounding pit and fissure indicating undermining demineralization of enamel Softened enamel that may be flaked with explorer Chalky or opaque appearance of enamel when dried with compressed air Radiogrphically radiolucent area spreading laterally under the occlusal enamel Management of pit &fissure caries Pit and fissure caries treatment decision making : pit and fissure caries Pit and fissure caries treatment decision making Non cavitated cavitated Caries unlikely No progression Caries likely progression No treatment Sealants Antimicrobials fluorides Restorations Antimicrobials fluorides Management of smooth surface caries : caries on proximal surface of teeth or on gingival third of buccal or lingual surface Bitewing radiograph useful coz proximal caries not accessible to visual or tactile examination easily Early lesion appears as localized radiolucency below the proximal contact Proximal radiolucency should be examined clinically coz most of them not associated with cavitation and do not require restoration Management of smooth surface caries Proximal surface treatment decision making : proximal surface noncavitated cavitated Proximal surface treatment decision making Surface intact Opacity of proximal Area may be present Radiolucency may Be present Opaque are may be Seen in enamel in trans illumination Surface broken Mechanical seperation Marginl ridge may be discoloured Opaque area in dentine On transillumination Radiolucency is present treatment : Proximal surfaces difficult to judge clinically Critical event in caries process is surface cavitation Cavitated surface must be restored Non cavitated only by antimicrobials and fluoride agents Radiolucency alone not diagnostic of cavitation Restoration of all radiolucent surface results in excessive unnecessary restorative treatment treatment Management of root caries : Usually shallow initially spreads laterally, light brown in colour without any patient symptoms Lesion development rapid coz no enamel protection ,less mineralized dentine The remineralization is likely coz the lesion is shallow initially and therefore easier for ions to penetrate and strengthen Should be watched for arrestment rather than restored at first because usually no pain associated with these lesions Management of root caries conclusion : Diagnosis, prevention and treatment of dental caries must be the foremost objective of operative dentistry Research efforts in understanding the caries process ,benefits of fluoride and development of anticaries vaccine must be continued Patient education and motivation should be stressed Clinical treatment must be accomplished expeditiously and appropriately conclusion Slide 96: Thank you You do not have the permission to view this presentation. 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See all Premium member Presentation Transcript Slide 1: Dental caries classification, histology,diagnosis and management recent methods By Dr huma iftekhar Supervised by Dr ASHOK KUMAR Co supervised Dr AMIT kUMAR GARG Slide 2: “CARIES”derived from latin meaning rot or rotten It is an irreversible microbial disease of calcified tissue of teeth characterized by demineralization of inorganic portion and destruction of organic substance of tooth which often leads to cavitation Introduction Caries a brief history : Phase I(1700-early 1900’s) Cause was a mystery Caries-gangrene of tooth t/t was only amputation or extraction Caries a brief history Early history : Phase II(EARLY 1900-1970’s) Era of G V Black Fillings preferred over extraction GV Black Early history Slide 5: Phase III(present era) Caries not a gangrene Is a complex disease Etiology of caries : No universally accepted opinion Different theories have evolved through years of investigation and observation millers theory proteolytic theory proteolytic chelation theory Etiology of caries Slide 7: WD MILLER best known early investigator on dental caries According to him dental decay is chemicoparasitic process Assigned essential role to three factors oral microorganisms carbohydrate substrate acid which causes dissolution of tooth material Slide 8: MILLER AND HIS CHEMICOPARASITIC THEORY SUSCEPTIBLE HOST FERMENTABLE CARBOHYDRATE PLAQUE DEMINERELIZATION ACID PRODUCTION Slide 9: Proteolytic theory: proposed by gottileb & gottileb(1944) caries a proteolytic process caries due to yellowish pigmentatation produced by proteolytic organisms Proteolytic chelation theory: proposed by schatz at al(1955) implies simultaneous microbial degradation of organic components and dissolution of tooth minerals by the process of chelation Caries multifactorial infectious ds : microbial causes Sreptococcus mutans higher proportion required in dental plaque Posses adherence activity to tooth surface Produces extracellular polysacchride from sucrose Lactobacillus Progression of caries Acid tolerant causes dentinal caries Actinomyces viscosus Acidogenic &acid acid tolerant Produces root caries Caries multifactorial infectious ds Slide 11: Dependent on dietry sucrose Affects thickness and chemistry of plaque Slide 12: Driven by frequency of eating classification : Based on location: pit and fissure smooth surface root caries Based on severity: incipient occult Based on rate of progression: acute chronic recurrent arrested Based on treatment and restoration design(therapeutic classification by G V BLACK) classification Pathophysiology of caries : Caries causes damage by demineralization and dissolution of tooth structure Pathophysiology of caries Slide 15: sucrose +cariogenic plaque nutrients to organic acids lowering of ph(if below 5.5) dissolution of tooth mineral In caries active individual ph remains below 5.5 for 20-50 mins following single exposure to sucrose Caries risk assesment : Caries risk assesment Clinical characteristic of lesion : Clinical characteristic of lesion Sufficient thickness of anaerobic plaque has the potential to become cariogenic Large population of mutans streptococci along with sucrose rich diet produces extracellular polysacchride Anaerobic and acidic environment produces cavitation Surface cavitation along tooth surface : Surface cavitation along tooth surface Slide 19: The first indication of tooth decay are white spots on the enamel caused by the loss of calcium. If the demineralization process outruns the natural remineralisation process, the lesion grows and a cavity is formed. The bacteria may invade the pulp of tooth causing a consistent tooth pain, especially during the night. The bacteria may also produce an abscess, and eventually the tooth may be extracted by the dentist. First indication of tooth decay is white spot on enamel caused by loss of calcium If the demineralization process outruns the remineralization process lesion grows and cavity is formed Bacteria may invade pulp of tooth Causing consistant tooth pain The bacteria may eventually produce a abcess And eventually tooth can be extracted by dentist Cosequenses of caries G. v. black classification of cavities : G. v. black classification of cavities It represented a system of cavity design for restorations rather than carious lesion At that time it was thought that it is not possible to remineralize carious lesion In the absence to control the disease by any other means the margins of cavity were placed in self cleansing areas This led to initial cavity design being rather larger than necessary New classification of lesion of exposed tooth surface : New classification of lesion of exposed tooth surface Proposed in 1997 carious lesions occurs only on three sites on the crown & root which are areas subjected to plaque accumulation Site 1: pits fissures and enamel defects on occlusal surfaces of posterior teeth or other smooth surfaces Site 2: approximal enamel in relation to areas in contact with adjacent teeth Site 3: cervical one third of crown or on the exposed root surfaces Defining according to size and extent of lesion : Defining according to size and extent of lesion Communicating relationship between BLACKS & site ,size concept : Communicating relationship between BLACKS & site ,size concept Site 1: size 0,1,2,3,4-pit and fissure caries Cavity located on occlusal surface of posterior teeth or any simple enamel defect on smooth surface of any teeth Black class 1:smaller size 0 ,1 could not be performed so the black classification begins with site 1,size 2 Slide 25: Site 2:size 0,1,2,3,4- approximal lesion commencing in relation to contact area cavity located on approximal surface of any tooth (anterior or posterior) Blacks class II : lesions occuring between posterior teeth only. There was no equivalent of size 0 or 1 ,so blacks classification begins with size 2 site 2 Blacks class III : lesions occuring between anterior teeth only classified as size 2 site 2 Blacks class IV : extension of class III classified as site 2 size 4 Slide 26: Site 3 size 0,1,2,3,4- cervical lesions Lesions in cervical region around full circumference of tooth Blacks class V : does not recognize lesions on approximal surfaces erosive abrasive lesion or small carious cavity on buccal lingual surface is site 3 size 0 if restoration required then site 3 size 1 a larger carious lesion is site3 size 2 interproximal lesion will be site 3 size 3 site 3 size 4 is for complex lesion Slide 27: Dental Caries Enamel Caries Dentin Caries Cementum Caries (Root caries) Smooth surface caries Pit and fissure caries Clinical sites for caries initiation : Clinical sites for caries initiation Pits and fissures Rapidly colonized by bacteria Caries expands as it penetrates into enamel Entry site much smaller than actual lesion Affects greater area of DEJ Lesion is an inverted V with a narrow entrance and wider area of involvement near DEJ Slide 31: Smooth surface caries proximal surfaces particularly susceptible to caries coz of extra shelter provided to resistant plaque Lesions have broad area of origin and a pointed extension towards DEJ Cross section shows a V shaped lesion with a wide area of origin and the apex towards DEJ Enamel caries : Enamel caries histology of enamel Enamel composed of hydroxyapatite crystallites organised into long columnar rods Each rod starts at DEJ and extends to the surface of crown Enamel is able to act like a molecular sieve which explains why incipient lesions produces pulpal response Clinical characteristic of enamel caries : Clinical characteristic of enamel caries Incipient lesion chalky white when dried These areas of enamel lose their translucency because of extensive subsurface porosity caused by demineralization Softened chalky enamel that can be chipped away with explorer is a sign of active lesion Slide 36: Incipient caries of enamel can remineralize Noncavitated enamel lesions retain most of the original crystalline framework which serves as nucleating agent for remineralization Supersaturation of saliva with calcium and phosphate ions serves as driving force for remineralization process Remineralized lesions are intact but discoloured brown black spots Zones of incipient enamel caries : Zones of incipient enamel caries Translucent zone Deepest zone represents advancing front of lesion Name refers to structureless appearance Not always present Pore volume is ten times greater than normal enamel Slide 38: Dark zone Next deepest zone Does not transmit polarized light Small air or water filled pore makes the region opaque Pore volume is 2-4% Some say that its size is indication of remineralization that has recently occured Slide 39: Body of lesion Largest of the incipient lesion Has the largest pore volume 5% at periphery 25% at centre The interprismatic areas and striae of retzius provides access to the enamel rods which is attacked by bacteria Bacteria may be present in this zone Slide 40: Surface zone Relatively unaffected by carious attack Lower pore volume (less than 5%) Hypermineralized Slide 41: Translucent zone Dark zone Body of lesion Surface of lesion Striae of retzius Zones of enamel caries Dentinal caries : Dentinal caries Histology of dentine: Decay progresses slowly through enamel and quickly through dentine Enamel is approx.. 99% mineral whereas dentine is a living tissue with 30% organic content Salivary buffer are more potent at the enamel surface than deeper in dentine DEJ is least resistant to carious attack and allows lateral spread of caries Slide 44: Dentinal lesions are V shaped with base at DEJ and the apex directed pulpally Pulp dentine complex reacts to carious attack by attempting to initiate remineralization and blocking off open tubules In slowly advancing caries vital pulp repairs demineralized dentine by remineralization of intertubular dentine and by apposition of peritubular dentine Slide 45: CARIES OF DENTIN Begins with the natural spread of the process along the DEJ and rapid involvement of the dentinal tubules. The dentinal tubules act as tracts leading to the pulp (path for micro-organisms). Early Dentinal Changes: -initial penetration of the dentin by caries dentinal sclerosis, -calcification of dentinal tubules and sealing off from further penetration by micro-organisms, -more prominent in slow chronic caries. Dentinal sclerosis Initial penetration of dentine by caries produces dentinal sclerosis Sclerotic dentine formation occurs ahead of demineralization Function is to wall off the lesion by blocking the tubule Slide 46: Behind the transparent sclerotic zone, decalcification of dentin appears. In the earliest stages, when only few tubules are involved, microorganisms may be found penetrating the tubules Pioneer Bacteria. Behind the transparent sclerotic zone decalcification of dentine appears In earlier stages when only few tubules are involved microorganism may be found termed as PIONEER BACTERIA Slide 47: Advanced dentinal changes Decalcification and confluence of dentinal tubules Tiny liquifaction foci are formed These are filled with necrotic debris ,increases in size by expansion This expansion will bend the tubules leading their distortion Slide 48: Ground section Early dentinal carious lesion Body of enamel lesion Intact surface Infected dentine Decomposed dentine Dead tracts Zones of dentinal caries : Zones of dentinal caries Caries advancement in dentine proceeds through three stages (1) Weak organic acid demineralize dentine (2) Organic material of dentine particularly collagen degenerates and dissolves (3) Loss of structural integrity followed by invasion of bacteria Slide 50: Five different zones have been identified Normal dentine Subtransparent Transparent Turbid Infected Zones are more clearly distinguished in slowly advancing lesion Slide 51: NORMAL DENTINE Deepest area Dentinal tubules with smooth odontoblastic processes with no crystals in lumen No bacteria in tubules Stimulation of dentine produces sharp pain Slide 52: Subtransparent dentine Zone of demineralization of intertubular dentine and initial formation of very fine crystals in tubular lumen No bacteria Stimulation of dentine produces pain Dentine capable of remineralization Slide 53: Transparent dentine Softer than normal dentine Shows further loss of mineral from intertubular dentine and many large crystals in lumen of dentinal tubules No bacteria Collagen cross linking remains intact Intact collagen serves as template for remineralization Slide 54: Turbid dentine Zone of bacterial invasion Widening and distortion of dentinal tubules Collagen, irreversibly denatured Dentine beyond self repair Cannot be remineralized Must be removed before restoration Slide 55: Infected dentine Outermost zone Consists of decomposed dentine with bacteria Not recognizable Removal is essential Caries diagnosis : Identifying and preventing problems or treating them in eary stages is one of the most important things we can do for our patients Continuing education and integration of newer technologies allow us to do this and provides minimally invasive and tooth preserving treatment Caries diagnosis Diagnostic protocols : Conventional methods Alternative methods Diagnostic protocols Slide 58: Conventional methods Explorer & mouth mirror radiogragh visual examination Alternative methods : Digital radiogragphy DIAGNOdent QLF(quantitative light induce fluorescence) Electronic carrier monitor Fibreoptic transillumination Alternative methods Caries diagnosis methods : Widespread use of fluoride has created harder enamel surface more resistant to decay While it has reduced the overall incidence of decay it has made detection of caries in its early stage more difficult Caries diagnosis methods DIAGNnodent : We are proud to announce the acquisition of new high speed laser caries detector DIAGNodent uncovers decay by comparing fluorescence of healthy and decayed tooth Healthy tooth-no fluorescence decayed tooth-fluorescence increases in proportion to decay DIAGNnodent Slide 62: DIGNOdent as a means of caries detector If the enamel defect leading to decayed area is smaller than head of explorer used to detect cavities the decayed area may not be visible by our naked eye DIAGNodent uncovers hidden decay by comparing reflected flourescence of tooth structure against the establish baseline reading to establish decay Slide 63: Diagnodent Higher sensitivity and specificity than radiograph Influenced by staining of tooth Tool for monitoring mineral loss Digital imaging : Use of digital radiograph offers many advantages over traditional radiography Radiation exposure to patient is reduced Digital imaging Digital imaging cont… : Eliminates chemical processing Hazardous waste and lead foil eliminated Images can be transferred without loss of original quality Images can be used for substraction purpose,excellent method for tracking bone loss over time It can track hidden and small carious lesions Digital imaging cont… Quatitative light fluorescence : Enhances early detection of carious lesions Sensitivity with excellent repeatibility & reproducibility Quatitative light fluorescence QLF limitations : Only discern enamel demineralization Cannot differentiate decay, hypoplasia or unusual anatomic findings Cannot differentiate between enamel and dentine lesions Cannot differentiate between active and inactive lesions Sensitive to stains, deposits QLF limitations Fibre optic transillumination : Enamel lesions gray and opaque Dentinal lesions orange brown or bluish Useful as a adjunct Fibre optic transillumination Digital imaging fiberoptic transillumination : Has elevated traditional transillumination to more sophisticated method When teeth transilluminated area of demineralization scatter light and incipient lesions appear darker Differs from DIAGNodent ,has two handpiece one for smooth other for occlusal caries detection But.. It does not have the capability to determine the depth of the lesion Digital imaging fiberoptic transillumination Digital fibreoptic transillumination : Digital fibreoptic transillumination Safely and instantaneously creates high resolution image. Discovers or confirm presence of decay that cannot be seen radigraphically, visually or through explorer. Newer method of caries detection : “C”smart toothbrush modern toothbrush that will able to tell user whether they have developing caries It uses laser technology that collects reflected light from caries and is sent to the microcomputer chip in the toothbrush Newer method of caries detection Here is a question : Are these methods sole method of caries detection ANSWER NO They are only adjunct to visual examination and not complete substitute for the clinical judgement Here is a question Moving from mechanical to preventive model : Moving from mechanical to preventive model Prevention of dental caries : Preventive treatment methods are designed to Prevention of dental caries Limit tooth deminerelization Limit of pathogen growth Increase resistance Of tooth to deminerelization Oral hygiene Dietry modifications Antimicrobial agents Immunizations Saliva function Xylitol gums fluorides(systemic &topical) Pit and fissure sealants Preventive resin restoration Air abrasion : Oral hygiene Daily removal of plaque by tooth brushing,flossing &rinsing Floss purpose to remove plaque from proximal tooth surfaces Mechanical plaque removal changes the species composition of plaque &denies habitat to potential pathogens Slide 77: Dietry modifications Identify source of sucrose in diet and reduce the frequency of uptake Caries activity stimulated by frequency rather than quantity Sugar free foods for snacks may be advocated Substitution of alchohol based sugar Salivary functions : Saliva-natural defence against caries Protective properties of saliva clearance buffer properties antibacteril properties Xerostomia increases caries susceptibility Salivary stimulants ( gums,paraffin or salivary subsitute)to patient with impaired function Salivary functions Xylitol gums : Natural five carbon sugar Acts directly on bacteria Gets substituted for fructose in bacterial metabolism cycle Environmental shift favouring nonpathogenic bacteria Xylitol gums immunization : Caries vaccine primarily based on IgA immunoglobulin Certain limitations potential side effects concerns of possible reaction with cardiac tissues cost immunization Pit and fissure sealants : Specifically designed for caries prevention in pit and fissure areas coz fluorides more effective in prevention of smooth surface caries Three important preventive effects mechanical filling of pits and fissures with acid resistant resin Filled pits no longer habitat for s.mutans and other oral bacteria Render pits easy to clean Pit and fissure sealants Preventive resin restoration : Composite resin with overlying sealant application Consevative and esthetic More technique sensitive Accepted on a global basis as the technique of choice for minimally invasive treatment of incipient or small carious lesions in pit and fissure areas Preventive resin restoration Atraumatic restorative treatment : Minimal intervention technique for management of dental caries Glass ionomers cements are used They are fluoride releasing materials Valuable tool in fighting caries in those areas where the disease is rampant Atraumatic restorative treatment Air abrasion : Minimal intervention technology creates narrow preparations less expensively and more efficiently Uses 27micrometers aluminium oxide powder at pressure of 40-160psi Low viscosity flowable composite is used Greater patient comfort Air abrasion Slide 86: Air abrasion system not only diagnose but can be used to treat caries. When used with improved composite resin early treatment of decay can be done with small conservative restoration Fluoride exposure : In trace amount increase the resistance of tooth to demineralization Exerts anticaries effects by three mechanism Enhances precipitation of fluorapatite ,less soluble & more acid resistant Inhibits enzymatic glycosyltransferase prevents glucose from forming extracellular polysacchride reduces bacterial adhesion In high concentration directly toxic to oral microorganisms Fluoride exposure Management of pit &fissure caries : Diagnostic criteria Softening at the base of a pit and fissure Opacity surrounding pit and fissure indicating undermining demineralization of enamel Softened enamel that may be flaked with explorer Chalky or opaque appearance of enamel when dried with compressed air Radiogrphically radiolucent area spreading laterally under the occlusal enamel Management of pit &fissure caries Pit and fissure caries treatment decision making : pit and fissure caries Pit and fissure caries treatment decision making Non cavitated cavitated Caries unlikely No progression Caries likely progression No treatment Sealants Antimicrobials fluorides Restorations Antimicrobials fluorides Management of smooth surface caries : caries on proximal surface of teeth or on gingival third of buccal or lingual surface Bitewing radiograph useful coz proximal caries not accessible to visual or tactile examination easily Early lesion appears as localized radiolucency below the proximal contact Proximal radiolucency should be examined clinically coz most of them not associated with cavitation and do not require restoration Management of smooth surface caries Proximal surface treatment decision making : proximal surface noncavitated cavitated Proximal surface treatment decision making Surface intact Opacity of proximal Area may be present Radiolucency may Be present Opaque are may be Seen in enamel in trans illumination Surface broken Mechanical seperation Marginl ridge may be discoloured Opaque area in dentine On transillumination Radiolucency is present treatment : Proximal surfaces difficult to judge clinically Critical event in caries process is surface cavitation Cavitated surface must be restored Non cavitated only by antimicrobials and fluoride agents Radiolucency alone not diagnostic of cavitation Restoration of all radiolucent surface results in excessive unnecessary restorative treatment treatment Management of root caries : Usually shallow initially spreads laterally, light brown in colour without any patient symptoms Lesion development rapid coz no enamel protection ,less mineralized dentine The remineralization is likely coz the lesion is shallow initially and therefore easier for ions to penetrate and strengthen Should be watched for arrestment rather than restored at first because usually no pain associated with these lesions Management of root caries conclusion : Diagnosis, prevention and treatment of dental caries must be the foremost objective of operative dentistry Research efforts in understanding the caries process ,benefits of fluoride and development of anticaries vaccine must be continued Patient education and motivation should be stressed Clinical treatment must be accomplished expeditiously and appropriately conclusion Slide 96: Thank you