Dental Caries Management

Study Notes

Type of decay:
- Acute decay: rapid destruction, less effective defensive and reparative mechanisms
- Chronic decay: slower process, periods of activity and rest, substantial repair possible
Duration of the decay process:
- Acute decay: rapid destruction, longer duration increases effects on pulpo-dentinal organ
- Chronic decay: longer duration increases chances for repair, but chronic caries can stimulate repair
Depth of involvement:
- Deeper involvement: greater intensity of irritation, greater possibility of pulpal destruction
- Effective depth: determines the pathway of irritants to the pulp tissue
Number and pathogenicity of micro-organisms:
- Affects the activity of the lesion in terms of acuteness or chronicity
- Type and metabolic activities of bacteria affect rate of dentine demineralization and proteolysis
Tooth dentinal resistance:
- Thickness of dentine, permeability of tubular structure, solubility of involved dentine in acids
- Architecture of dentine and tubular arrangement affect resistance to spread of decay
Individual reaction of the pulp-dentine organ:
- Variations in reaction due to individual differences in age, tooth condition, and pulpal tissue

Determination of pulpal state:
- Importance of proper diagnosis and estimation of prognosis
- Lack of correlation between symptomatic data and histopathologic findings
Evaluation terms employed to form a complete picture of the P-D organ:
- History of pain
- Thermal and electric pulp testing
- Pulp exposure
- Percussion
- Radiograph
Difficulty in determining the type and depth of the lesion:
- Acute or chronic caries
- Extent of pulp approximation
Clinical difficulty in judgment of soundness of remaining dentine:
- Tactile sense of the operator
- Caries detecting dyes (e.g., 0.5% basic fuchsin, 1% acid red)

Promoting or enhancing specific reparative capacities and preventing further irritation of the P-D organ:
- Minimal traumatic procedures
- Proper pulp medication
- Proper sealing ability of the final restorative material
- Periodic follow-up radiographs and vitality testing to assess the condition of the pulp tissue### Treatment of Deep Lesions
Deep lesions (deeper than 2mm from DEJ) require collecting information on the pulp-dentin organ status using diagnostic tools.
Undermined enamel should be removed, and softened carious dentin should be removed with a spoon excavator or a large, dull round bur at low speed.
Remaining dentin should be evaluated using basic fuchsin dye solutions, and non-reparable dentin should be removed.

In acute caries, the deepest layer of softened dentin should be left if:
- The pulp-dentin organ is healthy.
- The remaining dentin is reparable.
- The softened dentin is surrounded by hard, sound dentin.
In chronic caries, the soundness of the remaining dentinal matrix should be evaluated using dyes, and non-reparable dentin should be removed.

A suitable capping material (CaOH2 or ZOE) should be applied to cover the remaining dentin.
The patient should be recalled in 4-6 weeks (CaOH2) or 6-8 weeks (ZOE) for a radiograph and evaluation of the pulp-dentin organ status.

Direct pulp capping is indicated if:
- There are no signs of pulp degeneration.
- The exposure site is small, with no hemorrhage or immediate coagulation.
- The dentin at the periphery is reparable.
- The exposure site is not at a constricted area in the pulp chamber or root canal system.
The procedure involves:
1. Collecting data on the pulp-dentin organ status.
2. Removing undesirable enamel and unsound dentin.
3. Washing and irrigating the cavity floor and exposure site with sterile water.
4. Applying either CaOH2 or ZOE as a capping material.

The pulp can be damaged only by bacterial contamination.
Restorative materials must provide a tight seal for the capping procedure to succeed.
The goal of treating deep caries is to enhance calcific reparative capacity and prevent further irritation.