Caries.txt

• ID disease from signs & symptoms
• 1. recognize SS
• 2. Hx, Phys
• 3. Diff Diag
• 4. Hypothesis
• 5. Diagnostic tests
• 6. Diagnosis
• 7. Treatment

• 1. Detect lesions: differentiate caries-free v caries-affected
• 2. Factor RISK
• 3. Determine caries management options
• * avoid unjustified (overtreatment)
• * classifying carious lesions corresponding to the best management options for each lesion type

• pts benefit?
• OH improve?

detetion is part of diagnosis

• cavitated: RESTORATIVE management, form and function, proper OHI, NOT disease mgt
• Non-cavitated: non-restorative (control plaque, diet, Fl, CPP-ACP, monitor), cost concerns of professional application (usually if active)
• active: ongoing mineral loss (professional non-restorative or lesion specific OHI)
• arrested: no active mineral loss: professional intervention not needed

• Restorative: form, function, facilitate OH
• NO MGT OF DISEASE

• light: anterior interproximals, shadows
• DRY, clean
• 3-way syringe: dry
• mirror: retract tissue, reflect light
• sharp explorer: remove plaque with side, assess roughness w/tip & gentle pressure(vibrations), do not EXPLORE STICK(NOT valid detection)
• magnification
• systematic (isolate/dry quadrants)

• Dry w/ 3 way syringe to increace refractive index between sound and carious enamel
• allows visualization of surface texture
• look for white spots, lines, shadwows beneath enamel

• white (or yellow)
• opaque, chalky (neon-like)
• Rough texture

• variable color (whitish to black)
• shiny
• smooth texture

• soft, leathery
• dull, not shiny

hard & shiny

• caries: arch, banana, kidney-shaped (plaque accululation along present of former FGM)
• fluorosis: symmetric distribution of fine horizontal stiae (perichymatal enamel pattern)
• developmental defect(non Fl): round or oval, clearly defined from adjacent enamel on single teeth

• white lesions w/ symmetric distribution & fine horizontal striae reflective of perichymatal enamel pattern
• perikyma: pits around the long prisms of tooth enamel. They indicate the places where enamel-producing cells used to make contact to neighboring cells and are the result of normal enamel apposition.

developmental, non-flouride

• TF1: thin, white, opaque lines corresponding to perikymata, may include white areas along cusp tips, incisal edges or marginal ridges
• TF2: more pronounce lines appear as bands
• TF3: entire surface cloudy, white, opaque w accentuated perikymata
• perikymata: pits around the long prisms of tooth enamel. They indicate the places where enamel-producing cells used to make contact to neighboring cells and are the result of normal enamel apposition.

Caries Management by Risk Assessment

Risk Asessment

• caries risk assessment: Preventive Dentistry Consultation Notes
• MBI/PI categories
• OHI
• Fl trays
• Prevention Plan

• High Risk categories
• Visible caries/ dentin caries radiograph
• Restorations last 3 yrs
• frequent snaacks
• saliva reducing factors (meds, radiation, systemic)
• visually inadequate saliva
• Appliances

• YES” on visible cavitations or dentin in radiograph or on any two of:
• Restorations last 3 yrs
• frequent snaacks
• saliva reducing factors (meds, radiation, systemic)
• visually inadequate saliva
• Appliances

• Moderate risk & Protective factors
• exposed roots
• dev defects: deep pits/fissures
• interprox lesions, radiolucenies
• enamel white spots/discoloration
• recreational drug use
• Protective: Fl H2O, Fl toothpaste, mouthwash, salivary flow, xylitol (4x/day), CHX

Treatment recommendations

• Disease Indicators
• White spots
• Restorations <3yrs
• Enamel lesions
• Cavities/dentin

Risk Factors: Bacteria, absent saliva, diet(poor)

Protective: sealants, antibacterials, Fl, Effective diet

• Hx & clinical exam
• enter notes
• assign category
• treatment reccomendations
• explain
• instruct (writing)
• provide test results
• reassess in 3-6 months

• Radio: BW 24-36 months
• Recall: 6-12 month
• Fl:

• fuschin: Fusayama (1972) histologic stain for protein, discovered 2 layers(affected, infected) of carious dentin
• partially carcinogenic: replaced by 1% acid red

1% acid red in propylene glycol or polypropylene glycol

• infected w/bacteria, affected by acid
• infected (outer): highly-decalcified, fuschin stainable, irreversibly denatured collagen, unrecalcifiable
• affected (inner): partially-decalcified and recalifiable, no fuschin stain, sound collagen

stain only infected dentin to enhance removal, prevent over-excavation, improve accuracy

• sound: Rock hard, not discolored
• Low specificity= High FP rate
• often over-removed

• stain organic matrix (collagen) of less-mineralized dentin(not enamel), more stained, more disease
• don't stain bacteria (NOT RELATED TO PENETRATION OR ELIMINATION)
• must know limitations

• Low specificity = high FP
• especially in DEJ, near pulp because higher organic matrix comp

DEJ, near pulp where more organics(collagen)

NO, nonspecific protein, will stain food, pellicle and other organics trapped in pits & fissures

• Non ionizing, EARLY caries detection (3D-view) via scattering light principles
• Sound tissue: more light transmission
• Demineralized tissue:more scattering, more absorption

transmits (no shadows, scattering)

• enamel: gray shadow
• dentin: orange-brown or bluish

• High specificity for both FOTI and BW
• Lower sensitivity for FOTI vs BW
• another study showed high specificity and no sensitivity vs BW
• High Spec = Low FP
• Low sensitivity = misses a lot (High FN)

better than visual but steep learning curve, low performance w/stains

FOTI w/CCD intraoral

• Higher sensitivity in detection of early lesions not apparent in conventional radiography
• use of DIFOTI in conjunction with radiographs improves diagnostic accuracy
• NOT for depth
• Adjuntive(not replacement) diagnostic tool

• EARLY lesions
• visualizing suspicious fissures and confirming enamel or dentin cracks

light transmission is blocked at crack planes

• phenomenon where absorption of light of a given wavelength by a molecule is followed by
• the emission of light at longer (visible) wavelengths.
• Direct relationship between fluorescence and mineral content (distinguish sound and demineralized enamel)

• arc lamp to analyze sound vs demin enamel via 370nm (blue) wavelength
• lesion area(mm2), depth(% fluoresence loss), volume (area*depth)

• good corr btwn % fluoresence loss and lesion depth in vitro (0.85)
• smooth surfaces: sensitivity: .76 specificity .85
• occlusal: sensitivity .68 specificity .7

• early lesion detection & quantification
• storable/tranmittable data
• over time comparisons of remin & preventive tx

• IR light and has a 655 nm wavelength (red) reades moment(real time)/peak(max)
• probe uses 2-way FO system
• must be used on CLEAN DRY to reduce FP
• rotate & pivot to improve accuracy

• CLEAN/DRY (stains/plaque->FP)
• rotate & pivot tip

• 0-10 sound enamel
• 10-20 outer enamel caries
• 20-30 lower enamel caries
• >30 dentinal caries

• high sensitivity for dentinal caries but wide range
• higher sensitivity, lower specificity than visual (more FP)
• adjunct

• Δ in optical signature of healthy vs.demineralized tooth structure
• healthy(green) ->more translucent than decalicied(red)
• used on WET tooth surface
• tool must be calibrated (ceramic)

directed down long axis

• 80% sensitivity IP
• 92% occlusal

• atypical enamel morph
• restorations or sealants
• Calculus or plaque
• Stains (thick, dark brown)
• Food debris
• Contaminants on probe tip
• Probe not being in contact with tooth surface
• Tooth is dry (Midwest Caries I.D.) or tooth iswet (DIAGNOdent)

Six LEDs emitting blue light @ 405nm

• AC impedance spectroscopy
• Sound enamel =high electrical resistance.
• Demineralization = ↑enamel permeability = ↓electrical resistance
• By the time caries has reached dentin the resistance has dropped by a factor of 30.

• only drug proven to prevent
• dental caries lesions
• higher conc (5000 vs 1500) enhanced remineralization and inhibited demineralization

• Amorphous Calcium Phosphate Free & available for incorporation into tooth structure
• Best for pts. w/mild remin probs and high motivation
• Two-phase delivery system
• Prevents the calcium and phosphate from reacting

• low substantivity
• acid challenge (pH<5.5) breaks down ACP and not available after

• Casein Phosphopeptides (CPP)
• tooth-protective activity
• bind calcium and phosphate and keep them in a soluble, amorphous state
• provides SUBSTANTIVITY to ACP
• penetrate into the tooth enamel, work synergistically with fluoride and repair demineralized areas

insoluble calcium phosphate crystals

• pea-sized on finger
• smear on teeth

• High caries risk
• Infants & Children
• Expectant Mothers
• Orthodontics
• Whitening sensitivity
• Root exposure
• Chemotherapy, radiation

• CPP-ACP: 10%
• •NaF: 900 ppm* (OTC toothpaste: 1000 ppm*)
• •ph: 7.2

• superior anti-caries effect than Fluoride alone
• high risk for dental caries and dental erosion
• Remineralized(thickened) through the body vs surface only of Fl alone

• 5 :3 :1
• 5 / Calcium
• 3 / Phosphate
• 1 / Fluoride

• CT evidence insufficient to make conclusions regarding the longterm effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth
• not yet been substantiated
• Topically applied fluoride remains the standard for anti-caries effectiveness

• anticavity toothpaste 1.1 (5000ppm F-) blended/milled with organic materials
• • Calcium – phosphate bonds are broken
• • Calcium oxides become ‘protected’ by the organic materials
• • TCP ingredient can coexist with fluoride ions in an aqueous dentifrice base  High fluoride availability
• • Organic carry the calcium to the tooth surface, protected from fluoride ion  High fluoride bioavailability during application
• • Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface  Calcium bioavailability during application

saliva at tooth surface increase bioavailability

• Particulate “bioactive glass” material
• attach to tooth surface,
• → react with water
• → release Ca2+ and PO43- ions
• → new HA forms on tooth surface
• Found in NUPRO Sensodyne Prophylaxis Paste with NovaMin (5000ppm F- too)

• Foundational Principles
• • Resting saliva pH = 6.75
• • Stimulated saliva pH = 7.8
• • HA dissociates into Ca2+ and PO4 3- ions at pH < 5.5
• • Fluorapatite (FA) dissociates at pH < 4.5
• ∴ Saliva environment favors presence of HA and FA nanocrystals over ions

• Powerful oxidant, disinfectant (CONFLICTING)
• unstable releases nascent oxygen
• Disinfection of endodontic systems (CONFLICTING)
• Promote soft tissue healing (e.g. apthous ulcers)
• Tooth whitening (oxidation)
• HALT/REVERSAL OF CARIES LESIONS (NO EVIDENCE)

• • Wound healing – long history
• • Gangrene, infection, burns
• • Ocular diseases
• • Kills microorganisms, safe for human tissue cells (GOOD EVIDENCE)

• promote haemostasis
• • enhance local oxygen supply,
• • inhibit bacterial proliferation

• • Oxidizing action drives O2 beneath surface of lesion to
• kill bacteria
• • Neutralization of acids creates hostile environment for
• cariogenic bacteria
• • Lesion is populated with non-cariogenic bacteria
• (probiotic effect)
• • Remineralization from salivary or topically-applied
• sources of F, Ca, and PO is facilitated

prophy for restorative prior to etching

• Diffusion barrier for proximal lesion infiltration of NON-CAVITATED, smooth surface lesions
•  Interproximal
•  White spot lesions
• Infiltrate the porous body of lesion with low-viscosity resin
•  Block diffusion pathways INSIDE vs surface sealant for cariogenic acids
• Procedure: Acid-etch, rinse, dry  Drying solution (ethanol)  Infiltrate with resin  Light-cure
• Stats: higher penetration coefficient

digital subration images of radiographs

• strong evidence for the advisability of leaving behind infected dentin…”
• cariogenic bacteria isolated by a restoration pose no risk…”
• removing all vestiges of infected dentin from lesions approaching
• the pulp is not required for caries management

• black surfaces of amalgam-restored teeth
• had no caries progression
• • Knew of silver nitrate use for sensitive teeth
• • Showed 61% decay inhibition at 3 years w/silver nitrate
• Arrest of active lesions
• • Prevention of new lesions
• • May be more effective than fluoride varnish!*

• AgF: HA->FA (hydroxy apatite to fluoroapetite(less acid soluble)
• in infected area AgPO4s go into Thiols of AA and nucleic acids that aren't metabollically active for bacteria
• also only darkens infected areas

KI (potassium Iodide)

preclinically evident detection of demineralization

less than 1/3rd of enamel

• TP/(TP+FN)
• correct test result for all with disease
• ability to detect presence of disease when it’s actually present

• TN/(TN+FP)
• ability to rule out disease when it’s not present

• low sensitivity & high specificity
• False negatives more likely than false positive
• miss more than incorrect diagnos

• size: low accuracty for small proximal lesions, increases w/ lesion depth
• must be combined with clinical exam (visual/tactile)

yes

• between contact and gingival margin
• therefore do not superimpose teeth
• must be at least 30-40% to be radiographically visible

• cervical burnout: illusion of radiolucency of a radiopaque object as a radiolucent area or band between two extremely radiopaque areas.
• hypoplastic enamel
• morhological variation: lingual concavity, enamel hypoplasia (look like erosion)

• needs to be 30-40% demineralized
• overlap: less than 1/3rd ideal
• about 50% of proximal caries aren't detected

• DEPENDS ON RISK!!
• incidence = 10%, (50% sensitive, 95% specific, PPV = 53%)
• incidence = 50%, (PPV = 90%)
• Therefore PPV is better for high risk groups

• 6-12 months (children,adolescents)
• 6-18 adults

• 12-24 months children
• 18-36 adolescents
• 24-36 adults

• Deep buccal pits
• minimize by correlating w/ clinical exam

• superimposition of tooth structure
• insufficient radiographically detectable demineralization

• Beam hardening "scatter" artifacts from metallic restorations
• artifacts interfere w/ caries diagnosis
• typically only used for high risk