MANAGEMENT OF CARIES
PRESENTER: DR FARHEEN FATIMA
MODERATOR: DR ASIT VATS
CONTENTS
INTRODUCTION
PATHOGENESIS
PROGRESSION
TREATMENT
PREVENTION
MANAGEMENT OF DENTAL CARIES
CONCLUSION
INTRODUCTION
◦ Cariology is a science which deals with the study of etiology, histopathology,
epidemiology, diagnosis, prevention and treatment of dental caries.
◦ Dental caries is an irreversible microbial disease of the calcified tissues of the teeth,
characterized by demineralization of the inorganic portion and destruction of the
organic substance of the tooth, which often leads to cavitation.
◦ Dental plaque is an adherent deposit of bacteria and their products, which forms on all
tooth surfaces.
◦ Dental plaque is important for beginning of caries because it provides the environment
for bacteria to form acid, which causes demineralization of hard tissue of teeth.
PREVENTION OF DENTAL CARIES
◦ METHODS TO REDUCE DEMINERALIZING FACTORS:
◦ DIETARY MEASURES:
1. Sugar substitute: Xylitol, Sorbitol
Anticariogenic effects of xylitol-
Xylitol reduces plaque formation
It reduces bacterial adherence
It inhibits enamel demineralization
It has a direct inhibitory effect on S mutans Increases salivary flow
It is nonfermentable
It increases concentration of amino acids which neutralize the plaque acidity.
◦ 2. Fibrous food: Intake of fruits, vegetables and grains helps in:
◦ A. Increasing the salivary flow.
◦ B. Increases caries protective mechanism because these foods contain natural
phosphates and non-digestable fibers, moreover they do not stick to teeth.
◦ 3. Fats: Fats form a protective barrier on enamel or carbohydrate surface so that it
is less available for bacteria. They also speed up the clearance of carbohydrate
from oral cavity, thus decreasing cariogenic potential.
◦ 4. Cheese: Cheese is considered responsible for:
◦ A. Increasing the salivary flow.
◦ B. Increasing the PH.
◦ C. Promoting the clearance of sugar.
◦ B. Methods to improve oral hygiene:
◦ 1. Dental prophylaxis: Polishing of roughened tooth surfaces and replacement of
faulty restorations is done so as to decrease the formation of dental plaque,
therefore, resulting in less incidence of caries.
◦ 2. Tooth brushing.
◦ 3. Interdental cleaning.
◦ C) Chemical measures:
◦ Substances interfering with bacterial growth and metabolism:
◦ Chlorhexidine
◦ Urea and ammonium compounds
◦ Glutaraldehyde
II. Methods to increase
protective factors
◦ A. Methods to improve flow, quantity and quality of saliva: In patients with
hyposalivation, baking soda may help to neutralize acids. The mouth rinse is
prepared by mixing two teaspoons of baking soda in eight oz of water. This solution
is used for mouth rinsing after eating.
◦ B. Chemicals altering the tooth surface or tooth structure:
◦ Fluorides: clinical fluoride products such as (professional topical fluorides, fluoride
varnishes, mouthrinses, dentifrices, supplements in the form of fluoride tablets and
drops, fluoridated salt).
Advanced methods of caries
prevention
◦ A. Genetic modalities in caries prevention: In an attempt to produce the strains of S.
mutans which can not cause caries.
◦ 1. Genetically modified foods (probiotics): Modified fruits and vegetables are being
developed by incorporating antagonist peptides to work against glycosyl
transferase.
◦ 2. Genetically modified organisms: A new strain of S. mutans has been created
which lacks lactodehydrogenase gene, thus unable to produce lactic acid.
◦ 3. Lactobacillus zeae: Theses are genetically modified bacteria which produce
antibodies so as to attach to surface of S. mutans resulting in their death.
◦ B. Caries vaccine:Vaccine is an immunological substance designed to produce
specific protection against a given disease. It stimulates production of protective
antibody and other immune mechanism.
◦ Although many trials have been carried out on experimental animals in the
laboratories, no such vaccine is commercially available till date. Vaccine should be
given before eruption of deciduous teeth so as to achieve maximum benefits.
MANAGEMENT OF DENTAL
CARIES
◦ • The invention and application of engine driven or rotary instruments in operative
treatment of carious lesions has resulted in removal of considerable tooth structure.
But now a days other procedures have also been used for removal of caries like Air
abrasion, Ozone treatment of dental caries, Chemomechanical caries
removal and Lasers.
AIR ABRASION
◦ The study of the use of air abrasion technology for dental applications initiated by
Dr. Robert Black in the 1940's was successfully introduced in 1951 with the Airdent
air abrasion unit (S.S. White).
◦ Kinetic energy is used to remove carious lesion. In this method, a powerful fine
stream of aluminum oxide particles is targeted against the surface to be removed.
◦ There are 2 sizes of aluminum oxide particles:
◦ ✓ 27µm (more comfortable, less effective cutting).
◦ ✓ 50 µm (more abrasive cutting, but more discomfort).The abrasive particles hit the
tooth with high velocity and remove small amounts of tooth structure. Tip distance
must be (0.5 to 2 mm) from carious lesion.
◦ Nowadays, a number of variations in tip angulations and nozzle diameters are
available. Smaller nozzle diameters can be used for areas that are difficult to
access. The various tip angulations allow easy placement and orientation of the
handpiece thus easing the strain off the operator's hands.
◦ ADVANTAGES
◦ 1. Non-traumatic.
◦ 2. No micro chipping or micro fracturing.
◦ 3. Less discomfort.
◦ 4. No anesthesia.
◦ 5. Decreased thermal buildup.
◦ DISADVANTAGES
◦ 1. Lack of tactile sensation.
◦ 2. Risk of cavity over preparation and inadequate caries dentine removal.
◦ 3. Spread of aluminum oxide around dental operatory.
◦ 4. Danger of air emphysema.
◦ 5.Impaired indirect view.
◦ 6. Damage of dental mirror, optical devices like magnifying lopes
USES
◦ 1. Cavity preparation.
◦ 2. Internal cleaning of tunnel preparation.
◦ 3. Micro abrasion of enamel hypoplasia.
◦ 4. Stain removal.
◦ Air abrasion not used in:
◦ 1. Crown preparation.
◦ 2. Large caries defect.
◦ 3. Amalgam removal.
CONTRAINDICATIONS
◦ 1. Patients with dust allergy, asthma.
◦ 2. Patients with advanced periodontal disease.
◦ 3. Patients with fresh extraction.
◦ 4. Patients with recent placement of orthodontic appliances.
◦Precautions taken with Air abrasion:
◦ Use surgical mask, dry vacuum systems to reduce respiratory exposure.
◦ Use rubber dam, protective eyeglass and metal matrix to protect adjacent tooth
structure.
◦ Use disposable mirrors.
OZONE THERAPY
◦ Within the past few years, ozone therapy has been launched as a new method for
treating caries by Edward LyGh.
◦ Ozone (03) is a gas with a characteristic, penetrating odor that is present in small
amounts in atmospheric air.
◦ Ozone reacts with numerous inorganic and organic compounds. It bleaches dyes
and kills bacteria.
◦ Ozone destroys the bacterial cell membrane, where after the bacteria die. As
bacteria cause caries, it was natural to investigate whether ozone could be used
to treat caries.
◦ The ozone unit for dental use was initially developed under the name 'HealOzone’.
◦ The new version of HealOzone (Mark3) was launched in July 2004. According to the
manufacturer previous models can be upgraded to the most recent technical
functions.
◦ Oxygen delivery unit (Ozone unit - HealOzone) consists of:
◦ 1. Polyurethane console:
◦ A. Ozone generator.
◦ B. Vacuum pump.
◦ C. Desiccant.
◦ D. Hydrophobic filter.
◦ 2. Handpiece:
◦ ✓ Stainless steel, contra angle handpiece.
◦ ✓ Disposable polymer sealing cup attaches to the head (differently shaped silicone
cups are available that correspond to the form of various teeth and their surfaces; 5
sizes from 3 to 8 mm in diameter).This ensures close contact between the silicone
cup and the carious area of the tooth so that the ozone does not escape).
◦ ✓ Handpiece attaches to the console by detached hose.
◦ Delivers ozone at a rate of 13:33ml/sec.
◦ 3. Patient kit: tooth paste, oral rinse.
◦ Polymer cup adapted to carious lesion and air sucked to create a vacuum. Ozone
gas delivered for 10 seconds at minimum into the cup around the tooth surface.The
ozone in the silicone cup is collected again and reconverted to oxygen by the
apparatus (suction activated for 10 seconds while cup is still attached to carious
lesion to remove residual).
◦ The procedure usually takes between 20 and 120 seconds per tooth. Immediately
after ozone application the tooth surface is treated with a remineralizing solution
(reductant) containing fluoride, calcium, zinc, phosphate and xylitol dispensed from
a 2ml ampoule.
◦ Patients are also supplied with a patient kit, which consists of toothpaste, oral rinse
and oral spray, all containing fluoride, calcium, zinc, phosphate and xylitol, and
aims to enhance the remineralization process.
◦ One of the study to assess the effect of ozone therapy in combination with the daily
use of remineralizing products on root caries. The control period was up to 18
months, and the patients were recalled for examination and repeat treatment after
3, 6, 12 and 18 months.
◦ The trial showed that 69-100% of the ozone-treated lesions (duration of treatment
40 sec) became harder during the 18-month trial and none became softer.
◦ INDICATIONS
◦ 1. Primary root carious lesions.
◦ 2.Primary pit and fissure caries.
◦ ADVANTAGES
◦ 1. Kills more than 99% of microorganisms in carious lesion at a concentration of
2,200 ppm.
◦ 2. Oxidizes caries and speeds up remineralization.
◦ 3. Helps to remove organic debris on carious lesion.
◦ 4. Potentially whitens discolored caries.
◦ 5. Decreased treatment time.
◦ 6. Treatment painless and noiseless.
◦ 7. Does not cause any allergic reaction.
◦ 8.Microorganisms do not developed resistance to Ozone.
CHEMOMECHANICAL CARIES
REMOVAL (CMCR)
◦ Chemomechanical caries removal (CMCR) involves the selective removal of carious
dentine. The reagent is prepared by mixing solutions of amino acids and sodium
hypochlorite (NaOCl).
◦ Reagents commonly available in market are Caridex and Carisolv.
Development of Caridex,
Carisolv, Papacarie
◦ The idea of chemo-mechanical caries removal has been developed in 1970s by
Goldman who was primarily an Endodontist, while using sodium hypochlorite
(NaOCl) in removing organic materials in the root canals. This chemical has got the
ability to dissolve carious dentine and since that time, the idea of removing caries
chemically was borne.
◦ Caridex was introduced in the US market in 1984 by National Patent Medical.
◦ Carisolv was introduced in 1997 by Swedish Medi Team.
◦ Papacarie was developed in Brazil in 2003, by Bassadori et al, (Papacarie: a word
that means "eating caries").
Application & Mode of action of
Caridex
◦ The delivery system of Caridex consisted of:
◦ ✓ Reservoir for the solution.
◦ ✓ Heater: warmed liquid to the body temperature.
◦ ✓ Pump: passed the warmed liquid through a tube to a hand piece and applicator
tip (20 gauge hypodermic needle, the tip of which had been modified into spoon
shape).
◦ It involves the chlorination and disruption of the partially degraded collagen fibers
in carious dentine with N-monochloro-D-2 aminobutyrate (NMAB).
◦ The carious dentine then becomes easier to remove by excavation using the
modified needle tip.
Application & Mode of action of
Carisolv
◦ The contents of the two syringes should be mixed immediately before use as its
effectiveness begins to deteriorate after 20 minutes.
◦ The mixed gel is applied to the carious lesion for 30 seconds and then the carious
dentine can be gently removed, using Carisolv specially designed, non- traumatic
hand instruments.
◦ The same procedure is continuously repeated until removing clear gel is achieved.
Advantages of Carisolv
◦ 1. No need for local anesthesia.
◦ 2. Conservation of sound tooth structure.
◦ 3. Reduced risk of pulp exposure.
◦ 4.Volume required is less.
◦ 5. Does not require heating or a delivery system.
◦ 6. Since it involves gel not liquid, it is much easier to use than caridex.
◦ 7. Better contact with the carious lesion.
◦ Disadvantages of Carisolv
◦ 1. Instruments may still be needed for the removal of caries or material.
Application & Mode of action of
Papacarie
◦ Papacarie when applied to the contaminated dentine has proteolytic, chlorinating
and oxidating properties on the affected collagen, without acting on the sound
dentine.
◦ It is able to remove the smear layer, which facilitates the penetration of adhesives,
thereby enhancing the adhesional properties of restorative materials, without
compromising on the shear bond strength.
Advantages of Papacarie
◦ 1. It does not require special instruments or equipments.
◦ 2. Easy to manipulate.
◦ 3. Fast acting.
◦ 4. Ideal consistency.
◦ Disadvantages of Papacarie
◦ 1. Instruments may still be needed for the removal of caries or material.
Lasers
◦ The use of lasers for cavity preparation and caries removal is based on the ablation
mechanism, in which dental hard tissue can be removed by thermal and/or
mechanical effect during laser irradiation (Keller et al., 1998).
◦ Lasers have shown to remove caries selectively while leaving the sound enamel
and dentin. They can be used without application of local anesthetics.
◦ Commonly used lasers for caries removal are Er:YAG and Er.Cr: YSGG lasers.
◦ Carious material contains a higher water content compared with surrounding
healthy dental hard tissues. Consequently, the ablation efficiency of caries is
greater than for healthy tissues.
Mechanism of action of Lasers
on hard tissue ablation
◦ Lasers have photomechanical effects, Laser light is highly energetic and when
exposed causes fast heating of dental tissues in small area.
◦ Fast mechanical shock waves occur due to photo-vaporization of water within the
tooth.
◦ This change creates high pressure, removing and destroying selective areas
of adjacent tooth.
Technique of Laser application
◦ Recommended setting for Er:YAG laser:
◦ ✓ Caries: 100-200mj.
◦ ✓ Dentin: 150-200mj.
◦ ✓ Enamel, 200-250mj.
◦ Gently touch target tissue with tip end.
◦ Direct water stream to the target tissue.
◦ Always keep operation area wet.
◦ Keep tip moving to provoke effective ablation and better cooling.
◦ For deep cut move the tip constantly up and down (pumping action).
Advantages of hard tissue laser
treatment
◦ 1. Pulp vitality not compromised.
◦ 2. Can remove caries effectively.
◦ 3. Can perform cavity preparation effectively.
◦ 4. Quality of cavity preparation equivalent to that with the handpiece.
◦ 5. Less anxiety, pain free and anesthesia free.
◦ 6. Little or no post-operative discomfort.
◦ 7. Ideal for children and adults (comforting for both patient and parent).
◦ Disadvantages of hard tissue laser treatment
◦ 1. Limitation of ErYAG: do not ablaze amalgam, gold and porcelain.
Conclusion
◦ "Prevention is better than Cure" so it is imperative that we, as dentists should focus
on treating not only those who are ill, but also treat those who are more likely to get
ill... We have a variety of new agents which can be used to prevent dental caries
but application of these agents in clinical trials is still limited in the developing
countries. Moreover dental caries is a multifactorial and all preventive(esp.non-
fluoride) measures should be evaluated properly in human trials so that they can be
introduced at the community level for the prevention of dental caries.
