Contemporary Operative Caries management: Consensus recommendations on minimally

invasive caries removal

 Selective caries removal as management for non-cleansable cavitated carious lesion –
should be norm
o Justification: provide a cavity of adequate proportion to support mechanically
the final restoration in more superficial lesions.
o Maintaining pulp health = priority in deeper lesion, carious tissue retained
selectively over the pulp
- Level of hardness (soft, leathery, firm, and heard dentine) = criterion for determining
clinical consequences of the disease
- New strategies for carious tissue removal:
o Selective removal of carious tissue (selective removal to soft dentine and firm
dentine)
o Stepwise removal
o Non selective removal to hard dentine (complete caries removal) – no longer
recommended
Dental Caries: disease that results from an ecologic shift in the bacteria within the dental
plaque biofilm
- Not an infectious disease – can be managed behaviourally by controlling causative
factors
Improved evidence 
- Removal of large quantities of dental hard tissue no longer justified due to development
of adhesive bioactive/biointeractive resto materials
- Carious tissue removal simply to remove bacteria to halt caries process not logical or
justified
- Structurally intact dentine that can be remineralized should be preserved
Aims of restorative management:
1. Aid biofilm control on a restored, rather than from a cavitated, tooth surface and
thereby manage caries activity at this specific location
2. Protect the pulp-dentine complex and arrest the lesion activity by sealing the coronal
part with an adhesive dental material
3. Restore the function, form and aesthetics of the tooth.

Guiding Principles for removal of carious tissue:

1. Preserve non-demineralized and remineralisable tissue
2. Achieve an adequate peripheral seal by placing the restoration material onto sound
dentine and/or enamel where achievable
3. Avoid discomfort/pain and dental anxiety
4. Maintain pulp health by avoiding dentine excavation close to the pulp so minimising the
risk of pulp exposure; ie, leave softer affected dentine in close proximity to the pulp if
required. Avoiding pulp exposure significantly improves the lifetime prognosis of the
tooth and reduces long-term management cost
5. Maximise longevity of the tooth-restoration complex by removing enough soft dentine
to place a durable restoration of sufficient bulk and resilience
Non-cavitated carious lesions:
- Managed non-operatively using biofilm disruption and removal + topical remin or by
therapeutic fissure sealing over early lesion (occlusal pits and fissures)
Non-cavitated but radiographically extensive:
- Can be therapeutically fissure sealed by integrity of seal must be monitored
- Trampoline effect possible from the underlying softer infected, completely
demineralized dentine  mechanical failure of the sealant
Cavitated carious lesion:
- Cleansable  can be made inactive and managed non operatively by hygiene
procedures and remin
- Not cleansable pathologically active and progress, need further operative
interventions for management

Clinical presentation of dentine:

Soft dentine:
- deforms when dental explorer pressed onto it
- can be easily scooped up with little force
- moist
Leathery dentine:
- does not deform when instrument pressed on it
- can still easily lift
- tackiness
- caries- affected dentine
Firm dentine:
- physically resistant to hand excavation, pressure required
Hard dentine:
- pushing force needs to be used and only sharp cutting edge or bur will lift it

- periphery of cavity should ideally be surrounded by sound enamel to allow for optimal
adhesive seal

strategies for removing carious dentine

1. nonselective removal to hard dentine
a. complete excavation
b. only hard sound dentine remains so that demineralized dentine completely
removed
c. no longer advocated
2. selective removal to firm dentine
a. leaves leathery dentine pulpally
b. treatment of choice
c. however, in deeper lesions, puts the pulp at risk of physiological stress
3. selective removal to soft dentine
a. deep cavitated lesions
 b. soft carious tissue left over pulp to avoid exposure and stress to pulp –
encouraging pulp health
c. reduces risk of pulp exposure in deep lesions significantly
4. stepwise removal
a. carious tissue removal in 2 stages
b. soft carious tissue left only over the pulp in the first visit and peripheral dentine
prepared to hard dentine to allow a complete and durable seal of the lesion
c. a provisional resto (last up to 12 months) is placed
d. resto removed and the previously retained carious dentine further removed until
firm dentine reached
e. 2nd visit: clinical evidence that it increases pulp exposure, adds cost, time and
discomfort
f. Not for primary teeth

Specific Caries Management protocols:

1. Atraumatic restorative treatment (ART)
a. Uses hand instruments for opening small cavities and for removing carious tissue
b. Cavity sealed with adhesive restorative (GIC)
c. In small and medium dentine cavities – ART follow selective removal to firm
dentine protocol
d. Deep lesions – selective removal to soft dentine
2. Hall technique:
a. Sealing carious lesions in primary molar teeth using preformed metal crowns
b. Crown filled with Glass ionomer luting cement and seated firmly on tooth 
avoids need for tissue removal and la

- placement of separate cavity lining materials are not necessary to control pathological
progression within the sealed lesion, but might help impede monomer penetration and
 avoidance of fracture of the remaining dentine when resin composite is the restorative
material.
SUMMARY (chatgpt):
- Authors recommend a stepwise approach to caries removal that involves using a
combination of visual, tactile, and radiographic examinations to determine the extent of
the decay.
- The first step in this approach is to visually inspect the tooth for any signs of decay, such
as discoloration or softness. The second step involves using a dental explorer to detect
any softness or cavities in the tooth's surface. The final step is to use radiographic
imaging to determine the extent of the decay beneath the tooth's surface.
- Once the extent of the decay is determined, the authors recommend selective caries
removal, which involves removing only the decayed portion of the tooth while
preserving as much healthy tooth structure as possible. The authors provide
recommendations on the use of various instruments and techniques for caries removal,
including hand instruments, rotary instruments, and lasers. They note that the choice of
instrument or technique should be based on the individual patient's needs and the
extent of the decay.
- The article also emphasizes the importance of patient-centered care and the use of
evidence-based practices in caries management. The authors stress that the goal of
caries management should be to preserve the tooth's natural structure and function
while minimizing patient discomfort and maintaining long-term oral health.

Glass-Ionomer cement restorative materials: a sticky subject

Etching:
enamel - removes smear layer and increase porosity, exposes collagen network –
micromechanical, need to create HEMA (+ hybrid layer)
Bridging monomer: MDP (goes through smear layer) – self etching: ionic bonding
Dentine –
Conditioner: polyacrylic acid, used for glass ionomer systems
Liner on top of the soft mushy dentine and then RC

GICs
- Tooth coloured, adhesive, fluoride leaching properties
- Used as restorative, lining, luting and sealing materials
o for anterior approximal restorations, cervical restorations, core buildups when
there is sufficient tooth structure remaining
- are a type of dental restorative material that have been used for decades to repair
decayed or damaged teeth. They are known for their ability to bond to tooth structure
and release fluoride, which can help to prevent further decay.

- Derived from organic acids and glass component

- Referred to as acid base reaction cements
o Acid: aqueous polymeric acid
o Glass: fluoroaluminosilicate
 - Finishing and polishing advised with rotary instruments + lubricated with petroleum jelly
or bonding resin to prevent dehydration and maintainace of water balance in system as
they are water-based materials
- Use of GIC limited bc of brittleness and low compressive strength
RMGIC:
- Overcome problems with conventional materials (moisture sensitivity and low physical
properties like mechanical strength)
- Incorportation of a small quantity of monomers + initiators involved in polymerization
reaction
- Fundamental acid base curing reaction supplemented by second polymerization
reaction
o Initiated by light (light cured RMGIC)
- Luting cements not dept on light activation
o HEMA
- Water component of conventional GIC replaced by water/HEMA mixture
- By definition, RMGIC contain basic ionleachable glass, water soluble polymeric acid,
organic monomer and initiator system. Material must be capable of auto setting even if
designed to be light cured.
- RMGIC has greater mechanical resistance and better physical properties, but it has
clinical limitations such as decreased biocompatibility due to the presence of
the 2-hydroxyethyl methacrylate (HEMA) monomer, which is considered
cytotoxic in contact with the pulp tissue, thus limiting its use in deep cavities
What is HEMA: bridge
- HEMA is a hydrophilic monomer, meaning it has an affinity for water, and it is able
to form strong chemical bonds with both enamel and dentin.
- HEMA functions as a wetting agent, helping to spread the adhesive material evenly over
the tooth surface and penetrate into the dentin tubules.
- Once the adhesive has penetrated the dentin, HEMA then undergoes polymerization,
forming strong covalent bonds with the collagen fibers in the dentin.
- HEMA is also known for its ability to reduce post-operative sensitivity, which can be a
common problem with adhesive restorations. This is thought to occur due to the ability of
HEMA to fill and seal the dentin tubules, preventing the flow of fluid and reducing the
transmission of external stimuli to the underlying pulp.
- HEMA has been shown to be cytotoxic at high concentrations and may also cause
allergic reactions in some patients.
- Additionally, the hydrophilic nature of HEMA can make it susceptible to water sorption
and degradation over time, which can compromise the longevity of the restoration.

High viscosity material – Fuji IX

Broad categories of GIC available today: Conventional, resin modified, metal modified
- Presented as hand-mized power:liquid material or capsulated and more recently paste
 - Increasing the powder:liquid ratio results in an increase in viscosity and a ‘drier’ mix
which may
- reduce the ability of the material to effectively ‘wet’ the substrate. This may have an
effect on the bonding and ultimately the retention of the restoration. The use of
capsulated materials reduces the possibility of errors in the powder:liquid ratio while
mixing, as they are supplied in capsules containing premeasured amounts of powder
and liquid separated by the liquid which is encased in a ‘pillow”.

- GICs are known for their ability to bond to tooth structure and release fluoride, which
can help to prevent further decay. The article also discusses the setting reaction of GICs,
which is a complex process involving the release of ions from the powder component
and the formation of a gel-like matrix.

- The chemical adhesion is achieved through the interaction of the GIC with the
hydroxyapatite crystals in the tooth structure, while the micromechanical adhesion is
achieved through the penetration of the GIC into the irregularities on the tooth
surface.

- the bond strength of GICs can be improved by using a high-viscosity GIC or by using a
conditioner or primer to prepare the tooth surface. The section also describes the
different techniques for using GICs, including the sandwich technique, the resin-
modified GIC technique, and the atraumatic restorative technique.

o Conditioning the dentine surface prior to placement of GIC essential for

encouraging adhesion of cement to substrate – bond strength of GIC higher if
dentine is penetrated
o Bond strength of RMGIC to RC higher than conventional GIC  formation of
catalyst rich air inhibited surface layer on RMGIC

- One of the key advantages of GICs is their ability to bond to tooth structure. The author
explains the bonding mechanism of GICs and discusses the factors that can affect the
bond strength, such as the type of GIC, the tooth substrate, and the method of
application. The article also discusses the different techniques for using GICs, including
the sandwich technique, the resin-modified GIC technique, and the atraumatic
restorative technique.

- some of the limitations of GICs, such as their susceptibility to moisture contamination

during the setting reaction and their relatively low strength compared to other
restorative materials.

The "Biocompatibility" section discusses the biocompatibility of GICs, which refers to their
ability to be well-tolerated by the body without causing adverse reactions.
 - GICs are generally considered to be biocompatible, with a low incidence of adverse
reactions such as allergic responses or toxicity.
- some studies have reported adverse reactions to GICs, particularly in patients with a
history of allergies.

The "Microleakage" section focuses on the issue of microleakage, which refers to the seepage
of fluids and bacteria along the interface between the GIC and the tooth structure.
- microleakage can lead to secondary caries, which can compromise the longevity of the
restoration.
- the factors that can contribute to microleakage, such as the marginal fit of the
restoration, the type of GIC used, and the moisture content of the tooth during
placement.
- various methods used to evaluate microleakage, such as dye penetration and bacterial
infiltration assays.

The "Fluoride Leakage" section discusses the ability of GICs to release fluoride ions over time.
- fluoride release is one of the key benefits of GICs, as it can help to prevent further decay
and promote remineralization of the tooth structure.
- rate and amount of fluoride release can vary depending on factors such as the type of
GIC used, the pH of the surrounding environment, and the amount of moisture present
- various methods used to evaluate fluoride release, such as ion-selective electrode
analysis and spectrophotometric analysis.

Moisture sensitivity section

- need to maintain the water balance in GIC – led to recommendation that the surface of
a newly placed glass ionomer be protected from water loss and water fain
- RMGIC thought to be less prone to moisture sensitivity due to the resin network
reducing diffusion of water into cement and protecting cement from dissolution by early
contact with water.
- One of the greatest advantage of RMGIC: earlier finishing and polishing
Clinical Uses:
- Non carious cervical lesion – need for cavity prep and mechanical retention reduced
- Good potential in root caries
- Ageing population due to adhesive qualities and fluoride release
- Non or minimal load bearing situation’s
o Use high viscosity GIC for occlusal and approximal carious lesions provided they
can be conservatively prepared and restored
- Cervical lining (open sandwich technique) – GIC should be kept well below contact area
- Restoration of primary teeth: GICs are often used for the restoration of decayed primary
teeth due to their ability to bond to tooth structure and release fluoride, which can help
to prevent further decay.
- Restoration of permanent teeth: GICs can also be used for the restoration of permanent
teeth, particularly in situations where esthetics is not a primary concern.
 - Core build-ups: GICs can be used as a base or core build-up material in preparation for
the placement of a crown or bridge.
- Luting agents: GICs can be used as a luting agent for the cementation of metal and
porcelain-fused-to-metal crowns.
- Sealants: GICs can be used as a preventive measure to seal the pits and fissures of teeth,
which can help to prevent the development of decay.
- advantages include their ability to bond to tooth structure, release fluoride, and provide
a good seal against microleakage.
- disadvantages include their relatively low strength and esthetic limitations.

GIC are not deisgned to be placed under occlusal load

Classification and prognosis evaluation of individual teeth – a comprehensive approach

The article "Classification and prognosis evaluation of individual teeth—A comprehensive

approach" by Nachum Samet and Anna Jotkowitz provides a detailed overview of the
classification and prognosis evaluation of individual teeth in dentistry.

The article first discusses the importance of accurate classification and prognosis evaluation in
the planning and execution of dental treatments. The authors emphasize the need for a
comprehensive approach that considers multiple factors, including the patient's general health,
the specific characteristics of the tooth in question, and the planned treatment modality.

The article then describes a classification system for individual teeth that is based on several
factors, including the tooth's periodontal status, the presence of caries or other pathology, and the
presence of existing restorations. The classification system includes four categories: teeth with
good prognosis, teeth with questionable prognosis, teeth with poor prognosis, and hopeless teeth.

The authors then describe the criteria used to evaluate the prognosis of individual teeth in each
category. For teeth with good prognosis, the criteria include factors such as the absence of
significant periodontal disease, the absence of deep caries or other pathology, and the presence of
a healthy pulp. For teeth with questionable prognosis, the criteria include factors such as the
presence of moderate periodontal disease, the presence of deep caries or other pathology, and the
presence of a compromised pulp. For teeth with poor prognosis, the criteria include factors such
as the presence of advanced periodontal disease, the presence of extensive caries or other
pathology, and the presence of a non-vital pulp. For hopeless teeth, the criteria include factors
such as the presence of extensive destruction of the tooth structure or supporting bone, the
presence of a non-restorable pulp, and the patient's overall prognosis.

The article also discusses the various factors that can influence the prognosis of individual teeth,
including the patient's age, oral hygiene habits, and medical history, as well as the planned
treatment modality. The authors emphasize the importance of a multidisciplinary approach that
involves collaboration between the dentist, periodontist, endodontist, and other specialists as
needed.
Patient level considerations:
- biologic risks:
o impaired salivary flow/function
o medical conditions that impair immune function and healing
o high S.mutans salivary count
o family history
o other missing teeth
- behavioural risks
o compromised or poor oral hygiene
o cariogenic diet
o low exposure to fluoride
o parafunctional habits  increase risk to individual teeth or to entire dentition
o smoking
o willingness and motivation to adhere to tx
- Financial and personal risks
o Motivation
o Available resources for dental care
o Willingness to commit finances, time and effort
o Low dental IQ
Overall, the "Classification and prognosis evaluation of individual teeth—A comprehensive
approach" article provides a detailed overview of the classification and prognosis evaluation of
individual teeth in dentistry. This information is essential for accurate treatment planning and
execution and for optimizing patient outcomes.
Evaluation of individual teeth
Criteria for analysis. Four main criteria and
2 additional factors that may compromise
these criteria are evaluated:
1. Periodontal condition and alveolar bone
support
2. Restorability, ie, remaining sound tooth
structure
3. Endodontic condition
4. Occlusal plane and tooth position
The 2 additional factors, which may compromise
the above, are evaluated when applicable.
These include:
1. Anatomic irregularities
2. Iatrogenic compromising factors

The smear layer:

- is a thin layer of debris that is created on the surface of a tooth during preparation.
- It is composed of small particles of tooth structure, debris from cutting instruments, and
other organic and inorganic materials.
 - The smear layer can be removed by rinsing the tooth with an acid solution, such as
phosphoric acid

The hybrid layer

- is formed when a bonding agent is applied to the tooth surface after the smear layer has
been removed.
- The bonding agent penetrates into the tooth structure and forms a layer of resin that fills
in the voids and gaps created by the removal of the smear layer.
- This layer of resin is called the hybrid layer because it is a combination of the tooth
structure and the bonding agent.

The hybrid layer is important because it helps to create a strong bond between the tooth
structure and the restoration.
It provides a barrier against microleakage and helps to prevent the ingress of bacteria and
fluids into the interface between the tooth and the restoration. The quality of the hybrid layer
can affect the strength and longevity of the restoration, so it is important to ensure that it is
formed correctly during the bonding process.

1. Dental caries: When dental caries (tooth decay) penetrate through the enamel and dentin layers
of the tooth, they can expose the underlying nerve endings and cause sensitivity.

2. Tooth wear: Tooth wear, such as that caused by aggressive tooth brushing or bruxism
(grinding and clenching of the teeth), can cause the enamel layer to wear away and expose the
underlying dentin, leading to sensitivity.

3. Gum recession: Gum recession can occur due to gum disease, aging, or overbrushing, and it
can cause the tooth roots to become exposed, leading to sensitivity.

4. Dental procedures: Certain dental procedures, such as teeth cleaning, root planing, and tooth
whitening, can cause temporary sensitivity due to the removal of the surface layers of the tooth.

5. Cracked or fractured teeth: A crack or fracture in the tooth can expose the dentin and cause
sensitivity.

6. Acidic foods and drinks: Acidic foods and drinks, such as citrus fruits, carbonated beverages,
and wine, can erode the enamel and expose the underlying dentin, leading to sensitivity.

7. Dental restorations: Some dental restorations, such as dental fillings and crowns, can cause
sensitivity if they are too close to the nerve endings in the tooth.
It is important to identify the underlying cause of dentine hypersensitivity in order to provide
appropriate treatment and prevent further damage to the tooth. Treatment may include the use of
desensitizing toothpastes or gels, fluoride treatments, or dental procedures such as fillings or root
canal therapy.

Brownstrom’s hydrodynamic theory of dentine hypersensitivity

- Moving fluid excites nerve endings, odontoblasts
- Pressure changes (irritation of the tubules)

Caries + flossing
- Cleansable surface and biofilm
- Ecological plaque hypothesis
- Prevention of biofilm build-up approximal – flossing
Know difference between secondary and tertiary dentine + bonding to them as tertiary Is more
irregular

Pericoronitis