Management of Carious Lesions GN PDF

Management of Carious Lesions Oral and Dental Science Josh Hudson Pre-reading ‘Ae$ology and sequela of dental caries’ Lecture ‘Histopathology of enamel and den$ne caries’ Lectures GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to preven$on, diagnosis and treatment...

Management of Carious Lesions Oral and Dental Science Josh Hudson Pre-reading ‘Ae$ology and sequela of dental caries’ Lecture ‘Histopathology of enamel and den$ne caries’ Lectures GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to preven$on, diagnosis and treatment 1.14.1 Assess and manage caries, occlusion and tooth wear, and, where appropriate, restore the den$$on using minimal interven$on maintaining func$on and aesthe$cs 1.14.5 Explain the role of a dental therapist in restora$on of teeth 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous pa$ent history Intended Learning Outcomes By the end of this session you will be able to: List the direct management op$ons for various presenta$ons of dental caries List the indirect management op$ons should extensive loss of tooth $ssue occur Describe the role preven$on plays in caries management Describe the diJerences between the use of each op$on Caries Recap SuscepAble Caries tooth surface Plaque Bacteria Time Fermentable Carbohydrate ICDAS Recap When dry Score 1 = First visual Score 4 = Dark Shadow change in enamel from den$ne Score 2 = Dis$nct visual Score 5 = Dis$nct enamel change in enamel cavity with visible den$ne When wet or dry Score 3 = Localised Score 6 = An extensive enamel breakdown cavity into den$ne How do we approach caries management?  Conservative as possible and reinforced preventative measures Extent of caries Not cavitated, reversible and can remineralie With improving home OH routine Fluoride application Diet advice Irreversible — restorations required  Occlusal caries usually a lot deeper than appears on BW Extent of caries Radiographs underestimate decay - especially occlusally Reproduced from – Dental Caries. PiTs, 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 Prst stage of treaAng any paAent with any carious lesion is.. Diet advice (reducing volume and frequency of sugars) PREVENTION! PREVENTION! Oral Hygiene Advice (how to clean eUecAvely) PREVENTION! n Increasing Fluoride Exposure These stages are required alongside any opera$ve treatment  The Prst stage of treaAng any paAent with any carious lesion is.. PREVENTION! PREVENTION! PREVENTION! Preventa$ve advice should be given as per the Delivering BeTer Oral Health toolkit Minimally Invasive DenAstry We should undertake the technique that requires the least amount of tooth structure removal We should use materials that will be long lasAng The RestoraAve Spiral Fissure sealant Caries Crown Restoration Extraction and implant/ Edentulous Bridge/denture How would each of these presentaAons be managed? Arrested Caries Black, firm — arrested lesion As from describing dental caries lecture, this is inac$ve No need for ac$ve treatment unless aesthe$c concerns PrevenAon is essen$al Review as poten$al to re- ac$vate May need to restore for aesthetic reasons or due food/plaque retention Enamel Caries (white spots) Fluoride treatment, improved OH ICON can used to remove white spots Reversible ATempt to arrest AVOID DRILL DUE TO RESTORATIVE SPIRAL Preven$on (OHI, diet advice) Ac$ve preven$on strategies to increase ]uoride and mineral exposure exposure (high ]uoride toothpaste, mouthrinse, ]uoride varnish, tooth mousse etc) Enamel Caries – Fissure Sealant Reversible ATempt to arrest AVOID DRILL DUE TO RESTORATIVE SPIRAL As well as preven$on, can undertake simple addi$ve treatment This can be using ^ssure sealants to ‘seal’ the carious enamel to deprive the bacteria of nutrients and aTempt to arrest the lesion Requires regular review to ensure sealant not broken or leaking which will lead to caries progression Now into denAne….  Extent of caries in denAne If just into outer 1/3 and you can visualise area (non cavitated and cleansable) — may not require restoration As soon as cavitated will require restorations Requires interven$on Outer 1/3 of denAne Irreversible Outer to middle 1/3 denAne Restora$ve material Inner 1/3 of denAne Pulpal protec$on Moisture control Root caries Seal Enamel Caries/Outer 1/3 DenAne Caries Now has become irreversible Restora$ve treatment needs to be undertaken to avoid progression This takes the form of a preventa$ve resin restora$on (PRR) for occlusal surfaces This ul$mately involves removal of the caries within the ^ssures with a drill, placement of a composite restora$on and then sealant over this S$ll need preven$on (OHI, diet advice) to reduce risk of caries elsewhere Reproduced from – Piccard's Guide to Minimally Invasive Den$stry DenAne Caries – Outer to Middle 1/3 Restora$ve treatment needs to be undertaken to avoid progression S$ll need preven$on (OHI, diet advice) to reduce risk of caries elsewhere Ac$ve preven$on strategies to increased ]uoride exposure (high ]uoride toothpaste, mouthrinse, ]uoride varnish etc) Standard direct restora$on DenAne Caries – Outer to Middle 1/3 Local anaesthe$c Removal of caries with drills and hand instruments Restora$on of the tooth Temporary restora$ons Glass ionomer cements – semi permanent Amalgam Composite  DenAne Caries – Outer to Middle 1/3 Temporary Restora$ons Glass Ionomer Cements Composite Restora$ons Amalgam Restora$ons Amalgam cannot be used in pregnant or breas\eeding women unless speciPc indicaAon (SDCEP 2018) DenAne Caries – Outer to Middle 1/3 The majority of permanent restora$ons will be amalgam or composite resin Cochrane systema$c review (Alcaraz et al 2014) suggests a slightly higher failure rate of composite than amalgam Composite Restora$ons due to secondary caries However, amalgam being phased out due to environmental concerns rela$ng to its mercury content (agreement to phase down as part of Minemata conven$on) Amalgam Restora$ons DenAne Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Den$stry DenAne Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Den$stry DenAne Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Den$stry DenAne Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Dentistry DenAne Caries – Outer to Middle 1/3 Reproduced from – Piccard's Guide to Minimally Invasive Den$stry Root Caries More likely in periodontal patients, xerostomia, and patients with recession Silver diamine fluoride can be used if unable to place restoration in these area As men$oned in the describing dental caries lecture, root caries management is slightly diJerent Needs to be managed with preven$on 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 diecult DenAne Caries – Inner 1/3 More than 1 indicator required before diagnosis This is extensive caries which may have begun to invade the pulp These pa$ents may have pulpi$s 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 trea$ng these cases as may be outside of your scope ‘Stepwise ExcavaAon’ and the AtraumaAc RestoraAve Technique (ART) These are considered more minimally invasive approaches to deep caries management Stepwise excava$on involves; Removal of super^cial layer of necro$c caries infected den$ne Placement of calcium hydroxide base and provisional restora$on Re-enter 6-9 months following ter$ary den$ne forma$on Removal of remaining arrested caries infected den$ne + permanent restora$on This risks pulpal exposure during second re-entry and more $me consuming ’Stepwise ExcavaAon’ and the AtraumaAc RestoraAve Technique (ART) ART is considered a more modern version of stepwise excava$on ART involves; Removal of super^cial layer of necro$c caries infected den$ne Restora$on 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 Systema$c reviews suggest higher success when using ART (Schweindicke et al 2013, Barros et al 2019) DenAne 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 restora$on is placed over the exposed pulp to help this heal prior to placing a restora$on above this These may include materials such as calcium hydroxide or bioden$ne This may allow the pulp to recover and survive without the need for root canal treatment Systema$c reviews available to evaluate success of such treatment (Cushley et al 2020) DenAne Caries – Inner 1/3 If the caries is clinically or radiographically into the pulp then there is likely irreversible in]amma$on or necrosis of the pulp These teeth can then only be treated with root canal treatment or extrac$on In root canal treatment instruments are used to remove the dental pulp, the pulp chambers and canals are disinfected and then a ^lling is placed into these The coronal aspect of the tooth is then restored with a rou$ne restora$on Caries with limited tooth Assue remaining If the caries is extensive and there is not enough tooth $ssue remaining above the gingivae, extrac$on may be the only solu$on Tooth replacement op$ons would then need to be discussed with their den$st What addiAonal restoraAve treatments are there? Not within remit of dental hygienist or therapist AddiAonal restoraAve opAons Generally caries is treated with direct approaches (clinician builds the ^lling into the tooth) Can also be treated with indirect approaches (restora$on is made by a dental technician and cemented in place by the clinician) Examples include; inlay, onlay or crown AddiAonal restoraAve opAons – 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 den$st to cement into the mouth This eliminates some of the issues with direct restora$ons which will be discussed later in the course AddiAonal restoraAve opAons – Crowns When extensive tooth $ssue is lost due to caries, the tooth becomes inherently weak and more at risk of fracture At this point the den$st may decide to prepare the tooth for a crown They do this by reshaping the tooth to create space for the crown to ^t over the top Because this encases the tooth 360 degrees it provides strength to the weaker underlying structure How does this vary for paediatric paAents? Paediatric Caries Management Due to their teeth size and thin enamel surfaces, caries progresses rapidly in the deciduous den$$on Preven$on is essen$al for this cohort as with adults however ]uoride doses need adjustment and pa$ent’s parents need to be involved Fissure Sealants As men$oned previously, ^ssure sealants can be used to ’seal’ early-stage caries This is therefore important for paediatric pa$ents where ^rst permanent molars are high risk Need regular review to ensure have no failed ConvenAonal Management Techniques If caries is not extensive (e.g. unlikely pulpal involvement, enough tooth $ssue remaining to restore) conven$onal restora$ve techniques as used in adults can be u$lised Dieculty with this is; Inadequate moisture control for composite (GIC ojen used instead which is poorly retained) Limited reten$on Caries ojen more progressed so not feasible Cannot use amalgam in