MANAGEMENT OF DEEP CARIOUS LESIONS

1MANAGEMENT OF DEEP CARIESHow Deep Is a Deep Caries Lesion?

Deep caries lesions point toward the potential exposure of the pulp.

Lesions that penetrated to within three fourths of the entire dentin thickness or more as evaluated on x-rays.

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FACTORS INFLUENCING THE SUCCESS OF PULP THERAPY(Oper. Dent. 2002; 27: 2117 ; Dentin Caries,Progression & Management)334pain - not reported even when caries invades dentin except when deep lesions bring the bacterial infection close to the pulp.

Episodes of short-duration pain - occasionally during earlier stages of dentin caries. pain - stimulation of pulp tissue by movement of fluid through dentinal tubules.5When bacterial invasion of the dentin is close to the pulp, toxins and a few bacteria enter the pulp . Initial pulpal inflammation is evident clinically by production of sharp pains - lingering only a few seconds (10 seconds) in response to a thermal stimulus. A short, painful response to cold suggests reversible pulpitis .

6Reversible pulpitis - limited inflammation of the pulp - the tooth can recover if the caries producing the irritation is eliminated by timely operative treatment.

When the pulp becomes more severely inflamed, a thermal stimulus produces pain that continues after termination of the stimulus, typically longer than 10 seconds - irreversible pulpitis.

7 TYPES AND LAYERS OF DENTINAL CARIOUS LESIONS

TWO TYPES : ACUTE AND CHRONIC FIVE LAYERS OR ZONES

ZONES OF DECAY

8DECAYED ZONEDevoid of minerals

Collagen fibers have lost their cross striations

High concentration of micro-organisms

Clinically similar in acute & chronic lesionHas to be removed.

9SEPTIC ZONEHighest concentration of microorganisms

Collagen fibers have fewer cross striations

Dentinal tubules are widened

Softer in an acute lesion than in chronicHas to be removed.

10DEMINERALIZED ZONEDentin is only demineralized & dentinal matrix still intact

Destructive & repair activities takes place.

11TRANSPARENT ZONEArea of disturbed mineralization repair

Zone of dentinal sclerosis & calcific barrier

More pronounced in chronic decay

Extremely hard than normal dentin Should not be excavated.

12OPAQUE ZONETransparent zone

Characterized by intra-tubular fatty degenaration

Sclerosis of dentinal tubules

More pronounced in acute lesions

1314 Carious dentin has been identified by two layers

The outer carious layer is infected un-remineralizable with irreversible deteriorated collagen fibers, with no odontoblastic processes, insensitive and therefore, should be removed.

15The inner carious layer is un-infected, remineralizable with reversibly denatured collagen fibers, sensitive, and so should be preserved.

The dye stains only the infected outer carious dentin.

AFFECTED & INFECTED DENTIN

DEJPULPENAMELDENTIN16Infected dentinAffected dentinSoftened demineralized dentin teeming with bacteriaCollagen is irreversibly denaturedCannot remineralize

Soft necrotic tissue, followed by dry leathery dentin flakes away with an instrument Dyes: 1% Acid red in propylene glycol stains only irreversibly denatured collagenSoftened deminerlized dentin not yet invaded by bacteria

Collagen cross linking remains

Acts as a template for remineralization Softer than normal dentin, discoloured but does not flake easily

Does not stainEFFECT OF CARIES ON THE P-D ORGAN18TYPE OF DECAY19DURATION OF DECAY PROCESSACUTE DECAY

- more massive destruction of tooth structure

CHRONIC DECAY

Greater chances for repair

20DEPTH OF INVOLVEMENT 21NUMBER & PATHOGENECITY OF MICROORGANISMS22TOOTH RESISTANCE2324 EFFECTIVE DEPTH(RDT) Is the area of minimum thickness of sound dentin separating the pulpal tissue from carious lesionsImportance of Remaining Dentin Thickness (RDT)25Dentin is the best insulator for the pulp. Therefore, it is better to conserve remaining sound tooth structure rather than replace lost tooth structure with an artificial material.

RDT , from the depth of the cavity prep. to the pulp is the single most imp. factor in deciding the best method of pulp protection.Role of RDT26RDTEffect of toxic substances on pulp0.5mm25%1 mm10%2 mmminimal or nil27CARIES EXCAVATION METHODSCATEGORYMETHODMechanical RotaryHandpiece + bursMechanical Non Rotary

Hand excavators, Air abrasion. Air polishing. Ultrasonic. Sono abrasionChemo mechanicalCaridex Carisol, EnzymesPhotoablationLasersExcavators, handpieces and burs28 For caries removal a round bur is recommended with diameter corresponding to size of carious lesion. Larger burs recommended.

Water irrigation is optional because low speed (700-800 Rpm) is employed.

29 Slow-speed bur or hand excavator can be used for carious dentine excavation. As the hand excavator will remove softened tissue with more sensitive tactile feedback than a bur, this method is the more self-limiting of the two. Polymeric Burs30 Consists of a polymer (PEKK- Polyether- ketone-Ketone) with hardness of 50 KHN, which was higher than hardness of carious dentin(0-30KHN) but lower than sound dentin (70-90KHN).Ceramic burs31 The cera burs are all ceramic round burs made of alumina-yttria stabilised zirconia and are available in different sizes.

CHEmO-MECHANICAL METHODCaridex sodium hypochlorite solution buffered with an amino acid containing mixture of aminobutyric acid, sodium chloride and sodium hydroxide.

Carisolv - consists of two carboxymethylcellulose based gels: a red gel containing 0.1 M amino acids (glutamic acid, leucine and lysine), NaCl, NaOH, erythrosine (added in order to make the gel visible during use); and a second containing sodium hypochlorite (NaOCl 0.5% w/v)

3233The two are thoroughly mixed in equal parts at room temperature before use and then applied, using the hand instrument, onto the exposed carious dentine and left for 60 seconds prior to gently but firmly abrading away the softened dentine to leave a hard, caries-free cavity.

cutting tips of the hand instruments

34Caries excavation by sono-abrasion is based on the useof cutting tips coupled to high-frequency, sonic, air-scaler handpieces under water cooling. A maximum 2-N torque force should be applied.

SONO ABRASIONAir abrasion35Air abrasion system uses 27um diameter alumina particles to remove tooth stains and to prepare shallow cavities.Cutting efficiency depends on type and size of abrasive particles as well as particle speed and angle of surface approachFluorescence aided caries excavation (FACE)36 A slow speed hand piece with a fiber optic violet light source (370-420 nm) allows the operator to use a 530 nm yellow glass filter, areas exhibiting orange red fluorescence can be identified and removed with a bur.Lasers37- Erbium laser.- wavelengths( 2.94um and 2.78um).THANK YOU3839

TYPES OF PULP THERAPY40FACTORS AFFECTING PULP THERAPY

(BDJ , Dec 2001,Vol191,No.11)41AGE (BDJ , Dec 2001,Vol 191,No.11)42FACTORS(BDJ , Dec 2001,Vol 191,No.11)

43A more favourable prognosis for the pulp following direct pulp capping may be expected if:

44The tooth has been asymptomatic (no spontaneous pain, normal response to thermal testing, and is vital) before the operative procedure.

The exposure is small, less than 0.5 mm in diameter.

The hemorrhage from the exposure site is easily controlled.45The exposure occurred in a clean, uncontaminated field (such as provided by rubber dam isolation).

The exposure is relatively atraumatic and little desiccation of the tooth occurred, with no evidence of aspiration of blood into the dentin (dentin blushing).

Calcium hydroxide Ca(OH)2:

46Most common pulp-capping agent

Antibacterial and disinfects the superficial pulp

High pH (about 12.5) How does Ca(OH)2 work??

47Liquefaction necrosis of the superficial pulp

Neutralization of toxicity in deeper layers

Coagulative necrosisIrritation of adjacent pulp

Minor inflammation response Hard tissue barrier

48Dentin bridges beneath calcium hydroxide pulp caps contain tunnel defects, therefore an additional base material is necessary to seal the exposed pulp from the external environment.

Calcium hydroxide materials tend to soften, disintegrate, and dissolve over time.

Direct Pulp CappingTreatment of an exposed vital pulp by sealing the pulpal wound with a dental material placed directly on a mechanical or traumatic exposure to facilitate the formation of reparative dentin and maintenance of the vital pulp.

Ingle 2008Definitions

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50Calcium hydroxide promotes reparative dentin bridges over any area of frank pulpal exposure.

Such repair usually occurs in 6 to 8 weeks and may be evident radiographically in 10 to 12 weeks.

Success may be improved with a resin-modified, glass-ionomer liner placed over the calcium hydroxide.51Why?

Conservative treatment

Saves the tooth and Preserves vitality INDICATEDExposure is less than 0.5 mm in diameterExposure is in clean, uncontaminated fieldA pin point exposure having sound dentin at the periphery, with no hemorrhage.The bleeding coagulates immediately.Exposure was not made during excavation of infected dentin.

52DIRECT PULP CAPPINGOBJECTIVES

Treat the damaged pulp tissue

Aid in formation of secondary dentin

5354History- No recurring or spontaneous pain. No swelling.Preoperative assessment-Normal vitality tests. Not tender to percussion. No swelling. No radiographic evidence of periradicular pathology. Young patient. Radiographically obvious pulp chamber and root canal.Clinical findings- Pink pulp Bleed if touched but not excessively.DIRECT PULP CAPPING(Endodontics , 3rd edi.,C Stock ,R walker )ISOLATION Rubber dam

Cavity Caries freePulp wound exluding blood or serum

55DIRECT PULP CAPPINGWashing of exposed pulp Sterile water or saline

Achieve haemostasis

Profuse bleeding > 5 min Severe pulp inflammation

(Endodontics , 3rd edi.,C Stock ,R walker )5657

sterile cotton pellet to control bleeding Mix capping agent 58

Apply to exposure site

Base/liner then restore DIRECT PULP CAPPING(Endodontics , 3rd edi.,C Stock ,R walker )Permanent ,well adapted restorative material is then placed.

If composite is used Resin modified GIC as a base is applied.

5911/12/201360Healing with calcium hydroxide pulpal tissue is disinfected and necrosed by the calcium hydroxide.Dentin bridge formation below the necrotic zone.

11/12/201361 Other pulp capping agentsMineral Trioxide Aggregate or MTA 62Composition:

Tricalcium silicate

Tricalcium aluminate

Tricalcium oxide

Silicate oxide

Mineral Trioxide Aggregate or MTA 63Composition:

Tricalcium silicate

Tricalcium aluminate

Tricalcium oxide

Silicate oxide

Properties: 64Low or no solubility

PH value 10.2 after mixing and rises to 12.5 after 3 hours

Antibacterial effect

Induces pulpal cell proliferation

Stimulation of mineralized tissue formation

(Mineral Trioxide Aggregate: A Comprehensive LiteratureReviewPart I: Chemical, Physical, and Antibacteria lProperties) (Direct pulp capping with mineral trioxide aggregateJ Am Dent Assoc 2008;139;305-315) (MTA AND CALCIUM HYDROXIDE FOR PULP CAPPINGJ Appl Oral Sci 2005; 13(2): 126-30) Properties:

It is defined as a procedure in which the material is placed on a thin partition of remaining carious dentin that, if removed might expose the pulp.Ingle 6th edition

The deliberate retention of softened dentin near the tooth pulp and medication of the remaining dentin with calcium hydroxide.Sturdevant 2007INDIRECT PULP CAPPING6566

67In a tooth with a deep carious lesion, no history of spontaneous pain, normal responses to thermal stimuli, and a vital pulp (shown by electric testing), a deliberate, incomplete caries excavation may be indicated. This procedure is termed indirect pulp capping and is characterized by placement of a thin layer of calcium hydroxide on the questionable dentin remaining over the pulp.INDIRECT PULP CAPPINGApplication of an agent to a thin layer of dentin/remaining caries to maintain the vitality of the pulp.

Indicated when a deep carious lesion is encroaching on ,but not actually into the pulp.

68INDIRECT PULP CAPPING(Endodontics , 3rd edi.,C Stock ,R walker )OBJECTIVES :

to prevent pulp exposure. To aid pulpal recovery by medication.To Maintain a normal & healthy pulp.69IndicatedNo history of spontaneous pain.Normal response to vitality tests.The pain does not continue after the removal of a hot or cold stimuli.No periradicular changes should be evident.

70INDIRECT PULP CAPPING(Endodontics , 3rd edi.,C Stock ,R walker )Excavation of all carious dentin might risk a traumatic breach in the pulp .

Some of carious dentin over the pulp is LEFT

71INDIRECT PULP CAPPING(Endodontics , 3rd edi.,C Stock ,R walker)Remaining carious dentin is dressed with Ca (OH)2To kill residual bacteriaEncourage remineralization

Followed by application of Zinc Oxide EugenolPrevent bacterial leakage

72INDIRECT PULP CAPPING

73PulpotomyDefinition

Pulpotomy is defined as the surgical removal of infected coronal pulp and its objectives are preservation of the radicular pulp vitality and relief of pain.Indications In the treatment of pulpally involved permanent teeth with open apices and vital pulp.75Administer local anasthesia

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FINAL RESTORATION

The quality of the final restoration is critical to the long-term maintenance of pulp vitality and sustained normal function of the pulp-capped or pulpotomized tooth.

The more conservative the restorative treatment, preserving the remaining healthy tooth structure, the higher the probability of pulp survival.

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Keys to clinical success with pulp capping: A review of the literature. Operative dentistry 2009,34-5,615-625

Analysis of Pulpal Reactions to Restorative Procedures, Materials, Pulp Capping, and Future Therapies American dental journal 2002,vol 13 no 6 509-520

Ingles endodntics 6th edi.

Mc Donalds,DENTISTRY FOR CHILDHOOD & ADOLSCENT 8TH edi.

M.A. Marzouk: OPERATIVE DENTISTRY: A clinical guide to dental traumatology, Louis Bermann, 1st edition.

REFERENCES80