Dental Caries

Diagnosis and Treatment Options

Dental Caries
Infectious , multifactorial disease.
Characterized by the loss of mineral contents of
the calcified tissue.
Presents in a spectrum of presentation.
Lesion status: incipient/cavitated;
active/inactive
Subclinical

Demineralization

Remineralization

Incipientlesion

Demineralization

Remineralization

Cavitatedlesion

(IrreversibletoothMorbidity)

Treatment Options
Traditional - detection of caries lesion followed
by immediate restoration.
Current management philosophy - treatment
decision should be based on the status of the
lesion (incipient vs cavitated, active vs inactive),
and other patients factors (age, frequency of
visit, oral hygiene status, dental IQ, motivation,
risk factor).
Non-surgical management (remineralization) of
the disease should be part of the treatment plan.

Examples of Treatment
Options
Cavitated, active - surgical (restoration)
Non-cavitated, active - surgical or nonsurgical (remineralization)
Cavitated, inactive - surgical (stress
bearing area) or non-surgical (non stress
bearing area)
Non-cavitated, inactive - non-surgical

Dilemma of Caries Diagnosis

No reliable objective diagnostic
technique to differentiate between
incipient lesion and cavitated lesion.
No reliable objective diagnostic
technique to differentiate between
active and inactive caries lesion

Diagnosis and Treatment Options

Based on location
Pits and fissures
Smooth surfaces
Proximal surfaces
Root caries
Secondary caries

Pits and Fissures Caries

Demineralizationaroundthe
wallandbottomofthepits
(incipientlesion)

Enamel

Oncedemineralization
reachtheDEJ,itbegins
spreadinglaterally

Dentin

Startinfectingthe
underlyingdentin(surgical
interventionindicated)

Diagnosis of Pits and Fissures Caries Traditional Method

Usinganexplorertoprobe
intothepit/fissureafeelof
catchorastickindicate
thepresenceofcariesatthe
bottomofthepit/fissure

Problem with the Traditional Method

Evenatthestagewheresurgical
treatmentisindicated,the
occlusalenamelmaystillbe
intact
Thecatchorstickyoufeel
whenyouuseyourexplorerto
probeintoanintactpitsisa
resultofthewedgingeffect

Possible Result of Probing into

an Incipient Lesion

Diagnosis of Pits and Fissures

Caries - Current Method
Use an explorer to
remove plaque and food
debris from the fissure
orifice
Under good lighting,
isolation (dry) and
magnification; visually
inspect for any damage
to the enamel
Look for any subtle
color changes around
the pits and fissures

Diagnosis of Pits and Fissures

Caries - Current Method
Enamel is low in opacity, thus
any changes in color (e.g. caries
dentin) in the underlying dentin
will show through the enamel
Look for a gray shadow or
opaque area around the pits and
fissures - a halo
Ignore the color change within
the pits and fissures
Bitwing radiographs may be
helpful in diagnosing deep lesion

Current Problems Relating to the

Diagnosis of Pits and Fissure Caries
Uneven diagnostic conclusion among
dentists
No reliable objective diagnostic
technique to differentiate between
incipient lesion and cavitated lesion.
No reliable objective diagnostic
technique to differentiate between
active and inactive caries lesion

New Technologies
New quantitative diagnostic system e.g.
DIAGNOdent
Laser Fluorescence
J Dent 2002;30:129-134
Specificity higher for visual
Sensitivity higher for DIAGNOdent
Frequeucy-Domain Infrared Photothermal

Radiometry and Modulated Laser Luminescence.

Jeon RJ et al. Caries Res 2004;38:497-513

Treatment Options
Conclusive evidence of the presence of cavitated lesion

Bitewing radiographs
Definitive halo around
the pits and fissures
Cavitated enamel

SURGICAL

Treatment Options
Presence of questionable
cavitated lesion
Heavily stained pits and
fissures
Questionable halo

Sealantsorrestorewithcomposite
Considerpatientsageandcariesriskstatus

Treatment Options
Deep pits and fissures

Sealants in young or caries active or prone

patients

Treatment Options - Surgical

Lesion specific restoration should be the
primary option.
Material specific restoration can be
considered if unable to isolate or for
economic reason.

Important Research
Mertz-Fairhurst EJ et.al. JADA
1998;129:410-412
Large occlusal lesions were treated with acid etch
composite restorations, leaving soft, demineralized
dentin both at the DEJ and in the base of the
cavity. The teeth were followed over 10 years.
There were no report of failed restoration, pulpitis
or pulp death.

Empirical Evidence
Sealing caries may not work.
It will work if you can maintain a
complete and absolute seal of the
enamel.
However, a complete seal is very
difficult to achieve.
Beside pits and fissures, there may be
micro cracks on the enamel.

Proximal Caries - Diagnosis

Bitewing radiographs
Trans-illumination - placing the mirror or light
source on the lingual side of anterior teeth and
directing light through the teeth. Lesion will
show through as a dark area
Opacity or color change under the marginal
ridge (under dry and clean environment)

Radiographic Diagnosis of
Proximal Caries
Triangularshaped
radiolucency
gingivaltothe
proximalcontact
areapointing
towardsDEJ

Radiographic Diagnosis of
Proximal Caries
Triangular
radiolucencypoint
endshortofDEJ

PointendrightatDEJ
Radiolucencyindentin

Treatment Options

Radiolucency in dentin

SURGICAL INTERVENTION

Treatment Options
Triangular
radiolucency
point ended
right at DEJ

SURGICALORNONSURGICAL
Shoulddependoncariesstatus/activitiesandother
patientsfactors

Treatment Options
Triangular
radiolucency point ended short of DEJ

NON-SURGINCAL MANAGEMENT

Treatment Options - Current

philosophy
Unless there are clear evidence of radiolucency
in dentin, all decision to initiate surgical
intervention should take into consideration of
patients caries risk status and other patients
factors.
Reason: these lesions may be arrested lesions or
potentially can be converted from active to
arrested lesion using various non-surgical
management
techniques.

Longitudinal Radiographic Data

on a Patient (mesial of #3)
1984

1995

2003

1987

Inactive , Cavitated Lesion

Treatment Option - Surgical

Small lesion
Lesion specific restoration should be your
primary choice; material specific
restoration if unable to isolate or for
economic reason

Treatment Option - Surgical

Medium/large lesion
Direct Restoration - lesion specific vs
material specific
Indirect Restoration - should only be
considered if patients caries status become
more stable

Current Problems Relating to the

Diagnosis of Proximal Caries
Incipient lesion = triangular
radiolucency point short of DEJ
Cavitated lesion = triangular
radiolucency point at or past DEJ
Disagreement among dentist in exactly
where the point end, and when should
surgical intervention indicated

Current Problems Relating to the

Diagnosis of Proximal Caries
No reliable objective diagnostic
technique to differentiate between
active and inactive caries lesion
Best evidence: longitudinal
radiographic data on the patient
Supporting evidence: patients caries
risk and other patients factors

Future
Quantitative data on the exact amount of
mineral loss (incipient vs cavitated) - e.g.
technology use in diagnosing pits and fissure
caries (DIAGNOdent)
Better understanding in the differences
between active and arrested lesion - e.g.
qualitative and quantitative differences in the
mineral contents; microbiological differences?
Active

Time?

Arrested

Smooth Surface Caries Diagnosis

Dry, clean, magnified

Plaquecoveredsurface

Cleanedsurface

Diagnosis of Smooth Surface Caries

Incipient
(chalky white,
brown, black)

Cavitated

Diagnosis of Smooth Surface Caries

Arrested(Shiny,white,brown)
Active(Matte,white)

Treatment Options

Incipient, active
Incipient, arrested
Cavitated, arrested

NON-SURGICAL (control measures depends on the

caries status of the patient)

SURGICAL (patient has esthetic concern)

Treatment Options
Cavitated, active (matte surface)

SURGICAL

Problem with Treatment Option

No objective diagnostic tool to differentiate
between active and arrested lesion. Thus
sometime it may be difficult to decide when
to initiate surgical intervention.

Treatment Options
Composite
RMGI - patient with very high caries
potential
Amalgam

Root Caries
Supragingival caries
lesion located at CEJ
Diagnostic criteria
similar to smooth
surface lesion
Treatment options
similar to smooth
surface lesion (1st
preference = RMGI)

Disease Trend in Dental Office

Because of the decrease in the incidence of dental
caries (primary caries) in most industrialized
countries; maintenance of previously inserted
restoration has become the major workload
in a typical dental practice.
THUS
Evaluation of existing restorations is becoming
the main focus of the subjective and objective
examination of your patient. How you are
handling the findings is whats going to define
your treatment or your practice philosophy.

Existing Restoration - Clinical Status

SecondaryCaries
MarginalIntegrity
marginaldefect
overhang
openmargin

Contour
proximalcontact
axialcontour
occlusion

BiomechanicalForm
restorationfracture
toothfracture

Esthetic
patientsesthetic
concern

Secondary Caries
Cariouslesion
locatedatthemargin
ofarestoration
Itisthemost
commonreasonfor
replacinganexisting
restoration

Secondary Caries

Diagnosis of Secondary Caries

DiagnosisshouldNOTbebasedonusinga
NOT
sharpexplorerandtryingtogetastick
atthemarginofarestoration

Toolsusedfordiagnosisarebasedonthelocationof
themargin

Diagnosis of Secondary Caries

Visually Accessible Area

Primary Diagnostic Tool

Visual
Dry, clean, magnified, properly
illuminated

DiagnosisofSecondaryCaries
Visually Inaccessible Area

Tools
Tactile
&
Bitewings
Radiograph

Common Mistakes in Diagnosing

Secondary Caries
Use of a sharp explorer and
probe in to a defect, using a
stick as the diagnostic
criteria for the presence of
secondary caries
An uniform radiolucent line
around a composite
restoration - may be due to
the presence of a thick layer
of adhesive resin.
Radiographic burnout at CEJ

Secondary Caries - Treatment Options

Surgical
Reasons
Most of the time when the lesions are detected, they are
frank cavitated lesion.
These lesions are more likely to be active lesion (time
frame of the development of the disease)
These lesions are in a very retentive area (limited ability
for non-surgical management techniques to work; similar
to pits and fissure caries)

Secondary Caries - Treatment Options

Direct vs indirect
Financial
Patients caries status, oral hygiene
status, dental IQ, motivation, risk
factors