Management of Carious Lesions PDF

Management of Carious Lesions Oral and Dental Science Josh Hudson Pre-reading ‘Aetiology and sequela of dental caries’ Lecture ‘Histopathology of enamel and dentine caries’ Lectures GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to prevention, diagnosis and treatme...

Management of Carious Lesions Oral and Dental Science Josh Hudson Pre-reading ‘Aetiology and sequela of dental caries’ Lecture ‘Histopathology of enamel and dentine caries’ Lectures GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to prevention, diagnosis and treatment 1.14.1 Assess and manage caries, occlusion and tooth wear, and, where appropriate, restore the dentition using minimal intervention maintaining function and aesthetics 1.14.5 Explain the role of a dental therapist in restoration of teeth 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous patient history Intended Learning Outcomes By the end of this session you will be able to: List the direct management options for various presentations of dental caries List the indirect management options should extensive loss of tooth tissue occur Describe the role prevention plays in caries management Describe the differences between the use of each option Caries Recap Susceptible Caries tooth surface Plaque Bacteria Time Fermentable Carbohydrate ICDAS Recap Score 1 = First visual Score 4 = Dark Shadow change in enamel from dentine Score 2 = Distinct visual Score 5 = Distinct enamel change in enamel cavity with visible dentine Score 3 = Localised Score 6 = An extensive enamel breakdown cavity into dentine How do we approach caries management? Extent of caries Extent of caries Reproduced from – Dental Caries. Pitts, NB et al  Extent of caries Enamel caries Early enamel Arrested caries (white spot Increasing Severity breakdown lesion) Caries into Caries into outer Caries into inner middle 1/3 of 1/3 of dentine 1/3 of dentine dentine Caries with Caries into pulp limited tooth tissue remaining Philosophies in the management of dental caries The first stage of treating any patient with any carious lesion is.. Diet advice (reducing volume and frequency of sugars) PREVENTION! PREVENTION! Oral Hygiene Advice (how to clean effectively) PREVENTION! n Increasing Fluoride Exposure These stages are required alongside any operative treatment  The first stage of treating any patient with any carious lesion is.. PREVENTION! PREVENTION! PREVENTION! Preventative advice should be given as per the Delivering Better Oral Health toolkit Minimally Invasive Dentistry We should undertake the technique that requires the least amount of tooth structure removal We should use materials that will be long lasting The Restorative Spiral Fissure sealant Caries Crown Restoration Extraction and implant/ Edentulous Bridge/denture How would each of these presentations be managed? Arrested Caries As from describing dental caries lecture, this is inactive No need for active treatment unless aesthetic concerns Prevention is essential Review as potential to re- activate Enamel Caries (white spots) Reversible Attempt to arrest AVOID DRILL DUE TO RESTORATIVE SPIRAL Prevention (OHI, diet advice) Active prevention strategies to increase fluoride and mineral exposure exposure (high fluoride toothpaste, mouthrinse, fluoride varnish, tooth mousse etc) Enamel Caries – Fissure Sealant Reversible Attempt to arrest AVOID DRILL DUE TO RESTORATIVE SPIRAL As well as prevention, can undertake simple additive treatment This can be using fissure sealants to ‘seal’ the carious enamel to deprive the bacteria of nutrients and attempt to arrest the lesion Requires regular review to ensure sealant not broken or leaking which will lead to caries progression Now into dentine….  Extent of caries in dentine Requires intervention Outer 1/3 of dentine Irreversible Outer to middle 1/3 dentine Restorative material Inner 1/3 of dentine Pulpal protection Moisture control Root caries Seal Enamel Caries/Outer 1/3 Dentine Caries Now has become irreversible Restorative treatment needs to be undertaken to avoid progression This takes the form of a preventative resin restoration (PRR) for occlusal surfaces This ultimately involves removal of the caries within the fissures with a drill, placement of a composite restoration and then sealant over this Still need prevention (OHI, diet advice) to reduce risk of caries elsewhere Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Dentine Caries – Outer to Middle 1/3 Restorative treatment needs to be undertaken to avoid progression Still need prevention (OHI, diet advice) to reduce risk of caries elsewhere Active prevention strategies to increased fluoride exposure (high fluoride toothpaste, mouthrinse, fluoride varnish etc) Standard direct restoration Dentine Caries – Outer to Middle 1/3 Local anaesthetic Removal of caries with drills and hand instruments Restoration of the tooth Temporary restorations Glass ionomer cements – semi permanent Amalgam Composite  Dentine Caries – Outer to Middle 1/3 Temporary Restorations Glass Ionomer Cements Composite Restorations Amalgam Restorations Amalgam cannot be used in pregnant or breastfeeding women unless specific indication (SDCEP 2018) Dentine Caries – Outer to Middle 1/3 The majority of permanent restorations will be amalgam or composite resin Cochrane systematic review (Alcaraz et al 2014) suggests a slightly higher failure rate of composite than amalgam Composite Restorations due to secondary caries However, amalgam being phased out due to environmental concerns relating to its mercury content (agreement to phase down as part of Minemata convention) Amalgam Restorations Dentine Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Dentine Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Dentine Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Dentine Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Dentine Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry Root Caries As mentioned in the describing dental caries lecture, root caries management is slightly different Needs to be managed with prevention Can then be restored with composite (if moisture control can be achieved) and GIC if not Ideally this is done under rubber dam as in the photo however placing this can be difficult Dentine Caries – Inner 1/3 This is extensive caries which may have begun to invade the pulp These patients may have pulpitis symptoms Once caries removed, may need to undertake some form of pulp treatment This may be a direct or indirect pulp cap May need to have root canal treatment Therapists be weary of treating these cases as may be outside of your scope ‘Stepwise Excavation’ and the Atraumatic Restorative Technique (ART) These are considered more minimally invasive approaches to deep caries management Stepwise excavation involves; Removal of superficial layer of necrotic caries infected dentine Placement of calcium hydroxide base and provisional restoration Re-enter 6-9 months following tertiary dentine formation Removal of remaining arrested caries infected dentine + permanent restoration This risks pulpal exposure during second re-entry and more time consuming ’Stepwise Excavation’ and the Atraumatic Restorative Technique (ART) ART is considered a more modern version of stepwise excavation ART involves; Removal of superficial layer of necrotic caries infected dentine Restoration with a chemically adhesive high viscosity glass ionomer cement to seal remaining tooth and cut of bacterial nutrient supply No need for re-entry following this GIC surface layer (2-3mm) can be removed in future and composite placed Systematic reviews suggest higher success when using ART (Schweindicke et al 2013, Barros et al 2019) Dentine Caries – Inner 1/3 Even if using ART, the pulp may become exposed as shown in this picture ‘Pulp capping’ treatment may then be undertaken where a restoration is placed over the exposed pulp to help this heal prior to placing a restoration above this These may include materials such as calcium hydroxide or biodentine This may allow the pulp to recover and survive without the need for root canal treatment Systematic reviews available to evaluate success of such treatment (Cushley et al 2020) Dentine Caries – Inner 1/3 If the caries is clinically or radiographically into the pulp then there is likely irreversible inflammation or necrosis of the pulp These teeth can then only be treated with root canal treatment or extraction In root canal treatment instruments are used to remove the dental pulp, the pulp chambers and canals are disinfected and then a filling is placed into these The coronal aspect of the tooth is then restored with a routine restoration Caries with limited tooth tissue remaining If the caries is extensive and there is not enough tooth tissue remaining above the gingivae, extraction may be the only solution Tooth replacement options would then need to be discussed with their dentist What additional restorative treatments are there? Not within remit of dental hygienist or therapist Additional restorative options Generally caries is treated with direct approaches (clinician builds the filling into the tooth) Can also be treated with indirect approaches (restoration is made by a dental technician and cemented in place by the clinician) Examples include; inlay, onlay or crown Additional restorative options – inlay or onlay The caries is removed before an impression (mould) of the tooth is taken and this is sent to the dental lab They then produce a plaster model of the teeth and build the onlay/inlay on this This is then sent back to the dentist to cement into the mouth This eliminates some of the issues with direct restorations which will be discussed later in the course Additional restorative options – Crowns When extensive tooth tissue is lost due to caries, the tooth becomes inherently weak and more at risk of fracture At this point the dentist may decide to prepare the tooth for a crown They do this by reshaping the tooth to create space for the crown to fit over the top Because this encases the tooth 360 degrees it provides strength to the weaker underlying structure How does this vary for paediatric patients? Paediatric Caries Management Due to their teeth size and thin enamel surfaces, caries progresses rapidly in the deciduous dentition Prevention is essential for this cohort as with adults however fluoride doses need adjustment and patient’s parents need to be involved Fissure Sealants As mentioned previously, fissure sealants can be used to ’seal’ early-stage caries This is therefore important for paediatric patients where first permanent molars are high risk Need regular review to ensure have no failed Conventional Management Techniques If caries is not extensive (e.g. unlikely pulpal involvement, enough tooth tissue remaining to restore) conventional restorative techniques as used in adults can be utilised Difficulty with this is; Inadequate moisture control for composite (GIC often used instead which is poorly retained) Limited retention Caries often more progressed so not feasible Cannot use amalgam in