treatment of deep caries General and local treatment

treatment of deep caries. General and local treatment of plural caries. Medicinal facilities and physical methods in complex therapy of dental caries. Therapeutic dentistry department Lecturer: Yavors’ka-Skrabut I. M.

RATIONALE ¡ Incipient enamel caries is caused by specific microorganisms l Streptoccus mutans plus sucrose reduces the p. H in the plaque to a critical level of 5. 0 -5. 5, which can overcome the buffering capacity of saliva and result in demineralization of enamel

RATIONALE ¡ Incipient enamel caries is caused by specific microorganisms l l High bacterial counts are the result of the patient’s diet, and be reduced by altering the diet. A high Strep. mutans count generally indicates large and/or frequent ingestion of sucrose.

RATIONALE ¡ Incipient enamel caries is caused by specific microorganisms l l A high lactobacillus count generally indicates a high proportion of carbohydrates in the patient’s diet. A normal saliva flow rate (1 -2 ml/minute) and buffering capacity (5 -7 p. H) discourages demineralization and encourages remineralization; a low flow rate (0. 7 ml/minute or less) and buffering capacity (<4 p. H) will encourage demineralization and caries activity

RATIONALE A diet diary can indicate dietary intake, and dietary counseling may result in an altered diet that will decrease caries activity. ¡ Lactobacillus counts are significantly higher in patients with open caries lesions; restoration of these lesions will produce a dramatic drop in the count. ¡

RATIONALE Caries begins as a subsurface lesion which can be remineralized as long as the surface remains intact. ¡ Supersaturated salivary calcium and phosphates in the presence of fluoride can slowly remineralize demineralized enamel. ¡ Remineralized enamel is more resistant to subsequent demineralization than original intact enamel ¡

RATIONALE ¡ The effect of oral hygiene/plaque control on caries activity is controversial. Oral hygiene is much less important than diet, but complete plaque removal daily will reduce caries on exposed tooth surface

RATIONALE ¡ Various anti-microbial mouthwashes will reduce certain cariogenic microorganisms, but may also interfere with the normal oral flora and allow overgrowth of undesirable organisms. For example, Chlorohexadine Gluconate mouthwashes may reduce Strep. Mutans counts, but will not reach organisms in deep lesions. Deep lesions should therefore be eliminated with caries control restorations before instituting anti-microbial therapy.

RATIONALE ¡ Fluoride applied in various ways (systemic, clinical and home) decreases cariogenic organisms and promotes remineralization.

RATIONALE ¡ Vigorous treatment to a testable endpoint (the 4 lab tests of saliva at recall) is preferable to vague, ineffective treatment ad infinitum. Patient are very discouraged when they follow the dentist’s advice and caries activity still continues.

RATIONALE ¡ Not all patients require the same treatment – some will be overtreated and some under-treated unless proper diagnosis and treatment is done. It is important to determine which patients have the signs, symptoms and history that are indications of high caries activity and need to be placed on a Caries Risk Management Program.

Treatment planning for restorative dentistry (high caries risk ) ¡ The restorative treatment must be coordinated with all the means utilized in the Caries Risk Management Program (diet, oral hygiene, fluoride, antimicrobials, saliva stimulation, etc. )

Treatment planning for restorative dentistry ( high caries risk ) ¡ Early elimination of all dentinal caries is very important in eliminating the source of Strep. Mutans. Caries control restorations may be necessary to accomplish this quickly.

Treatment planning for restorative dentistry ( high caries risk ) Types of lesions and choice of treatment: ¡ Routine use should be made of fluoride application to cavity preparations and fluoride-releasing liners, bases and restorative materials. ¡

Types of lesions and choice of treatment ( high caries risk ) Smooth surface incipient caries; ¡ Sticky pits and fissures with incipient caries ¡ Small and moderate lesions ¡ Deep lesions ¡ Root caries ¡

Types of lesions and choice of treatment ( high caries risk ) ¡ Smooth surface incipient caries: l ¡ Reminerlize with clinical topical fluoride applications and home application of fluoride by various means ; toothpaste, rinses, brush-on gels, custom trayapplied gels, ect. Sticky pits and fissures: l Pit and fissure sealants

Types of lesions and choice of treatment ( high caries risk ) ¡ Sticky pits and fissures with incipient caries l l ¡ Preventive resin/sealants (Remove caries, place composite in the cavity and cover all with sealant) Definitive amalgam restorations Small and moderate lesions l Definitive amalgam, composite or glass ionomer restorations

Types of lesions and choice of treatment ( high caries risk ) ¡ Deep lesion: l ¡ Caries control restorations with Zn. Oeugenol, glass ionomer or amalgam, and the definitive resotrations after caries activity has decreased Root caries: l l Fluoride applications Glass ionomer restoration

Treatment planning for restorative dentistry ( high caries risk ) ¡ Routine use should be made of fluoride application to cavity preparations and fluoride releasing liners, bases and restorative materials

The indication for placing of patients on a Caries Risk Management Program

A previous history of caries, demonstrated by numerous restoration, especially with recurrent caries. ¡ Numerous large carious lesion, especially those with depth greater than width. ¡

Unpigmented demineralized areas on smooth surfaces, often on the lingual third. Lesions on the lingual surfaces indicate an even higher risk. ¡ Recent incidence of new lesions on recall examinations. ¡ Patients requiring extensive reconstructive procedure ¡

Patients (especially the elderly) with root caries. ¡ Patients that report a history of a physical condition, medical treatment (especially radiation therapy), medication and dietary changes that would influence saliva or oral flora ¡ History of continued high quantity intake of carbonated beverages ¡

¡ Patients with active caries-lesions that are unpigmented, of a soft consistency, moist, sensitive to Sweets, cold or excarvation, and with depth greater than width.

DX ACTIVE INACTIVE COLOR LIGHT DARK CONSISTENC Y MUSHY FIRM MOISTURE WET DRY SYMPTOM SENSITIVE NONE SHAPE DEPTH>WIDTH>DEPTH

Caries control restoration ¡ The goal is elimination of the source of cariogenic organisms by removal of caries from all deep lesions and placement of temporary restorations early in the treatment. This is very important in effecting reversal of the active caries process.

Caries Control Restoration ¡ Cavity preparation is done quickly without definitive cavity preparation. Undermined enamel be left to aid in retention of these treatment restorations, especially if restoratives are used that bond to tooth structure.

Caries Control Restoration ¡ Pulpal response to the restorative treatment can be observed and endodontic treatment instituted if necessary before planning definitive restoration.

Caries Control Restoration ¡ The restoration protects the pulp against further insult and promotes healing of the lesion by remineralization of affected dentin and stimulation of reparative dentin.

Caries Control Restoration ¡ Patient comfort and mastication are quickly improved by decreasing sensitivity from open cavities, food impaction, ect. Occlusal and proximal stability is maintained.

Caries Control Restoration ¡ Restorative materials used for caries control restoration. l Ca. OH is bacteriocidal and stimulates reparative dentin l Reinforced Zinc Oxide-eugenol is obtundant, reducing pain and sensitivity; it is bacteriocidal to organisms deep in the cavity, and it seals margins well for several months, preventing ingress of nutrients to the organisms. Strength is fair.

Caries Control Restoration ¡ Restorative materials used for caries control restoration. l Glass ionomer-bonds to tooth structure for improved retention, it release fluoride which reduces organisms and promotes remineralization, has good marginal seal, fair strength, and is esthetically pleasing. l Amalgam has excellent strength, maintains occlusal and proximal relationships, fair marginal seal, best for long term temporary

Caries Control Restoration ¡ ¡ Similar restorations can be used to quickly restore deep lesions for emergency patients when time is limited. Caries control restorations should be left in place until caries activity tests indicate a significant decrease in caries activity. Definitive restorations can then be placed with a promise of much greater longevity.

Caries Control Restoration ¡ Indirect pulp capping is often done in conjunction with caries control restorations. l l Pulp must show radiographic and clinical signs and symptoms of vitality. All caries is removed at the periphery, establishing a sound DEJ.

Caries Control Restoration

Caries Control Restoration ¡ Indirect pulp capping is often done in conjunction with caries control restorations. l All infected dentin is excavated with large round burs and excavators, being careful not to expose the pulp. Basic fuchsin effectively identifies infected dentin. l A small amount of firm caries (affected dentin) is left over sites of potential exposure.

Caries Control Restoration ¡ Indirect pulp capping is often done in conjunction with caries control restorations. l l Calcium hydroxide liner is placed in the deepest areas. The high p. H of the Ca. OH will neutralize acid, kill bacteria and stimulate formation of restorative dentin. The resin-forced ZOE, glass ionomer or amalgam restoration is placed

Caries Control Restoration ¡ Indirect pulp capping is often done in conjunction with caries control restorations. l After 6 -8 weeks the entire restoration is removed, any remaining caries is removed and a definitive restoration is planned.

Pit & Fissure Sealing Techniques

Glass ionomer sealants § § § § Chemical bond to enamel. Fluoride release. New GIC material- Fuji 7 high fluoride release (6 x more) than other restorative GICs. has good flow properties and flow well into pits/fissures. moisture tolerant. has a strong fused layer which is acid resistant & continues to offer protection to occlusal surface even when it appears “visually” lost due to wear. Restorative GICs tend not to be suited as fissure sealants as are thicker and do not flow well into narrow/deep pits & fissures

Glass ionomer sealants

Partially erupted teeth, Seal or wait until fully erupted? For composite resin: If seal whilst partially erupted: § Risk of sealant failure § Risk of caries development For Glass Ionomer Fissure sealant: § can be placed in situations where tooth can be partially erupted because of its ability to be placed in conditions where moisture control can not be optimally maintained.

Diagnosis of pit/fissure caries - can be very difficult! 3 Possibilities: 1. No caries 2. Definite caries 3. Questionable caries

Is there caries or is this only stain?

Management of Questionable pit/fissure early caries § Monitor tooth surface over period of time in conjunction with other caries preventive measures. § Mechanically open up fissures with a bur/air abrasion and check if carious (invasive? ) Fissure seal with fissure sealant. §

Moisture control § § Rubber dam § single or multiple isolation Relative isolation with cotton roll

Fissure exploration Bur tip should be as fine as possible. L 10 L 20

Fissure exploration Place bur in central fossa of occlusal fissure.

Upright bur so that it is in the long axis of the tooth; however, bur can be leant towards the § ‘direction of travel’ movement, away from the tip. Depth is determined by: § depth of staining present § what is required to alter the anatomy of the fissure so that the sealant can flow to its full depth (approx 0. 5 mm). § § Avoid cuspal inclines. Note that the depth may therefore vary.

Demonstrates initial investigation to distal part of occlusal fissure system

Initial investigation into complete fissure system

Completed fissure investigation 1. Wash (5 seconds) 2. Dry with mild air (10 seconds)

Completed fissure investigation (cont. ) Visually check the prepared fissure system: • Any staining? • Is it clean? (Note that the depth may vary. )

Fissure sealant materials § Select appropriate material to complete the fissure sealant. You can use: • resin system • Glass Ionomer Cement (G. I. C) system, • Resin Modified Glass Ionomer Cement (RMGIC)

Application of etchant Apply etchant to fissure system for 15 seconds.

Wash thoroughly for minimum 20 seconds to remove etchant.

Dry thoroughly. Note that natural tooth should have a frosty appearance.

Applying sealant Step 1 § § Spread sealant evenly. One can use applicator or micro-brush, or sealant can be applied directly to surface. Avoid porosity (bubbles). (DO NOT blow air to spread the sealant. )

Applying sealant Step 2 § Note that the occlusal fissure system is completely covered with resin material but does not extend up to the cusps.

Light cure resin material for 20 seconds.

Checking the sealant § Using explorer: § ensure material is completely cured § check margins § ensure material is bonded to enamel.

Composite resin finishing point

Treatment of dental caries by: AMALGAM. Properties, indications, inserting, carving, polishing.

AMALGAM ¡ Amalgam is the most widly used permanent filling in dentistry. It is prepared by mixing the alloy with mercury. ¡ The reaction between mercury and alloy is termed an amalgamation reaction. It results in the formation of a hard restorative material of silvery – grey appearance ¡

Amalgam Use and Benefits ¡ ¡ Dental amalgam, in widespread use for over 150 years, is one of the oldest materials used in oral health care. Its use extends beyond that of most drugs, and is predated in dentistry only by the use of gold. Dental amalgam is the end result of mixing approximately equal parts of elemental liquid mercury (43 to 54%) and an alloy powder (57 to 46%) composed of silver, tin, copper, and sometimes smaller amounts of zinc, palladium, or indium. ¡

Amalgam q q MERCURY (Hg) – is a liquid at room temperature and it is able to form a workable mass when mixed with the alloy. The reaction between mercury and alloy is termed an amalgamation reaction. Dental amalgam has been used for many years with a large measure of success. It is the most widely used of all available filling materials.

Composition ¡ The composition of the alloy powder particles varies from one product to another. ¡ Composition of CONVENTIONAL AMALGAM ALLOY: Metal: Weight: Silver (Ag) . . . 65% min. Tin (Sn) . . . . 29% max. Copper (Cu). . . . 6% max. Zinc (Zn) . . . . 2% max. Mercury (Hg). . . . 3% max.

Composition ¡ 1. Silver - Increases strength, expansion and reactivity. Decreases creep. Corrosion products are Ag. Cl and Ag. S. ¡ 2. Tin - Increases reactivity and corrosion. Decreases strength and hardness. Corrosion products are Sn. O, Sn. Cl, and Sn. S. ¡ 3. Copper - Increases strength, expansion and hardness. Decreases creep. Corrosion products are Cu. O and Cu. S.

Composition ¡ 4. Zinc - Increases plasticity, strength and the Hg: alloy ratio. Decreases creep. Causes secondary expansion. Corrosion products are Zn. Cl and Zn. O. ¡ 5. Mercury - Wets the alloy particles. Decreases strength if in excess amounts. Implicated in toxic and allergic reactions.

Effects on properties of an amalgam restoration imparted by ingredients. PROPERTY INGREDIENT Silver Tin Copper Zinc Strength Increases Durability Increases Hardness Increases Expansion Increases Decreases Increases Flow Decreases Increases Decreases Color Imparts Setting time Decreases Increases Workability Increases Cleanliness Increases Decreases

Amalgam The role of zinc (Zn) : is as a SCAVENGER during the production of the alloy. The alloy is formed by melting all the constituent metals together. ¡ ¡ ¡ There are tendency for oxidation to occur. OXIDATION of tin (Sn), copper (Cu) or silver would seriously affect the properties of the alloy and amalgam. ¡ Zinc reacts rapidly and preferentially with the available oxygen, forming a slag of zinc oxide (Zn. O) which is easily removed. ¡ Many alloys contain no zinc. They are described as ZINC- FREE ALLOYS.

Amalgam: properties ¡ ¡ ¡ 1. DIMENSIONAL CHANGES 2. STRENGTH 3. PLASTIC DEFORMATION (CREEP) 4. CORROSION 5. THERMAL PROPERTIES 6. BIOLOGICAL PROPERTIES

1. DIMENSIONAL CHANGES ¡ A large contraction would result in a marginal gap down which fluids could penetrate. ¡ A large expansion would result in the protrusion of the filling from the cavity. Zinc reacts readily with water producing hydrogen: Zn + H 2 O –––––– Zn. O + H 2 The liberation of hydrogen (H 2) causes a considerable expansion. ¡

2. STRENGTH ¡ The strength of dental amalgam is developed slowly. It may take up to 24 hours to reach a reasonably high value and continues to increase slightly for some time after that. ¡ 15 – 20 minutes after placing the filling , the AM is relatively weak. It is necessary, to instruct patients not to apply undue stress to their freshly placed AM fillings. ¡ There is good correlation between strength and mercury content. Optimum properties are produced for amalgams containing 44 -48% mercury. ¡

3. PLASTIC DEFORMATION (CREEP) ¡ Amalgam undergoes a certain amount of plastic deformation or creep when subjected to dynamic intra-oral stresses. ¡ The gamma 2 phase of AM is responsible for the relatively high values of creep. ¡ The copper- enriched amalgams, which contain little or no gamma 2 in the set material, have significantly lower creep values ¡ Gamma 2 phase is responsible for high creep.

4. CORROSION ¡ Corrosion is a matter which may significantly affect the structure and machanical properties. The heterogeneous, multiphase structure of AM makes it prone to corrosion. ¡ The gamma 2 phase of a conventional AM is the most electrochemically reactive and readily forms the anode in an electrolytic cell. The rate of corrosion is accelerated if the AM filling contacts a gold restoration. ¡ ¡ Smooth surfaces are less prone to concentration cell corrosion.

5. THERMAL PROPERTIES AM has a relatively high value of thermal diffusivity Dentine is replaced by a good thermal conductor. ¡ The coefficient of thermal expansion value for AM is about three times greater than that for dentine. ¡ ¡ This results in considerably more expansion and contraction in the restoration than in the surrounding tooth when a patient takes hot or cold food or drink. ¡ Thermal expansion may cause microleakage around the fillings since is no adhesion between AM and tooth substance. Microleakage plays an important part in initiating such lessions. ¡

6. BIOLOGICAL PROPERTIES ¡ ¡ ¡ Certain mercury compounds are known to have a harmfull effect on the central nervous system. Some studies have shown a higher concentration of mercury in the blood and urine of patients with AM fillings than those without. Another potential problem concerns allergic reactions, usually manifested as a contact dermatitis. Mercury or freshly mixed AM should never be touched by hand. Mercury is readily absorbed by the skin.

Usage and preparation of amalgam ¡ The dental specialist has the direct responsibility for the correct preparation and use of amalgam. ¡ Incorrect use may produce a faulty restoration that can cause or contribute to the loss of a tooth. ¡ Therefore, the dental specialist must use extreme care in preparing a good mix of amalgam that will provide the best qualities obtainable from the alloy.

MANIPULATIVE VARIABLES The manipulating of AM involves the following sequence of events: ¡ ¡ ¡ 1. Proportioning and dispensing 2. Trituration 3 Condensation 4. Carving 5. Polishing

1. PROPORTIONING AND DISPENSING ¡ Alloy/mercury ratios vary between 5: 8 and 10: 8. ¡ Those mixes containing greater quantities of mercury are „wetter“ and are generally used with hand mixing. ¡ Those mixes containing smaller quantities of mercury are „drier“ and are generally used with mechanical mixing. ¡ Spherical particle alloys, for example , require less mercury to produce a workable mix.

1. PROPORTIONING AND DISPENSING ¡ ¡ For optimum properties, the final set amalgam should contain less than 50% mercury. The optimal final mercury content ranges from an average of 45% for lathe-cut materials to an average of 40% for spherical materials.

2. TRITURATION ¡ The mixing or trituration of AM may be carried out by hand or in an electrically powdered machine which vibrates a capsule containing the mercury and alloy. ¡ Trituration by hand is not extensively practised in developed countries nowadays. Mechanical mixing is far more widely used - amalgamator. Trituration times 5 - 20 seconds are normal. ¡

2. TRITURATION The advantages of mechanical trituration are as follows: ¡ 1. A uniform and reproducible mix is produced. ¡ 2. A shorter trituration time can be used. ¡ 3. A greater alloy/mercury ratio can be used. Amalgamator

3. CONDENSATION ¡ Material is condensed into the prepared cavity using a flat-ended, steel hand instrument called an amalgam condenser. The technique chosen for condensation must ensure the following. ¡ 1. Adequate adaptation of the material to all parts of the cavity base and walls. ¡ 2. Good bonding between the incremental layers of amalgam ¡ 3. Optimal mechanical properties in the set amalgam by minimizing porosity and achieving a final mercury content of 44 -48%.

3. CONDENSATION ¡ There should be a minimal time delay between trituration and condensation. ¡ If condensation is commended too late, the amalgam will have achieved a certain degree of set and adaptation, and final mechanical properties are all affected. ¡ There is a good correlation between the quality of an AM restoration and the energy expended by the operator who condenses it. It needs to use a high condensating force. Lower forces are required to condense spherical particle amalgams than lathe -cut materials. ¡ ¡

Condensing instruments ¡ Amalgam carriers and condensers are used for this purpose.

4. CARVING ¡ Soon after condensing the AM, the surface layer , which is rich in mercury, is carved away with a sharp instrument. ¡ If carving is delayed too long the material may become too hard to carve and there is a danger of chipping at the margins.

4. CARVING ¡ Amalgam carvers

5. POLISHING ¡ Polishing is carried out in order to achieve a lustrous surface having a more acceptable appearance and better corrosion resistance. ¡ The fillings should not be polished untill the material has achieved a certain level of mechanical strength, otherwisw there is a danger of fracture , particularly at the margins. Many products require a delay of 24 hours between placing and polishing. ¡

5. POLISHING ¡ Polishing kits

¡ Polishers Black Dark purple Green

Amalgam indications ¡ ¡ ¡ ¡ In primary and permanent dentition In stress bearing areas of the mouth Small to moderate - sized cavities in the posterior teeth As a foundation to crowns When oral hygiene is bad When moisture control is a problem When cost is a concern

Amalgam contraindications ¡ ¡ ¡ When esthetics is important When patient has a history of allergic reactions to the alloy When cost is not a concern

Amalgam fillings

Amalgam fillings

r o f u o y k n a Th ntion!