Definition :

Dental caries is an infectious microbiologic disease of the teeth that results in localized dissolution & destruction of the calcified tissues. requiring restorative intervention & even extraction..

Etiology
food bacteria

tooth

Dentine Caries
Affected & Infected Dentin:
In operative procedures, it is convenient to term dentin as either.. Affected dentin: is softened, demineralized dentin that is not yet invaded by bacteria inner carious dentin ( does not requires removal ). OR Infected dentin: outer carious dentin & Bacterial plaque is both softened & contaminated with bacteria ( requires removal ).

Caries Detecting Die

Caries detection solutions have been used by clinicians to distinguish between affected and infected dentin.
These are protein dyes that stain denatured callagen of carious dentine

Response to dental caries

In the earliest stages of exposure to microorganisms, there is an effort to seal the tubules. This is accomplished by increased calcification. The result is a visible change known as transparent dentin or dentinal sclerosis .

In addition, pulpal odontoblasts, stimulated by the advancing carious lesion, will rapidly deposit dentin. The dentinal tubules in this new dentin are irregular, making them less permeable this type of dentin is known as : irregular dentin , reparative dentin , secondary dentin or tertiary dentin . Dentinal sclerosis and reparative dentin may be successful deterrents if the carious lesion progresses slowly.

When the first operative dentistry guidelines were established, the term caries excavation was defined as a synonym for cavity preparation, which in turn consisted of mechanical treatment of the injuries to the teeth produced by dental caries, as would best fit the remaining part of the tooth to receive a filling

From this definition, it appears that caries excavation procedures were regarded as one of the many mandatory steps to prepare a tooth to receive the filling material

Furthermore, it has been described that the carious lesion should be excavated until a hard pulpal floor was reached and that generally, when the cavity has been cut to form, no carious dentin will remain.

In short, carious dentin should be removed until a sufficiently solid layer of dentin was reached to support condensation of the restorative material (stability form) and to provide adequate retention for the filling material (retention form), promoting a successful and longterm survival of the restoration.

It is thus clear that when nonadhesive restorations were the only available option to directly restore decayed teeth, no distinct separation between caries removal and cavity preparation was made.

In practical terms, it means that excavation of carious dentin was performed to remove necrotic,soft material in order to best accommodate the filling material.

Management of deep caries

The objective is to focus on the: Diagnosis ttt modalities

Treatment Modalities
The results of diagnosis :
Pulp Exposure
Indirect pulp capping
Vital (traumatic) exposure Non-vital (carious) exposure

No exposure
Conventional cavity preparation and restoration

Direct pulp capping

Recent advances of caries removal :

carisolv Smartprep instrument

RCT

Indirect Pulp Capping

When caries is thought to extend close to, or into the pulp, excavation of the pulpal caries can be stopped at soft affected but not infected dentine (affected dentine could be remineralised if the acid production was halted). Medication is then applied over the pulpal dentine prior to placement of the definitive restoration.

Medication is left for 6 8 weeks .

During this waiting period :

The carious process is arrested Soft caries hardened

A protective layer of reparative dentine is laid down

However the difficulty with this tecnique is knowing:

how rapid the carious process has been how much tertiary dentine has been formed knowing exactly when to stop excavating to avoid pulp exposure.

Materials used for indirect pulp capping :

Calcium Hydroxide Although CaOH is the most commonly used it has been argued that its effect occurs only in case of its direct contact with pulp tissues . Therefore a material with better sealing ability should be used . Zinc oxide and Eugenol

Recently adhesive resin has been used

Direct Pulp Capping

Technique for treating a pulp exposure with a material that seals over the exposure site & promotes reparative dentin formation..
Requirements of direct pulp capping:

Asymptomatic vital tooth Pin-point exposure (0.5mm or less in diameter) Non-hemorrhagic or easily controlled. Dry, sterile filed Non-carious atraumatic exposure

Direct Pulp Capping Techniques

Calcium Hydroxide Technique Total etch technique

hemostasis

hemostasis

Disinfect cavity

Disinfect cavity primers

CaOH Resin modifieed glass ionomer

adhesives Resin modifieed glass ionomer

IRM Restoration

Restoration

Calcium Hydroxide Technique:

1. Bleeding must be controlled.

This control may be achieved by : Washing the area with sterile saline and drying it with either paper points or cotton pellets, Using cotton pellets soaked with hydrogen peroxide or 5.25% sodium hypochlorite, OR Using a hemostatic agent . If bleeding fails to stop after two or three attempts, then endodontic therapy should be considered. A disinfectant should be placed on the cavity floor.

The area is then air dried 3. Calcium Hydroxide is placed directly in contact with pulp tissue. This step is very important, for the better the contact of the calcium hydroxide dressing with the pulpal wound, the better the healing. 4. The calcium hydroxide should then be covered with a resin-modified glass ionomer extended onto dentin. 5. A permanent restoration is placed, with a dentin bonding system used to seal the margins of the restoration.
2.

An alternative is to place a zinc oxide-eugenol restoration over the calcium hydroxide cap. Zinc oxide-eugenol provides an excellent seal and, with its anti-microbial properties, makes for a very good temporary restoration. After three months, assuming pulp vitality and no symptoms, the zinc oxide-eugenol can be removed and a more permanent sealed restoration placed.

Total Etch Technique :

1. Enamel and dentin are etched with 32% phosphoric 2. 3. 4.

5.

acid for 15 seconds. The acid is rinsed off and the preparation is lightly dried. The entire preparation , including enamel, dentin and pulpal tissue , is treated with a dentin bonding system. Adhesive resin is applied onto the enamel, dentin and pulpal tissue and light cured, and a thin layer of resinmodified glass ionomer is also applied over and around the exposure site ( mechanically protect the perforation from intrusion of the restorative material during packing or condensation) and then cured. The restoration is subsequently completed in conventional fashion.

Chemo-mechanical caries removal

Carisolv is a chemo-mechanical method for minimally invasive caries removal . The system comprises :

a gel that selectively attacks denatured collagen in the carious dentine, thus making the carious dentine softer. a set of specially designed instruments used for removal of the softened material.

Carisolv gel consists of two carboxymethylcellulose based gels:

a red gel containing : amino acids (glutamic acid, leucine and lysine), NaCl NaOH Erythrosine (added in order to make the gel visible during use ). and a second containing sodium hypochlorite

The two gels are thoroughly mixed in equal parts at room temperature before use . The solution has a pH 11. The positively and negatively charged groups on the amino acids become chlorinated and further disrupt the collagen crosslinkage in the matrix of . the carious dentine.
The gel is then applied onto the exposed carious dentine and left for 30 to 60 seconds then the softened dentine is gently but firmly abraded away leaving a hard, caries-free cavity

A soft caries lesion

Gel application. Let gel slide onto the lesion. Wait 30 seconds.

The lesion is gently scraped with a star instrument

Re-applied gel stays clear. Cavity is hard with a probe.

The gel is removed with a dry pellet

Complete caries removal is checked with an explorer

The cavity is cleaned with wet pellets

Finished cavity

Advantages of carisolv

The patients perceive the method as much more comfortable than drilling and anaesthetics are seldom needed.
Action of excavator. Healthy dentine is also removed.

Saves time Avoids removal of unnecessary healthy dental tissues

Selective removal of softened dentine caries with the Carisolv instrument. Healthy dentine is not affected.

Smartprep instrument

The SMARTPREPTM Instrument is a polymer instrument that safely and effectively remove decayed dentin, leaving healthy dentin intact. It is a self-limiting instrument and is not hard enough to penetrate healthy dentin. As it gently removes decay and contacts the healthy dentin, the instrument's edges become rounded and unable to cut healthy tooth structure. A high-speed carbide bur is first used to gain access to the decay. After access has been created, the SMARTPREPTM Instrument is used in a slow speed handpiece (500-800 rpm) to complete caries removal. They are single-patient-use rotary instruments.

Advantages :

Conserve healthy tooth structure, Virtually no risk of inadvertent pulp exposure, Reduce the need for anesthesia and allow for same-visit cavity preparations on multiple quadrants, Designed to reduce post-operative sensitivity.

The restorative treatment doesn't cure the caries process, so identifying & eliminating the causative factors for caries must be the primary focus, in addition to the restorative repair of damage caused by caries.