MANAGEMENT OF DENTAL CARIES presentation conservative

REVIEW ARTICLE
DENTAL CARIES AND ITS
MANAGEMENT
By Dr.Anjali Gupta
International Journal of Dentistry Volume 2023,
Article ID 9365845, 15 pages

CONTENT
 Objective
 Introduction
 Caries removal strategies
 Non carious removal
 Non restorative cavity control approach
 Caries management by risk assessment
 White spot lesion management
 Stepwise caries removal technique
 Indirect pulp capping
 Atraumatic restorative treatment
 Preventive resin restoration
 Conclusion
 Refrences

OBJECTIVE
 In recent years, the management of dental caries has evolved signifcantly. Caries
prevention, early detection, and a diagnosis based on risk indicators and risk
factor assessments are the most current practical approaches.
 Furthermore, as proposed in minimally invasive dentistry, the new management
approaches preserve healthy tissue and maintain pulp vitality.
 This article overviews the latest minimally invasive dental caries management and
treatment options.The information will assist the reader in the early detection,
diagnosis, and treatment of dental caries.

INTRODUCTION
 Management of dental caries has changed significantly in recent years .The most
contemporary practical approaches are based on early caries detection .
 The new management approaches aim to preserve healthy tissue, as proposed in
minimally invasive dentistry.
 Restorative procedures are damaging to tooth tissue and may endanger the tooth
in the long term when it enters the restoration-re-restoration cycle .Therefore,
when restorative intervention is needed, the procedure used should be as
minimally invasive as possible.

CARIES REMOVAL STRATEGIES
 In general, there are two approaches to caries removal of cavitated carious lesions
in teeth with sensible and asymptomatic pulps
 1.NON SELECTIVE CARIES REMOVAL
 2.SLECTIVE CARIES REMOVAL

NON-SELECTIVE CARIES REMOVAL
 It is the traditional method of treating dental caries . It represents the removal of
both soft and firm dentine, regardless of the closeness of the carious lesion to the
pulp.
 It is also known as complete caries removal or complete caries excavation. It can
also be denoted as caries removal to hard dentine.
 Restorative mate rials can be effectively placed and retained because a strong
basis is available by providing hard sound dentine.
 However, it is associated with a high rate of pulp exposure.
 This method is deemed nonconservative and excessive.
Caries removal of hard dentine(black arrow)
Sot dentine (Green arrow)

SELECTIVE CARIES REMOVAL
 In this method, caries are selectively removed according to their proximity to the
pulp, and therefore, soft and/or firm dentine is left and pre served.
 This approach is also known as the partial caries removal (PCR) method.
 This approach is categorized into
One-step method
the caries dentine is selectively removed, and the cavity is restored with a
permanent restoration in a single visit. Indirect pulp capping (IPC) is an example of
a one-step method of this approach.
Two-step caries removal technique
such as the stepwise (SW) method, involves removing carious dentine in two
different clinical appointments.

 The selective caries removal method is further divided into two subcategories based on the type
of caries dentine removed:
1. Selective removal to firm dentine
 This involves removing peripheral dentine around the cavity margins to firm dentine but only
excavating to leathery dentine over the pulpal floor.
 There is resistance to a hand excavator on the pulpal floor, but the peripheral margins are left
hard after removal of dentine is complete.
 This is the treatment of choice in shallow or moderately deep cavitated dentine lesions.
2. Selective removal to soft dentine
 This is advocated as the treatment of choice as it lessens the risk of physiological stress or
exposure of pulpal tissue.
 Soft carious tissue is left over the pulpal tissues to avoid exposure, encouraging pulp health, while
peripheral enamel and dentine are prepared to hard dentine, to allow an effective adhesive seal
to be achieved by restoration placement.
 Selective removal to soft dentine reduces the risk of pulp exposure in deep lesions significantly
compared with non-selective removal to hard dentine or selective removal to firm dentine.

NON CARIOUS REMOVAL/CARIES SEALING
APPROACH
 It is indicated for a clinically non cavitated occlusal carious lesion that
radiographically appears to extend into the dentine.
 Hence, these lesions may be sealed using fissure sealants when plaque control
alone is insufficient to stop the decay .
 However, continuous monitoring is required to ensure the integrity of the sealant
material and that the lesion does not progress. This approach may also be
indicated for use in selective cavitated carious dentine lesions.
 Consequently, the carious lesion becomes inactive because it is sealed.
Composite resins or glass ionomers are used as sealant materials.

 A proximal carious lesion can be sealed after separating the affected tooth to reach the lesion.
 Resin infiltration and sealing were more effective than noninvasive treatments (e.g., fluoride
varnish) for halting non cavitated proximal lesions
 Sealing and resin infiltration of the carious lesion are two microinvasive approaches. Both involve
the removal of the dental hard tissue surface at the micron level, typically performed during an
etching step, such as in sealing or infiltration techniques .
 Sealing and resin infiltration of the carious lesion are two microinvasive approaches. Both involve
the removal of the dental hard tissue surface at the micron level, typically performed during an
etching step, such as in sealing or infiltration techniques.
 The infiltration techniques involve etching with an acid such as 15% HCl-gel for a specific time,
such as 120seconds, followed by an infiltrating resin

RESIN INFILTRATION
 Resin infiltration is an innovative approach for treating carious lesions that bridges
the gap between prevention and repair.
 This minimally invasive procedure stabilizes, fills, and strengthens demineralized
enamel without drilling into healthy tooth structure.
 The proximal and smooth surface carious lesion can be treated with this micro-
invasive infiltration up to the first third of the dentin.

PROCEDURE
Dry field is essential for success.
Rubber dam is placed to isolate the
field.
Etching with an acid such as 15%
HCl-gel for 120seconds,
Rinse for 30 seconds and dry
completely with air.
Remove any excess material and
light cure
Remove any excess material and
light cure,

NONRESTORATIVE CAVITY CONTROL (NRCC)
APPROACH
 This method is determined by the shape and depth of the carious lesion, the
patient’s ability to maintain good oral hygiene and avoid plaque accumulation, and
the patient’s aesthetic requirements.
 The cavity opening is widened to make it more cleanable, easy to clean and
improve patients’ abilities to clean it .
 As a result, the patient cleans the teeth repeatedly to remove the biofilm to stop
the progression of the lesion, remineralization therapies such as fluoride through
toothbrushing is utilized.
 It is critical to change patient behavior to control the biofilm and change the habits
that led to the development of the lesion.
 This approach is also recommended in cases of early-stage active root surface
caries with a shallow defect .

CARIES MANAGEMENT BY RISK
ASSESSMENT
 The Caries Management by Risk Assessment (CAMBRA) system, developed in
2002, is regarded as a reliable patient-centered approach. It takes a patient’s health
and lifestyle risk factors into consideration.
 Accordingly, patients are dividedinto three groups based on their risk of
developing dental caries: high, moderate, and low risk.

High and extreme risk patient
 Chemical therapy that represents the use of an anti bacterial agent and fluoride treatment.
 A combination of daily antibacterial therapy (0.12% w/v chlorhexidine gluconate mouth rinse)
and twice daily high concentration fluoride toothpaste (5,000ppm fluoride), both for home use.
 In high-caries-risk adult individuals, daily usage of a combination of chemical therapy and
restorative treatment was observed to decrease caries by 20–38%.
 Topical fluoride has resulted in a considerable decrease in smooth surface caries.
Cavity preparation is indicated and intervention immediately needed where more than one of
these findings is evident:
(1) A cavity is visually detected after cleaning and drying the tooth.
(2) There is pain or discomfort from cold water or food impaction.
(3) Tere is unacceptable appearance.
(4) Radiographs reveal carious lesions penetrating more than a third of the dentin.
(5) A patient is at high risk of caries.

WHITE SPOT LESIONS AND THEIR
MANAGEMENT (WSLS)
 This is one of the most conservative approaches to preserving tooth structure and pulp
vitality while avoiding invasive treatment.Te method is referred to as the “microinvasive
concept”.
 WSL can be treated noninvasively, as a result, with good oral hygiene, the use of fluoride-
containing toothpaste, mouthwash, gels, and varnish, casein phosphopeptide amorphous
calcium phosphate (CPP-ACP) and casein phosphopeptide-amorphous calcium phosphate
fluoride (CPP-AFCP), are all advised .
 It can also be managed using the resin infiltration technique, which has been shown to
delay or reverse the progression of non cavitated carious lesions.

STEP-WISE (SW) CARIES REMOVAL
(EXCAVATION) TECHNIQUE.
 The procedure involves two independent sessions spaced six months apart to
allow changes in the dentine and pulp to take place.
 It is indicated when the carious lesion is close to the pulp radiographically (about
75% into the dentine).
 The rationale behind the SW caries removal technique, is that partial caries
removal (PCR) followed by tooth sealing will result in the lesions being arrested.
 Furthermore, the counts of anaerobic and aerobic bacteria, Lactobacilli, and
Streptococci mutans would have decreased significantly by the end of treatment.
 Therefore, caries control does not necessitate complete dentinal caries removal .
 The SW technique is a viable treatment option irrespective of patient age, though
it may be more successful in younger patients

 In the first visit, the selective caries removal to soft dentine approach is used, and the tooth is
then restored with glass ionomer restoration.
 In the second appointment, 6 to 12months later, a fresh periapical radiograph, to evaluate
periapical pathosis, should be taken.
 Any signs or symptoms of a possible pulp pathosis should be evaluated, and a
sensibility/vitality test must be performed.
 Selective removal to firm/hard, dry dentine is carried out centrally, or glass ionomer may be
used as a base with no additional tissue removal, followed by a composite resin restoration .
 The SW technique can also be used successfully with a calcium hydroxide-containing base
material and a temporary filling .

INDIRECT PULP CAPPING
 Indirect pulp capping (IPC) is considered as a selective caries removal to soft dentine.
 The IPC approach is usually used in deep cavity preparations with or without residual
carious dentine that is near to the pulp but does not display apparent pulp exposure.
 It promotes reparative dentine formation by using material over sound or carious
dentine . Hence, it is an example of a selective carious removal method as soft caries
dentine is selectively removed .
 It aims to preserve the vitality of the pulp by selectively removing the caries soft dentin
followed by the placement of a therapeutic material.
 Calcium hydroxide is traditionally used as a liner, followed by a permanent filling
material. However, the use of calcium hydroxide has been questioned so it has been
replaced by other bio materials such as calcium silicate-based materials .
 This method can be carried out in one or two steps.The final restoration can be placed in
the same visit when the one-step method is used. If necessary, a second appointment is
scheduled after 6–8weeks.

ATRAUMATIC RESTORATIVE TREATMENT
 Atraumatic restorative treatment (ART) is a minimally invasive technique that involves the
removal of decayed tissue with hand instruments alone, usually without the use of anesthesia or
electrically powered equipment,
 The restoration of the dental cavity with glass ionomer cement or resin-modified glass-ionomer
cement and compomers.
 It consists of two clinical steps that are performed at the same clinical appointment.
 In the first step, soft caries dentine is removed with hand instruments and then restored with
high-viscosity glass ionomer restorative material.
 The nearby pits and fissures are sealed with the same material in the second step. Hence, a high-
viscosity restorative glass ionomer fills the cavity and is pushed into the adjacent pits and
fissures using the “press-finger” technique.

 The ART is a valuable therapeutic technique, especially in children, anxious patients, and those
with special needs, living in housing for older people, in remote areas or under resourced
communities and the out-reach environment when the appropriate dental instruments and
equipment are not available .
 The advantages of ART include the preservation of tooth structure and the absence of the need
for a local anesthetic, resulting in less discomfort than other standard treatments.
 The effectiveness of ART, on the other hand, is governed by a variety of factors, including the
prevalence of caries, the material used, and the operator’s experience .

PREVENTIVE RESIN RESTORATION.
 It is also known as conservative composite restoration (CCR).
 Preventative resin restoration (PRR) is a minimally invasive method that is usually
indicated for restoring small carious lesions in the posterior teeth .
 It involves the removal of caries in one stage . Only caries affected pits and fissures are
prepared to receive the filling.
 The pit and fissure caries are removed, and composite resin is used as a permanent
restoration.
 Glass ionomer may be used as a liner when the carious lesion reaches the dentine.
 When the resultant cavity is narrow, a flowable resin is usually used .
 The remaining fissures are then etched and sealed with a fissure sealant material.

CONCLUSIONS
 Caries management must be based on a caries risk assessment method that is
backed up by evidence.The newly available information, knowledge, and
materials should encourage professionals to implement this method.
 Approaches such as noninvasive, microinvasive, and minimally-invasive should be
considered, especially when the carious lesions are not cavitated.
 The selective caries removal approach is a viable option for preventing caries
progression, but careful case selection is required to achieve a good outcome.

REFRENCES
 International journal of dentistry volume 2023 article 9365845,
 Journal of Irish dental association 2020;67(1);36-42
 Journal of advanced medical and dental sciences research 2023;11(8);8-12
 Journal of American Dental Association, vol. 146, no. 2, pp. 79–86, 2015

MANAGEMENT OF DENTAL CARIES presentation conservative

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