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Prepared by Dr Lea Foster

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Dental Caries is a disease of the hard tissues, characterized by the decalcification of the inorganic portions of the tooth. Loss of the mineral content is the followed by breakdown of the organic matrix. This destructive process results from the metabolism of carbohydrates by microorganisms.

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caries (ker´ēz), n in dentistry, the decay of a tooth. Colloquial term is cavity. Advanced caries. caries, arrested, n the state existing when the progress of the decay process has halted. It is noted by its dark staining without any breakdown of tooth tissues.Caries Assessment Tool (CAT), n.pr an analysis that examines the risk factors for the development of dental caries in infants and young children. Risk factors such as the environment, family history, and general health can be identified early, thereby reducing a patient's risk for developing dental caries and other diseases of the teeth and gingival tissues.caries, baby bottle, n See caries, early childhood (EEC).caries, cemental (root surface), n the decay of the

caries, gross, n a form of caries with advanced dental decay that is easily seen clinically.caries, healed, n See caries, arrested.caries, incipient, n a decayed part of a tooth in which the lesion is just coming into existence.caries, nursing, n See caries, early childhood (EEC).caries, pit-and-fissure, n See cavity, pit and fissure. See also sealant, enamel.caries, plaque-related, n the caries associated with plaque formation. Most commonly located in the pits and fissures of the teeth, especially the molar and premolar teeth, and along the gingival tissue and also the margins associated with dental restorations.caries, proximal, n decay occurring in the mesial or , ( ), y

cementum that occurs as a result of gingival recession and exposure of the root surface. See also caries, cervical (root surface).caries, cervical (root surface), n the decay that appears on the root at the cementoenamel junction or the neck as a result of gingival recession and exposure of the root surface. See also caries, cemental (root surface).caries, chronic, n a form of caries that occurs over time and demands regular dental intervention.caries, compound, n a type of caries that affects two or more surfaces of a tooth.caries, early childhood (EEC), n a form of severe dental decay occurring in young children that is caused by long and frequent exposure to liquids that are high in sugar, such as milk or juice. Because this form can damage the underlying bone structure, it may affect the development of permanent teeth.caries, enamel, n the decay that occurs in the enamel of a tooth because of a fissure or the collection of bacterial plaque. It appears first as white spots, which later darken to brown.

distal surface of a tooth.caries, rampant, n a suddenly appearing, widespread, rapidly progressing type of caries.caries, recurrent, n the extension of the carious process beyond the margin of a restoration. Also called secondary caries.caries, residual, n (residual carious dentin), the decayed material left in a prepared cavity and over which a restoration is placed.caries, root, n tooth decay occurring on a portion of the root that is exposed. Root caries. caries, senile n older term for the decay noted particularly in the elderly when supporting tissues have receded; occurs in cementum, usually on proximal surfaces of the teeth.caries, smooth surface, n the decay that occurs on the smooth surfaces of the tooth. See also caries, proximal dental and S. mutans. 3

CavityG.V. Black

Class I

CariesMount and Hume

Site:1 – Pit and fissure2 Approximal Class II

Class IIIClass IVClass V

2 - Approximal3 – Close to Gingival Margin

Size:MinimumModerateLargeExtensive 4

Class I, II, III, IV,V

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Class I – Originating in occlusal or buccalpits and fissures

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Class II – Interproximallesions – posterior teeth

Mesio-occlusal (MO)Disto-occlusal (DO)Mesio-occluso-distal (MOD)

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Class III –Interproximallesions –anterior teeth

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Class IV –interproximal anterior lesions involving the incisal edge

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A Bit of EverythingA Bit of Everything

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Pits and fissuresInterproximalsInterproximalsCervical marginsRoot surfacesRestoration margins

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A multi factorial A multi-factorial disease

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1. Enamel lesion- no cavity

2. Enamel lesion –cavity

3 Dentine lesion

Pit and FissureApproximalCervical marginRoot cariesS h f ( l 3. Dentine lesion

4. Dentine lesion with pulpal involvement

Smooth surface (early childhood/ baby bottle)RecurrentIatrogenicArrested

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History, Clinical Examination and Diagnostic aidsand Diagnostic aids

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Pre-disposing factorsDietFluid consumptionOral Hygiene habitsLevel of understanding and motivationDrug therapy impacting on saliva flowMouth-breathing

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Visual diagnostic features

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Deep retentive fissure pattern

Dark staining

White enamel

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Visual diagnostic features

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Non-cavitated• Shadowing• White ‘reverse caries’

C it t d i l i d tiCavitated – involving dentine• Shadowing and reverse caries indicate the

extent of the lesion

Cavitated – involving pulp

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Visual Diagnostic Features

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White spot lesion –not cavitated

Cavitated –involving dentine

Extensive

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Visual diagnostic features

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May occur in conjunction with TBA/abfraction

lesions

Occurs below the level of the enamel

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Includes Early Childhood caries(AKA Baby bottle caries)Visual diagnostic features

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Affects primary upper anterior

teeth

As well as primary lower

4’s and 5’s33 34

Secondary CariesVisual diagnostic featuresVisual diagnostic features

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Affecting the margins of restorations

May occur as a fuction of failure of the restorative material

Or as a function of microleakage

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Damage caused by the operator in the process of treating other teeth

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Damage to the approximal surface of adjacent teeth during tooth preparation and the finishing of restorations can result in the formation of cariesVarious studies show the incidence of this type of damage being from 50 -90% (1-3)

Scratching/pitting of the surface of sound enamel at the contact Scratching/pitting of the surface of sound enamel at the contact will remove the fluoridated surface layer and leave a rough surface which retains plaqueFlattening of the adjacent tooth results in the creation of flat contacts – makes it impossible to restore a natural rounded contact area between teethLeads to food traps – new caries, recurrent caries in restorations & periodontal pocket formation

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How does caries feel to the probe?

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Probe may not stick –or there may be a catch

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Probe may or may not catch.

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Surface feels sound

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Chalky feelPitting of the enamel surface.Pits within the white spot lesion

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Loss of overlying enamelDentine is soft – probe tip can penetrate

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Lesions are dark and feel hard or very ‘leathery’P b ti d t t t il if t llProbe tip does not penetrate easily if at all

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Not able to reach these with a probeOther diagnostic aids?g

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Rather obvious – no mystery here

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RadiographyLaser induced fluorescenceFibreoptic transillumination

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DescriptiveIncipientModerate

Stages12ORModerate

AdvancedSevere

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OR

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IncipentUp to half way through enamel

ModerateMore than halfway through enamel up to DEJ

Stage 1 Stage 1

Stage 2

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AdvancedFrom DEJ up to halfway through dentine

SevereMore than halfway through dentiney g

Stage 3

Stage 4

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Diagnosis of interproximal caries

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Laser- Stimulated Fluorescence

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The tooth surface is illuminated by a red light(excitation wavelength at 655 nm, modulated) that is produced by a laser diode and transmitted by an optical fiber.The laser induces fluorescence in mineralized tooth tissues, at a greater intensity in carious than in sound tooth tissuesTh i d b i l fib h di d i h l Then transmitted by an optical fiber to a photodiode with a long pass filter (wavelength >680 nm) in the detection deviceNumerical value of the digital display (in units related to a calibration standard) correlates quantitatively with the intensity of the fluorescence detected and thus indicates the extent of caries (colour graphics have been developed also)Lussi et al. (5) suggested that a score of 20 indicates caries extending into the dentin, and this reference has been used in other studies using DIAGNOdent (6,7)

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General decline in the prevalence of dental caries owing to the increased use of fluoride in the form of fluoridated water, fluoride toothpaste, and fluoride agents that are applied professionally or at home.Pattern of caries has also changed: the proportion of caries found in occlusal fissures has risen and pit and fissure caries are now perceived as the predominant typesmain reason for these changes is that fluoride inhibits enamel breakdown, so caries reaching the dentin tend to progress beneath a clinically intact enamel surfacedifficulty in visually inspecting the fissures of molars - such cases of occlusal dentinal caries, known as “hidden caries”, are commonly missed on visual examination and carious cavities are seen only at a late stage of disease.Is regarded as a useful adjunct to other forms of conventional diagnosisReproducible and therefore excellent aid to monitor changes

(4,8,9,10,11)

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Transillumination

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CURING LIGHTUseful in the anterior regionCan help to visualize the l l f level of penetration of caries into dentine

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All our diagnostic techniques are aimed at early detectionare aimed at early detection

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Accurate diagnosis is the first step in determining the proper course of action

Preventive and minimum intervention strategies can then be applied

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Is active caries present

If so…..at what rate is it progressing

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the risk of recurrent caries increases

with marginal gap width

caries always progresses

rapidlyrestorations cure caries

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Prevention & remineralization

size and location of white spot lesions and

stained fissures

active and arrested

non-cavitatedenamel lesions

arrested non-

cavitatedlesions

within the outer third of dentin

slowly progressing

lesions within the outer third of dentin

rapidly progressing

lesions within the outer third of dentin

lesions in the inner

two thirds of dentin

secondary caries

adjacent to restorations

cavitatedlesions

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Intervention

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rapidly progressing

lesions within the outer third of dentin

lesions in the inner two thirds of dentin

secondary caries

adjacent to restorations

cavitated lesionsImmediate interventivetreatment

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Subsequent decisions about whether to place or replace restorations at other sites should be at other sites should be delayed until the most conservative options have been considered

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E0 – no caries, E1- outer enamel, E2 – Inner enamelD1 - outer 1/3 dentine, D2 – middle 1/3 dentine, D3 – inner 1/3 dentine

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1. Qvist, V., L. Johannessen, et al. (1992). "Progression of Approximal Caries in Relation to Iatrogenic Preparation Damage." Journal of Dental Research 71(7): 1370-1373

2. Medeiros, V. A. F. and R. P. Seddon (2000). "Iatrogenic damage to approximal surfaces in contact with Class II restorations." Journal of Dentistry 28(2): 103-110

3. Lussi, A. and M. Gygax "Iatrogenic damage to adjacent teeth during classical approximal box preparation." Journal of Dentistry 26(5-6): 435-441

4. Chu, C., E. Lo, et al. "Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques." Lasers in Medical Science

5. Lussi A, Megert B, Longbottom C, Reich E, Francescut P (2001) Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. Eur J Oral Sci 109:14–19. doi:10.1034/ j.1600- 722.2001.109001014.x

6. Reis A, Mendes FM, Angnes V, Angnes G, Grande RH, Loguercio AD (2006) Performance of methods of occlusal caries detection in permanent teeth under clinical and laboratory conditions. J Dent 34:89–96. doi:10.1016/j.jdent.2005.04.002y j j

7. Silva BB, Severo NB, Maltz M (2007) Validity of diode laser to monitor carious lesions in pits and fissures. J Dent 35:679–682. doi:10.1016/j.jdent.2007.05.005

8. Attrill DC, Ashley PF (2001) Occlusal caries detection in primary teeth: a comparison of DIAGNOdent with conventional methods. Br Dent J 190:440–443

9. Baelum V, Nyvad B, Gröndahl HG, Fejerskov O (2008) The foundations of good diagnostic practice. In: Fejerskov O, Kidd E (eds) Dental caries. The disease and its clinical management, 2nd edn. Blackwell Munksgaard, Oxford, pp 104–118

10. Jonas A. Rodrigues & Michele B. Diniz & Érika B. Josgrilberg & Rita C. L. Cordeiro - In vitro comparison of laser fluorescence performance with visual examination for detection of occlusal caries in permanent and primary molars Lasers Med Sci (2009) 24:501–506 DOI 10.1007/s10103-008-0552-4

11. Hibst, R., R. Paulus, et al. (2001). "Detection of Occlusal Caries by Laser Fluorescence: Basic and Clinical Investigations." Medical Laser Application 16(3): 205-213

12. Small Cavities, Big Problems - Diagnosis and Treatment of Non-Cavitated Carious Lesions http://www.dentalcompare.com/dentist_profile.asp?expertid=274&headerid=36

13. Anusavice, K. (1995). "Treatment regimens in preventive and restorative dentistry." J Am Dent Assoc 126(6): 727-74314. Evans, R. W., A. Pakdaman, et al. (2008). The Caries Management System: an evidence-based preventive strategy for

dental practitioners. Application for adults. Australian Dental Journal, Blackwell Publishing Limited. 53: 83-92.15. Anusavice, K. (2001). "Clinical decision-making for coronal caries management in the permanent dentition." J Dent Educ.

65(10): 1143-1146

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