deep cariuos lesions.ppt

Management of deep caries and the exposed pulp  ESE-approved definitions and terminology/ Deep caries  Caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp, which is radiographically detectable.  There is a...

Management of deep caries and the exposed pulp  ESE-approved definitions and terminology/ Deep caries  Caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp, which is radiographically detectable.  There is a risk of pulp exposure during operative treatment Extremely deep caries Caries penetrating the entire thickness of the dentine, radiographically detectable. Pulp exposure is unavoidable during operative treatment. Figure 1 Classification for deeper stages of caries. (a) Deep carious lesion with a zone of dentine separating the lesion from the pulp (b) and extremely deep penetrating the entire thickness of the dentine. the lesion from the pulp (b) and extremely deep penetrating the entire thickness of the dentine. Soft, firm and hard dentine Soft dentine can be excavated with minimum resistance using hand instruments, Whilst firm dentine should be resistant to excavation using hand instruments. Hard dentine should be sound and resistant to probe penetration and scratching. Selective carious-tissue removal Selective removal to soft dentine: Soft dentine is left only on the pulpal aspect of the cavity, whilst peripheral carious dentine is removed to hard dentine. Selective removal to firm dentine Firm dentine is left only on the pulpal aspect of the cavity, whilst peripheral carious dentine is removed to hard dentine. Non-selective carious-tissue removal Complete removal of soft and firm carious dentine from the periphery and central aspects of the cavity until hard dentine is reached. Vital pulp treatment (VPT) Strategies aimed at maintaining the health of all or part of the pulp. Indirect pulp capping Application of a biomaterial onto a thin dentine barrier in a one-stage carious-tissue removal technique generally to hard dentine. - Considered more aggressive than selective carious-tissue removal in one-stage and stepwise excavation. - Leaves neither soft nor firm carious dentine behind. Selective carious-tissue removal in one-stage - Application of a biomaterial onto a dentine barrier in an indirect one-stage selective carious-tissue removal technique. - Removal to soft or firm dentine. - Immediate placement of a permanent restoration. Stepwise excavation - Application of a biomaterial in an indirect two stage selective carious-tissue removal technique. - Temporary restoration placement between visits and re-entry after 6–12 weeks. - First stage involves selective carious removal to soft dentine, to an extent that facilitates proper placement of a temporary restoration, - and second stage removal to firm dentine. - Final placement of a permanent restoration. Direct pulp capping - Following the preservation of an aseptic working field, - Application of a biomaterial directly onto the exposed pulp, - prior to immediate placement of a permanent restoration. Class I. - No preoperative presence of a deep carious lesion. - Pulp exposure judged clinically to be through sound dentine with an expectation that the underlying pulp tissue is healthy (exposure due to a traumatic injury to the tooth or an iatrogenic exposure). Class II. - Preoperative presence of a deep or extremely deep carious lesion. - Pulp exposure judged clinically to be through a zone of bacterial contamination with an expectation that the underlying pulp tissue is inflamed. - Enhanced operative protocol recommended (aseptic procedure using magnification, disinfectant and application of a hydraulic calcium silicate cement). Partial pulpotomy Removal of a small portion of coronal pulp tissue after exposure, followed by application of a biomaterial directly onto the remaining pulp tissue prior to placement of a permanent restoration. Full pulpotomy Complete removal of the coronal pulp and application of a biomaterial directly onto the pulp tissue at the level of the root canal orifice(s), prior to placement of a permanent restoration. Pulpectomy Total removal of the pulp from the root canal system followed by root canal treatment, prior to placement of a permanent restoration. Classifications of disease severity to guide decision making in vital pulp treatment The American Association of Endodontists (AAE):, described pulpitis as either reversible or irreversible depending on clinical signs and symptoms (2013). The symptoms of reversible pulpitis range from: - no complaint - to a sharp pain sensation with hot/cold stimuli - and no tenderness to percussion; - notably, the symptoms should resolve after the removal of the stimulus. - Spontaneous, - radiating pain that lingers after removal of the stimulus - and causes sleep disturbance tend to indicate irreversible pulpitis. Clinical judgement is required, however, as irreversible pulpitis may be symptomless in anywhere between 14 and 60% of cases Recommendation Caries depth radiographically, as well as clinical indicators of activity (e.g. symptoms, progression rate, colour, sensibility tests), should be used to assist clinical decision-making after history, meticulous examination of the mouth and relevant tooth, and special tests. How should we diagnose the inflammatory state of the pulp? - The outcome of VPT is dependent on the inflammatory state of the pulp and the presence of microorganisms, - with carious exposures (class II) generally having a less favourable outcome compared with traumatic exposures (class I). Recommendation A detailed pain history and meticulous clinical examination supplemented with a high-quality periapical radiograph and pulp sensibility testing using low temperature cold testing are necessary to assess the status of the pulp.  How should we manage deep caries to avoid pulp exposure? - Selective carious-tissue removal (one-stage or two stage stepwise technique) is advocated in teeth with reversible pulpitis, - provided radiographic assessment indicates caries has a zone of dentine separating the carious lesion from the pulp chamber - One surface (occlusal) carious lesions are generally easier to manage and have more predictable outcomes. -Asepsis should be preserved throughout the procedure including the use of rubber dam. - A hydraulic calcium silicate or a glass–ionomer cement should be placed over the deep dentine in both one- and two- stage procedures. - The material should be carefully placed to cover all remaining carious dentine and have sufficient thickness to withstand ingress of new bacteria into the lesion. - The material should be able to promote, tertiary dentine formation.  How should we manage carious pulp exposure? - Treatment options after carious pulp exposure include direct pulp capping and pulpotomy (partial and full). - In general, pulp preservation in cases of carious pulp exposure is only advocated in teeth with reversible pulpitis. - Treatment of deep (and extremely deep) carious dentine should be done aseptically with sterile instruments, tooth disinfection and isolation by rubber dam. - the use of a hydraulic calcium silicate cement - Operator skill and experience is also important.  What materials should we use for VPT? - A hydraulic calcium silicate material or glass–ionomer should be placed during procedures aimed at avoiding pulp exposure onto the residual dentine prior to a definitive restoration. - After pulp exposure, during a pulp capping, partial pulpotomy or full pulpotomy, a hydraulic calcium silicate material should be placed directly onto the exposed pulp prior to definitive restoration. Hydraulic calcium silicate materials, such as mineral trioxide aggregate (MTA), have demonstrated superior histological and clinical outcomes compared with calcium hydroxide in treatment of the exposed pulp.  How should VPT cases be followed up and what is the expected prognosis? - After VPT, teeth should be carefully monitored by history and clinical examination at 6 months, supplemented by periapical radiograph at 1 year. - The follow up should continue at yearly intervals (if necessary) for 4 years thereafter. - The tooth should respond positively to pulp sensibility testing within normal limits. - It should be noted that teeth may not respond e.g. older patients, and that teeth which have undergone full pulpotomy are expected to be unresponsive to testing. - The patient should be free of pain and other symptoms; - there should be an absence of apical periodontitis and signs of internal root resorption, - whilst in immature teeth, there should also be radiological evidence of continued root formation.  Management of deep caries and the exposed pulp International Endodontic Journal, Volume: 52, Issue: 7, Pages: 949-973, First published: 15 April 2019, DOI: (10.1111/iej.13128)