Cario Post MT PDF

PhotoPolymerization Photoinitiators ○ Present in any dental resin (in context of specifically composite) ○ Violet light 380-420 nm Popular for aesthetic development of new composite materials ○ Blue light 420-490 nm ○ Our light cure covers bo...

PhotoPolymerization Photoinitiators ○ Present in any dental resin (in context of specifically composite) ○ Violet light 380-420 nm Popular for aesthetic development of new composite materials ○ Blue light 420-490 nm ○ Our light cure covers both spectrum ○ CQ ○ Norridge group 1 Lucirin TPO most common 380-420 peak at 381 - 390 nm Light in color Fast polymerization reaction progress Need violet in order to be light cured Bulk filled composite have added Lucirin TPO as a photoinitiator because you can apply those composite materials in a thicker layer quicker? Dotes not need any co initiators So Phootoinitiators start and develop faster ○ Norridge group 2 Camphorquinone most common (CQ) Used in almost all materials (temp materials, composite resins, etc) Yellow in pigment so doesn't work for some aesthetic restoration (cannto match color) Needs tertiary amine for reaction to be started 425-495 nm peak at 468 nm Unstable (sensitive to ambient atmosphere and light) ○ Good quality in shortest time possible Blue light needed Group 2 PPD-1 (can belong to both groups bc spectrum of activation is in violet light or short blue light) Lighter pigment than CQ 390-460 nm peak at 398 Needs co initiators Used in Combination with camphorquinone which is the main photoinitiators ○ And then PPD or Lucirin is added to the CQ so concentration of CQ is decreased Blue light needed Need co initiators for polymerization reaction to start ○ Ivocerin Vivadent product  Activated in a violet spectrum ○ PQ Activated with blue light and cured with violet light ○ Irgacure 819 ○ Polymerization: monomer → polymer Begins with exposure to blue light 400-500 nm wavelength Most effective wavelength 468 nm (max absorption of most common photoinitiator CQ) ○ Yellow isCQ and the coinitiator is green ○ Material exposed to blue light → decomposition of CQ → CQ reacts with tertiary amine → free radical form ○ Free radical → splitting of C=C (until all radicals are saturated)→ formation of polymer chains Length of chain affects quality of polymerization and teh shrinkage later on ○ Effectiveness of polymerization Factors related to RBC Resin based composite ○ Type and concentration for fillers, monomers, and other components When light goes through substance it can be transmitted, absorbed, reflected or scatter Shape and structure of organic and inorganic filler dictates how light behaves Each inorganic and organic components have refractive index but they are not equal When the polymerization starts, Refractive index of organic and inorganic begins to match (it might not be ideal but less discrepancy) Refractive index will allow the penetration of the light through the material easily so the closer the refractive index is the better the penetration of the light through composite materials will be Refractive index will have an impact on shade of polymerized composite material Uncured resin will have diff refractive index than does a cured resin Appearance should match (place on area close to restoration area) (cervical area and occlusal areas will be different) ○ Pigments are added to diff shade Some require longer or shorter curing time  ○ Inhibitors need to be present (BHT and PI) otherwise as soon as you open the bottle or package, its exposed to ambient light and the material will cure ○ Shade of RBC Dentin shade cure for 40s enamel for 20s bc dentin has more pigment and is darker Always read manufactured instructions (use the same unit of light in seconds) Irradiance of intensity of light also matters (how strong is your light curing unit?) ○ Type of photoinitiator Spectrum of light curing has to cover and match spectrum of photoinitiators that we have in composite material If you have lucirin, you need to have a curing light that emits blue and violet light together Factors related to LCU Type Light curing unit What is intensity/irradiance ○ ○ Irradiance = power density or intensity Total power of wavelength divided by the area of optical guide (600 mW/cm^2 for 400-500 nm, 1mm from surface) ○ Radiant exposure = energy density (total energy) = irradiance x exposure time (600mW.cm^2 x 30s = 18 J/cm^2) What is the amount of energy composite need to be received to be properly cured This formula is not used anymore because nowadays manufacturers are fabricating the strong, high irradiance light curing units (this calculation might not be accurate) Exposure time ○ How long to cure Size tip, and geometry and beam profile Effect of autoclaving and protective barrier Question 2: polymerization will be more efficient if ○ The refractive index of the organic matrix matches the refractive index of the filler particles  Halogen curing unit (quartz, tungsten-halogen, QTH) (clinical setting) ○ Need white light which needs to be filtered to in order to get blue light ○ 390-520 nm (blue and violet spectrum) ○ Advantage: has a bulb But You need to change it after a while ○ Has filters bc high irradiance (but properly replace bulb) Filters while light into blue light Has filters to reduce temperature If not maintained properly it can increase temperature and cause irreversible damage of pulp) Increase in 5.5 degrees celsius will cause pulpitis according to zach and coyne but new research said 10-12 degrees increase can still be okay without permanent damage to the pulp tissue Plasma curing unit (clinical setting) ○ 1990-1994 came out ○ Need white light which needs to be filtered to in order to get blue light ○ 420-490 nm and 2400 mW/cm^2 ○ High irradiance with narrower spectrum so they only emit blue light but still need filters ○ Did not perform well with thickness of 2mm of composite material LED curing light 450-480 nm ○ Don't need filter to fit through the light bc you get blue light right away More efficient be no excess dispersing og light ○ First gen: only blue light Came as a cold light source which means it does not produce any temperature No temp filters needed Single diodes were connected in a different way to achieve proper irradiance  Later single diode was substituted witha chip to increase irradiance Light arranged so irradiance can be achieved ○ II generation 430-480 nm 500mW/cm^3 Chip added Has heat sinks? To do the same job as temp filters in halogen light curing unit ○ III generation Polywave Dual peak Emit blue and violet 430-490 and 420 - 490 If you have CQ base composite you might use only a blue based mono wave light curing unit but If lucirin added then need polywave light Cordless or corded Cordless: need to charge (need two lights) ○ Battery might wear off and you won't know how ○ Don't know how irradiance changes with battery wearing ○ ○ Argon laser Can be used in both clinical and lab settings ○ Pulsed blue laser Lab setting ○ Blue Diode laser Lab setting Polymerization program ○ Continuous vs discontinuous  ○ ○ Continuous: emit all same irradiance level High, medium, and low intensity ○ Discontinuous: emits for certain some of light at low irradiance then high irradiance Staged mode: 500 then after ten seconds → 1000 Exponential Gradually increased up to 1000 Ramped mode: Combo of exponential and staged Exponential then continues irradiance until end of poymerization Pulsed mode Emits in pulses and then takes a break and repeats Soft start purpose is to slow down polymerization (give more time for radicals to form polymer chain) For longer polymer chain Procedural factors Environmental factors Effect of ambient and operating light Effect of surrounding atmosphere Focused light on loupe is high temp so it might light cure your composite ○ Even orange filter use might still cure it Temperature in patient mouth ○ Affects polymerization of material ○ Curing tip Where light comes in Internal housing : diameter of lens but is smaller than external housing External housing Higher diameter tip Different irradiance limited  ○ If same power but different diameter then focus is different Not as focused light ○ Beam profile Four chips on our valo light curing unit with different irradiance Two are blue, one is short blue, and one is violet If beam profile unit is uniform then that means Each portion of curing tip diameter emits the same irradiance But in light cure we don't know where the chips are located on teh tooth Hot spots: higher irradiance Cold spots: not sufficient energy For polywave light curing unit Use multiple exposures in diff positions depending on shape of the drilled hole Because diff areas will have diff colors 1 curing cycle is 20s Rotate light with each exposure to compensate for insufficient polymerization ○ Polywave LED not ideal bc chips interferes with homogeneity of our light Unit A emits 900 in blue and 200 in violet CQ based if maybe you are using temporary restoration Unit b 700 in blue and 400 in violet Lucirin based (more in violet spectrum) Which is better? Depends what your working on Unless we do spectrophotometry test we don't know how much in blue and how much in violet is produced  ○ Access to the preparation/restoration and LCU design Last molar is hard to reach (TMJ issues) Pen design can reach all the way in back ○ Direction of light guide tip Perpendicular close to surface as possible (use protective sleeve) If curing class two, then some areas of composite in shadow and could lead to secondary caries Near gingiva ○ Distance from the surface Irradiance decreases with distance How old is light how is it distributed Radiometer ○ Measure irradiance of light curing unit ○ Doesn't tell us beam profile or tip diameter ○ But if you have a polywave curing light you need radiometer than can detect both blue and violet light MARC ○ Measures curing parameter of the LCU under clinical conditions ○ Total energy is time x delivered irradiance ○ Tells Actual time Light irradiance Peak wavelengths Radiant exposure/what is total energy delivered to restoration Degree of conversion ○ How good is your composite set ○ Never have 100% Maybe up to 90 Usually 75-90 Anything that is less than 50-55 means its not polymerized well ○ Good degree of conversion: If you have 2mm thick composite and u have 85 degree conversion at bottom and 100 at surface Shrinkage ○ Always present cannot avoid ○ Ways to avoid: Light curing unit, technique of placement of composite, proper material ○ Pre-gel: when radical starts forming ; attack double bonds Molecules adjust the position to form nice and long chains ○ Gel phase: polymer starts forming Molecules cannot move anymore ○ Post-gel phase: termination phase ○ Our goal is to extend pre-gel phase to decrease polymerization shrinkage Allows polymer chain to get more network, more longer, more better formed chains  Lessen stress Use soft start or discontinuous mode (exponential) Exponential has 1000 final ○ Prolonged pregel phase so less shrinkage High irradiance has 1000 final ○ Short pre-gel phase so tey will hit the gel phase quicker But in exponential the pre- gel phase is longer bc les polymerization shrinkage Even if u have standard mode u can replicate discontinuous slope Get Closer and closer to surface as you cure ○ C factor Number of surfaces bonded and unbonded matters Higher stress is higher shrinkage and higher C factor Class four has smallest c factor and least stress because there is no boundary so more space for molecules to slip in a better position You can find full white line on the margin of restoration as a consequence of the polymerization shrinkage But white line can also be consequence of improper marginal finish or improper bonding procedure Marginal gap can cause fracture between composite and the tooth or crack in teh tooth If there is any fracture in the composite or in the tooth or in the adhesive itself its called cohesive fracture because it is in the substance by itself If fracture is made between the composite and the bonding or between the composite and the tooth then that's adhesive fracture because it happened on the adhesive surface Patient will feel pain ○ In pregel: molecules can move Polymerization shrinkage can form white line White line can also be because of improper marginal finish or improper bonding procedure Creates marginal gap and maybe a fracture in the composite ○ This is called cohesive fracture Adhesive fracture on adhesive surface Patient will feel pain from this ○ Oxygen inhibition Glycerin gel only on last layer Whenever you light cure there always oxygen left which reacts with free radical to form peroxide radicals Efficiency of initiation is reduced Sticky (improperly cured) ○ Temperature increase Increase irradiance so even though they are supposed to be cold source of light they can produce heat  Temp can cause damage of healthy pulp tissue and burn soft tissue ○ Cytotoxicity Composite material organic matrix with monomers will be hydrolyzed and diluted in oral cavity (both body and pulp tissue) Can cause cytotoxicity for the body and pulp If not cured properly Yellowish appearance of restoration ○ Eye Protection Blue light - retina Violet light - cornea Cumulative damage Orange filter use Kids eyes are sensitive Some antidepressants and steroid therapy, antiinflammatory drungs and anti-malaric drugs can affect the patient's sensitivity to light ○ Infection control Autoclaving Disinfection solutions Replace with each patient Diosin optic fibers can be damaged without protection and decrease up to 30-40% of irradiance Plastic barrier has to be snug (if air in side there we can lose up to 30% of light) Make sure seam is not on beam profile ○ Valo Know each power modes irradiance Extra power 3200 ○ Use for extraoral High power 1400 ○ Use for extraoral Standard 1000 ○ Air cool ○ Dentin mineral decreases with age Incorrect (increases with age) ○ Enamel has more compressive strength Incorrect ○ Know which clamps go on which tooth Non-invasive caries management What is caries ○ Need tooth, bacteria (strep mutans and lactobacillus able to cause demineralization), diet, time ○ Biofilm must be mature enough where growth of bacteria is ideal ○ Takes weeks and months for lesions to occur  ○ When all factors come together there are also modifying factors within the patient (i.e. saliva) that influence likelihood Diet (sugars further progressio of lesiosn) ○ Monosaccharides ○ Disaccharides ○ Polysaccharides ○ Sugars are made from small building blocks ○ Table sugar comes from sugar cane (tropical climate) and sugar beets (colder climates) Washed and crushed then sugar juices that are extracted are further refined → result in table sugar ○ Sugars can be arranged into fibers Tougher Gives texture Helps with digestion ○ Sugars can be stored in form of glycogen ○ Starch - form of polysaccharides Potatoes Form of sugar but not sweet Salivary amylase break down starch into the glucose which tastes sweet Starch made of amylose and amylopectin Amylose : long chain of molecules (hundreds of molecule long) Amylopectin: a molecule that is branched (20-30 building blocks) ○ Disaccharides Sucrose - table sugar Ring of six (hexose) linked to ring of five (pentose) Hexose is glucose Pentose is fructose Can be further broken down by saliva (special enzymes) Lactose - milk sugar Glucose and galactose Maltose Glucose and glucose ○ Monosaccahrides Glucose Fructose Galactose Ring of six atoms ○ sugar/sucrose 50 50 frctose adn glucose ○ High fructose corn syrup 55-55% fructose/45% glucose 90-90% fructose/10% glucose Depending on how it is process the ratio can be different  Fructose has similar sweetness to glucose Glucose can be metabolized by almost all cells in our body Fructose is fermented in the liver High amounts of this can be problematic for liver ○ Agve nectar 70-90 fructose and 10-30 glucose Sugars - types ○ Some have naturally occurring components ○ Most are chemically similar to sucrose ○ Caries: doesnt matter is sugar is organic or not the molecule itself is chemically exactly the same Doesn't matter that honey is naturally occurring it can still be harmful for teeth Sugar metabolism ○ Sugar when digested taken into the cell and further metabolized Invertase will hydrolyzed into glucose and fructose Glucose taken into cell wall and go through glycolysis → pyruvate → lactic acid or formic acid, acetic acid, ethanol ○ Sugar can be used outside of cell and form glucans or fructans Creates sticky matrix that allow caries causing bacteria to stick better to teeth ○ Salica will buffer pH to go back up to neutral ○ pH above 5.5 = remineralization ○ Depending on salivary flow rate we might see pH value rebound faster If patient cannot buffer with saliva we need to recommend baking soda rinses Cariogenic challenge - frequency and time ○ Breakfast - pH drops below critical value for enamel Dentin has higher threshold (demineralized much easier) ○ Saliva pH goes back up to normal ○ Lunchtime - another laid of carbs and sugars that triggers pH value to go below 5.5 ○ pH goes back up to normal ○ Dinner - another drop ○ Rinse with water can help rinse away sugars ○ Patients with more snack throughout the day pH drops more frequently As pH tries to go back up after meals we feed the bacteria again and leads to another drop in pH pH more in the red zone (does not go back into green area) ○ Vipeholm study Run by government and sugar industry In ancient times people would use smokes to get bugs and parasites out of mouth bc they though it caused caries  Study done in mental hospital Showed positive correlation between consumption of sugar and caries increment More often consume sugar = more caries occur Sugar - nutritional facts ○ Can get info about sugar on nutritional facts ○ Serving size : how much the label is describing ○ Calories: ○ Nutrients: want to achieve balanced diet that contains a little of all things Avoid bad things ○ Daily values : ○ Important to look at carbohydrates Fibers Sugars (naturally occurring) Added sugars ○ Sugar usually comes in crystalline form But honey may have different amount bc its not crystalline ○ Teaspoon = 4g of sugar about Daily average intake ○ 17x teaspoon or 71.14 grams of sugar Yearly average ○ About 57 pounds Intake sources ○ Largest sources of sugar are Dessert and sweet snacks and Sugar sweetened beverages ○ Sauces also have sugar Acidity counteracted by sugar WHO guideline for free sugar intake ○ Less than 10% of total energy intake ○ Depends on gender ○ 14g = 6 teaspoons for females ○ 36g = 9 teaspoons for males Coke ○ Contains acid for fizz Phosphoric acid ○ Regular consumption of acidic beverages is erosion Vitamin water ○ Contains 27g or added sugar Naked smoothie ○ Sugars are bound to fibers in the fruit ○ Juices: squeezes out of fibers ○ Natural fibers are more helpful for digestion Regular purging Sugar alcohols  ○ Sugar alternative that look like sugar molecules but have an OH group attached ○ Don't have same cariogenic effect ○ Sweetness is similar sometimes maybe less sweet ○ Depending on type of food and how its produced, it will have different sugar alcohols ○ Xylitol Not heat stable (limitation) Originally from birch tree ○ Too much sugar alcohol can have bloating effect or diarrhea Artificial sweeteners ○ Much more powerful than sugar alcohols ○ Need less to have the same amount of sugar ○ Too much might taste bitter ○ Have been seen to be carcinogenic Oral hygiene ○ Plaque control is important If you don't have plaque you can eat more sugar (bacteria cannot ferment) ○ Chemical agent (bactericidal or bacteriostatic) Toothpaste Mouth rinse Spray Varnish Chewing gum Caries risk management ○ Depending on which caries risk category, we have prescription grade agents moderate high and extreme high CHX 0.12% 1x/day for 1 week per month In remaining time they can use NaF rinse (o.o5% OTC) 1.1% NaF (5000 ppm) Low risk does not need ○ Moderate high and extreme high 5% (22600) NaF varnish Do at office Nutritional counseling Oral hygiene instructions Xylitol 6-10g per day Antibacterial properties Phasing it out at USC ○ Body of evidence is sparse ○ Patients with diabetes it might cause blood clotting ○ Extreme high Baking soda rinse to buffer pH Prescribe calcium phosphate toothpaste  MI paste contains amorphous calcium phosphate and stabilized by milk protein amorphous calcium phosphate called recodent Gives more minerals to the area Check salivary flow rate and pH ○ Every patient OTC toothpaste OTC NaF rinse 0.05% (230 ppm) NaF rinse Silver diamine fluoride ○ Antimicrobial (silver) ○ Fluoride (remineralizing function) ○ Amine (stabilizer) ○ 38% SDF ○ Used to arrest caries without drilling ○ Desensitizing agents lower pain by plugging up tubules or avoiding action potential ○ Causes silver to precipitate and stains heavily As exposed to light it turns slightly black bc silver particle falls out Looks blue initially but if its old it goes away ○ Remove superficial caries dentin with spoon excavator ○ Works best for cavitated lesions ○ Other countries have diff percentages ○ In some patients you remove later on and put tooth colored restoration ○ If lesion is hard then SDF can be removed? But if still soft then apply more Caries excavation Carie management goals ○ Prevet new lesions from appearing (main goal) ○ Prevent existing lesions from advancing further Incipient Early lesions (white spots, brown spots, with no cavitation) Cavitated (ICDAS5 or 6) ○ Preserve tooth structure with non-operative care at more initial stages and conservative operative care at more extensive caries stages ○ In most cases remove the caries instead of use SDF (only if patient has anxiety) Only remove diseased structure (everytime you remove tooth structure we weaken them and lower the chances of long term survival) Burs ○ Use burs that matches size of caries ○ Targeted invasive treatment Lesion progression into dentin ○ ICDAS stage 1  Demineralization in enamel Radiographically outer half of enamel ○ Stage 2 Histologically Demineralization happening right below DEJ → triggers odontoblasts to obliterate tubules and cause sclerosis → Secondary dentin formation Denim continues and tooth Creates tertiary dentin inside pulp chamber ○ Stage 3 and 4 More cavitation of enael ○ Stage 5 Dentin exposure Zone of destruction (caries infected) orange part Minerals completely gone bc of lactic acid attack and the collagen fibers that are exposed are eaten by MMPs (complete destruction of collagen fibers) Scleoritic dentin under the lesion adn tertiary dentin inside pulp is something we don't want to remove bc we don't want to weaken the tooth unnecessarily Caries affected - demineralized dentin If close to pulp we might perforate and opening up the pulp Hard to distinguish sclerotic and tertiary dentin (maybe color wise) Demineralized dentin softer than sclerotic dentin ○ Hardness of dentin is different throughout all zone Infected Soft and moist Denatured collagen fibers ad demineralized things have leathery flakey appearance Affected Demineralization with no collagen destruction is harder Pulp Hardness decreases bc of wider tubules as we get closer to pulp Look for difference in hardness with excavator Makes diagnosis subjective Reactionary / reparative dentinogenesis ○ Mild stimulus (caries that slowly progresses; or lots of sensitivity from cold) Odontoblasts react to this Over months and year, sclerosis of tubules occur forming secondary dentin inside tubules (primary dentin with occluded tubules are called secondary dentin) Tertiary dentin created slowly (reactionary dentin) If stimils is slow grade we have steady and fairly solid apposition of reactionary dentin ○ Intense stimulus Salivary levels drop dramatically + poor hygiene  Maybe new medications or chemotherapy Odontoblasts dont have a lot of time to create protective wall Less organized tertiary dentin Caries lesion might go all the way to pulp Odontoblasts form tertiary dentin to try to bridge the gap ○ Aka reparative dentin Dentinogenesis - molecular pathways ○ Cascade of molecular processes occur ○ Helps Us understand the process and development of medications and agents that aid in formation of dentin? ○ Understand how bone is forming or formation of soft tissue If soft tissue goes away structural or aesthetic issues can arise Caries excavation ○ Icdas stage 5 on the left but stage 6 on right ○ Caries infected dentin plus plaque Demineralization extends to palatal area as well as to the buccal ○ In deep cavities we have lactobacilli S mutans on noncavitated surfaces and actinomyces on root srfacs ○ Be careful with spoon excavator bc you might push into pulp ○ Clean the periphery first then near the pulp!! ○ Initially use hand instrument to get debris out then use diamond or carbide bur to open up Once sufficient access is created use round carbide (6000rpm) and go along DEJ and clean that area out until you end up in healthy dentin Remove caries infected dentin until you hit caries affected dentin With shar explorer you will feel it is a little softer than sound structure Make sure you dont break through in areas near pulp ○ Small and dry flakes from clean dentin ○ Wet soft leathery flakes from infected dentin Caries detection - fluorescence ○ Can use on dentin esp on infected or affected dentin ○ Siroinspect Emits blue laser Fluorescence of caries and composite material While light is shining we use bur to remove that Laser light 405nm with 530nm filter Light up composite material so u can tell difference between filling and natural tooth  ○ Blue light based devices While excavating you can use but check again with the light Dyes ○ Stain caries infected and affected (demineralized dentin) ○ Stains matrix of less mineralized dentin, but not bacteria ○ Caries infected - dark, intense purple color ○ Caries affected (not as wet) - slight pink areas and slight darker areas ○ Dye penetrates along crack Don't want to follow stain blindly bc you will be in the pulp for sure Light stains you don't have to remove ○ ○ In periphery everything must be cleaned Caries excavation ○ 1. Outline : open access and or remove adjacent restoration if necessary Remove diseased enamel and restoration ○ 2. Use spoon excavator to remove soft carried infected dentin ○ 3. Circumferentially remove caries along DEJ with #2 at 8000rpm Newly exposed dentin should be hard and shiny (clean dentin) ○ 4. Clean margins Fissures might have stains too so clean that out using thin bur like 8888 ○ 5. Check with explorer ○ 6. Remove caries infected dentin from pulpo-axial wall switch #4 or #6 Some areas are stains from caries but it doesn't mean it is caries itself Caries excavation ○ Clean picture: dark areas could be due to penetration of staining particles (chromagens) into dentin Tertiary dentin might have different color from primary or secondary dentin ○ If you see red or blood then you are in pulp Lesion depth ○ shallow/moderate or deep? Shallow = outer areas far away from pulp Clean everything out from dentin Dont need to leave anything behind No risk of exposure of pulp ○ Deep Either remove dentin infected and affected not completely at once but in steps Stepwise (remove infected and leave affected and place temp filling)  ○ In time Tertiary dentin will build up inside pulp chamber, causing walls to build up (safety buffer) ○ Less pulpal involvement ○ Less postoperative pain and RCT Selective Leave affected dentin on wall but make sure surrounding is clean ○ Make sure you take recent radiographs Composite placed but recurrent caries or maybe residual caries ○ Clinically you excavate more than what you see on the radiograph ○ Placement of rubber dam necessary so there is no contamination with saliva or blood Pinpoint exposure of pulp ○ Pulp cap Need to have clean dentin surrounding it ○ If you expose pulp and there is lots of infected dentin around it then you might need to refer to endo after Pulpal management ○ Indirect pulp capping Close to pulp but not exposed yet (place calcium hydroxide liner that has some medication in there that is put over wall) Not that successful No benefit in comparison to no pulp cap (unnecessary procedure) You are taking away bonding structure Calcium hydroxide and RMGI sealing liner placed and bond to rest of tooth Creates mineralized tissue that closes the gap (bridge dentin) (if you place adhseive directly on teh pulp or other materials you will not have nay hard materials forming) ○ Direct pulp capping Pulpal tissues exposed but When Pulpal tissue not inflamed (and no pain) Hemostasis possible Calcium hydroxide or MTA (stimulates odontoblast to produce tertiary dentin or reparative dentin) ○ Pulpotomy Pulpal tissues exposed but When pulpal tissue partly inflamed (some pain on and off)  Part of pulp tissue removed Hemostasis possible Just removing coronal part of the root Want to make sure that the nerves in the roots are not inflamed (if continues to bleed the RCT needed) ○ Pulpectomy Pulpal tissue inflamed and you remove nerve completely Hemostasis not possible Always accompanied byt RCT If we have Dead nerve tissue (periapical lesion) immune system will come in to fight against it and cause pain and swelling Fill with good sealing material and do root canal Reversible pulpitis: ○ Patient has pain upon exposure to cold or hot but goes away after stimulus removed Irreversible pulpitis: ○ Pain occurs spontaneously ○ Without eating or drinking the tooth starts pulsating (dull throbbing pain) Dentin bridge ○ Putting just adhesive composite will irritate pulp and become inflamed even more and will need RCT ○ Medication can trigger Pulp capping materials do an ddo not put ○ ○ Bioceramics only on exposure side Direct pulp capping - medication ○ Dycal - calcium hydroxide based product Place don't smear Needs to harden ○ Cover medication with GC fuji liner (resin modified radio peg, dual cure, glass ionomer cement) maybe ½ mm beyond Reactionary dentin: tertiary dentin that is created in reaction by pulpal odontoblast against any outside stimulus (chemical, mechanical, thermal) Called Reparative dentin when there has been exposure of pulpal tissue Know specificity and sensitivity Hall technique  ○ Place stainless steel crown Good seal = no nutrients going to bacteria under the crown = death ○ No progression of caries If pain upon cold = partly inflamed (reversible pulpitis) Spontaneous throbbing pain = inflamed (irreversible pulpitis) First CHX - to remove dust Etch with phosphoric acid ○ Enamel ; create rough surface for micromechanical surface ○ Dentin ; remove smear layer remove hydroxyapatite Chx: Universal adhesive: ○ Why 2-4 coats? Solvent evaporation ○ Solvent comes from adhesive Light Cure ○ Valoe for 10s Cna use MTA and CaH but not the temp materials bc medication that are touching pulp ust be biocompatible ○ RMGIC have resinous composites ○ Not biologically friendly materials Resin infiltration Resin infiltration: Micro-invasive caries management but for a certain indication only Macro is drilling and filling Caries is a disease (not just a condition or symptoms) ○ In presence of infectious bacteria ○ All factors must come together in order to take full effect Not everyone gets a fair share of disease caries (some people don't get it at all) Cariogenic challenge ○ Demineralization happens below pH 5.5 for enamel and happens immediately after the consumption of fermentable carbohydrates ○ Depending on clearance and sugar and acids might take awhile for neutralization and removal of sugars for pH to go back to normal Also Depends on diet and frequency of eating ○ Frequency and time very important factors Increased frequency keeps pH low and more demineralization occurs Need time for pH to bounce back after meals Disease caries is a slowly progressing disease ○ Less than half of tooth involved is ICDAS 5 ○ Can take years for caries to form to stage 5 or 6 ○ From 0 to stage 3 or 4 can take up to 4 years patients with a rapid progression within months, but oftentimes something is wrong in these patients. It could be that the salivary flow is completely gone, or genetically, they have very weak  hypomineralized enamel and dentin which facilitates demineralization in presence of acids ○ Once surface breaks down = rapid progression of disease Make sure you use blunt or round probe or explorer when doing tactile or visual diagnostic (ou could create the cavity) Cavitation: invasive manner ○ Bur or hand instruments and fill Noncaviated: noninvasive ○ Sealants, fluoride, MI paste or other thing ICDAS stages 2,3,4 ○ Microinvasive so use resin infiltration Decision tree (non cavitated vs cavitated) ○ Non Cavitated If inactive don't do anything Active (white spot, brown spot, plaque, bleeding gums) Inform patient and tell them to brush better or floss better (noninvasive) Preventative Sealant placement (esp on deep grooves of permanent molars) ○ Deep groove becomes shallow and filled with restorative material without drilling ○ Bacteria cannot get to the groove anymore Therapeutic sealant ○ Patient already has ICDAS lesion stage 1, 2, 3 and you seal it and stop progression so it is inaccessible for the bacteria Resin infiltration (microinvasive tx) ○ If you dont know if it will progress further or if you dont know whether patient will comply ○ Cavitated If patient does not allow you to drill then you can arrest caries via SDF If possible to clean out infected and affected dentin or demineralized enamel then do restorative treatment and give toth back original form Make it cleansible Resin infiltration concept ○ ○ Radiolucency on radiograph is only in outer half of enamel on 29 (E1 lesion) Usually ICDAS 1 or 2 and usually not cavitated Did Not drill into this bc there was no cavitation  You would have to remove 2-2.5 mm of healthy enamel ○ Resin infiltration It is resin material but there are no filler particles in there Sugar cube with infiltrated resin did not dissolve in distilled water ICDAS stage 2 ○ ○ Decalcified enamel: right under contact points and plaque accumulates around it Microstructure: surface of enamel is roughedned up Lactic acid Creates little dimples (center of enamel rod dissolved) What we also see is that there is not really any communication at least visible communication to the enamel pores that go into the lesion underneath Usually no bacteria inside the holes bc it is too small fo it but acid can goo inside ○ Therapaeutic Sealant is diffusion barrier on top of tooth Works for accessible areas like occlusal Some issues: can debond so bacteria can be accessed again Interproximal does not work bc it gets messy (smear against both teeth and you cannot clean up nicely and overhangs occur) ○ Resin infiltration: Use pores inside enamel demineralized and fill with resin and put sealant inside of it Acts as a diffuse barrier from inside rather than on top of it Enamel demineralization ○ Highly mineralized surface in enamel lesion Lots of minerals in saliva that constantly get deposited inside the demineralized enamel ○ Later is Porous where acids like H+ can go through and demineralize it and create deeper pores ○ Pores make enamel look whitish layer here on top can be in the way, because it's so dense, and the resin molecules are much, much bigger than the acid molecules or the acid ions, so that we need to remove that. Use strong acid like HCL (dissolves hydroxyapatite on surface of enamel)  If you're using only the phosphoric acid, the 37% or 34.5 or whatsoever you have in that range, it will only remove a small amount here. Yeah, like 5 to 10 microns, whereas the hydrochloric acid, 15% used for the same amount of time will result here in around 40, 30 to 40 to 50 micrometers of removal of the outer surface ○ Resin is much bigger than acid ions Hydrochloric acid ○ On surface of enamel ○ Hydrochloric acid results in largeer removal enamel hydroxyapatie ○ Can do this on primary teeth too even tho enamel layer is thinner Infiltration of artificial lesions with adhesives ○ Use bovine teeth and demineralized the enamel Shown through red dye that goes in through the pores ○ Depending on what kid of adhesive you have it goes in deep or not at all ○ Heliobond penetrates complete but doesn't go down all the way ○ Exite goes all the way and fill completely mostly Better the longer you leave it on there ○ Adper (self etch adhesive) penetrates but leaves lots of voids Doesnt create solid barrier Infiltration of natural lesions with adhesives ○ Phosphoric acid does not open pores that much so not much adhesive penetration (black part is hypomineralized layer that was not removed) ○ If we use HCL for two min we are able to remove a lt for hypomineralized layer and allow resin to infiltrate Penetration depends on ○ Time : longer we apply the deeper it can go Even up to 20 min for deep penetration ○ Contact angle: Low surface angel = spread out and adapt on its own well Goes along hydrophobicity and hydrophilicity go along ? Resin material is hydrophobic Need substrate under that is receptive ○ Surface tension ○ Viscosity : runnier is better penetration Glycerin is much thicker like honey ○ Radius: size of pore Wide the pore depper and the faster it can penetrates Resin infiltration of enamel demineralization Caries inhibition with adhesives ○ Demineralized bovine enamel in first unsealed If you add acid the demineralization grows ○ If adhesive does not seal completely the demineralization can go in deeper  ○ Modified resin is a perfect barrier ; not too porous and provides protection from acids ○ Need to have as deep as possible penetration of resin ○ Goes About 150-300 microns deep ○ the deeper the lesion radiographically, is, the wider the pores and the deeper the resin actually can go Application time - primary teeth in vivo ○ Same as permanent and primary teeth application Advantage of resin ○ Resin Stabilizes surface ○ When we have demineralization the tooth becomes soft Porous and drops in hardness by 90% ○ Resin increases hardness (not 100% but enough to make it stable) Not more breakage of surface Clinical management of proximal lesion ○ Use in lesions only in enamel (E1, E2, D1) ○ Enamel is hydrophobic that why we can use resin ○ dentin is hydrophilic ○ As soon as lesion is D2 or D3 there is cavitation so this is more for drilling and filling ○ White spot in between Papilla covering it Use plastic wedge to separate teeth in micrometers (to extrude acid) Insert through contact point and extrude the acid ○ If mesial (of 4) and distal (of 5) lesion then use microtip and put acid between teeth for 120s ○ After etch you rinse and dry ○ Water might be inside pores and outside so Use 100% ethanol ICON to evaporate the water in there Because if we leave that water in there and we're trying to add that hydrophobic resin, it will not go in ○ Once dry, place new tip with resin fo rit to flow into the pores and leave it for 3-5 min Infiltrant made of resin monomer tegdma 80% 19% ethanoland photoinitiator and accelerator that allows it to be light cured Contains CQ so its yellowish ○ Light cure for 40s ○ Do second coat for one minute to smooth out irreguarity  Infiltration of proximal surfaces ○ Placebo is not effective Higher rate of progression after 18 months ○ In tested groups all lesions stayed stable Meta Analysis ○ Summary of clinical studies ○ Resin infiltration wins Facial lesions ○ White spots around ortho brackets (plaque stuck around brackets all the time) ○ Resin infiltration make it look like a normal tooht Filling pores of lesion and it vanishes ○ when you have normal, clear, translucent glass, the light goes through and you can see everything that is behind it which in enamel that is usually the hydroxyapatite that makes it translucent You will have micro porosities in here that are in the enamel because of its structure when it was being formed. But it's not really interfering a lot with the light going through. And so we see the teeth usually as translucent. When pores grow light going in is deflected from the interface of the enamel to the pores, and this effect is even worse when there's air in here instead of water. If we have the tooth wet, we don't see the white spot, but if it's dry we see the white spot, because the air here inside has a different refractive index. Refractive index dependent on the speed of light moving in a medium, and it moves differently in air than it moves, for example, in water or in enamel. Enamel refractive index 1.62 Air rerfactive index is 1.0 and water is 1.33 The closer the refractive index of the medium to the original medium here is to enamel the less refraction, the less deviation of light we have Resin infiltrant has refractive index of 1.46  we see that here the light is still, maybe a little deviated, but not as much as with water and with air, and that we then do have the light going through rather than coming back to us, so that we do not see this as a white spot anymore. ○ the porosities are filled with resin. Now, okay, this is not remineralization. There are no minerals in this. This is just resin based material. Sometimes retraction cords are used to push the gingiva away Cord changes distance between the lesion adn gingiva Then place barrier material Ccover with barrier material ○ Etch with HCL 2min ○ Rinse it away ○ Check if lesions are less prominent (means pores are opened sufficiently) Etch multiple times to get this effect Pores with air filled not water filled ○ Put infltrant in (flows easily on its own) ○ Light cure 40s ○ Second layer to smooth out ○ Light cure 40 s ○ Polish ○ Remove barrier Bleaching through resin infiltrant can affect ○ Lower concentration at home has a 10% carbamide peroxide which will break down into around 3.3% of hydrogen peroxide and the rest. Urea. Contact time of home bleaching is longer ○ Clear soft bleaching tray and place overnight ○ Home bleaching for 2-3 weeks every night ○ Time of bleaching too short to go through resin layer for in office bleaching Resin infiltration code is D2990 Brackets ○ Don't need to wait until the brackets come off Resin infiltration can be used for flurosis No shade match for resin bc it fills porosites and does not go over D1 can be included as long as it is not cavitated Microetch removes aprismatic enamel and exposes prismatic enamel