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Deep caries management

management of deep caries .

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Deep caries management

  2. 2. Dental caries is an infectious micro-biologic disease of the teeth that results in localized dissolution & destruction of the calcified tissues. requiring restorative intervention & even extraction.. Definition :
  3. 3. Etiology food bacteri a tooth
  4. 4. Dentin Caries Affected & Infected Dentin: In operative procedures, it is convenient to term dentin as either.. Affected dentin: is softened, demineralized dentin that is not yet invaded by bacteria  inner carious dentin ( does not requires removal ). OR Infected dentin:  outer carious dentin & Bacterial plaque is both softened & contaminated with bacteria ( requires removal ).
  5. 5. Caries Detecting Die  Caries detection solutions have been used by clinicians to distinguish between affected and infected dentin.  These are protein dyes that stain denatured callagen of carious dentine
  6. 6. Response to dental caries In the earliest stages of exposure to microorganisms, there is an effort to seal the tubules. This is accomplished by increased calcification. The result is a visible change known as transparent dentin or dentinal sclerosis .
  7. 7. In addition, pulpal odontoblasts, stimulated by the advancing carious lesion, will rapidly deposit dentin. The dentinal tubules in this new dentin are irregular, making them less permeable this type of dentin is known as : irregular dentin , reparative dentin , secondary dentin or tertiary dentin . Dentinal sclerosis and reparative dentin may be successful deterrents if the carious lesion progresses slowly.
  8. 8. The objective is to focus on the:  Diagnosis  ttt modalities Management of deep caries
  9. 9. Treatment Modalities The results of diagnosis : No exposure Pulp Exposure Indirect pulp capping Non-vital (carious) exposure  Recent advances of caries removal : carisolv Smartprep instrument Vital (traumatic) exposure Direct pulp capping Conventional cavity preparation and restoration RCT
  10. 10. DENTIN THICKNESS  We must remember that no material can provide better protection for the pulp than dentin.  The remaining dentin thickness, from the depth of cavity preparation to the pulp, is the most important factor in protecting the pulp from insult.
  11. 11. Remaining dentin thickness  Shallow cavity depth – Preparation 0.5 mm into dentin (ideal depth)  Moderate cavity depth – Remaining dentin over pulp of at least 1-2 mm  Deep cavity depth – Depth of preparation with less than 1.0 mm of remaining dentin over pulp
  12. 12. Remaining dentin thickness o The studies have shown that 0.5 mm thickness of dentin reduces the effect of toxic substances on the pulp by 75%, 1.0mm thickness of dentin reduces the effect of toxins by 90%,little if any pulpal reaction occurs when there is a remaining dentinal thickness of 2mm or more  It helps us to make a decision concerning the use of bases and liners.
  13. 13. Reactionary dentin deposition  Reactionary dentin deposition was observed beneath cavities with a RDT above 0.5 mm as well as beneath cavities with a RDT below 0.25 mm.  However, maximal reactionary dentin appeared to be beneath cavities with an RDT between 0.5 to 0.25 mm.  The area of reactionary repair was also influenced by the choice of restoration material (from greatest to least: calcium hydroxide, composite, resin-modified glass ionomer [RMGI] cement, and zinc oxide-eugenol). o Odontoblast numbers were maintained beneath cavities with a RDT above 0.25 mm.
  14. 14. Decision making in the use of sealers, liners and/or bases  Remaining dentin thickness in tooth preparation.  Thermal conductivity of restorative material  Presence or absence of pulpal symptoms- pain to stimuli – Thermal – Sweets (osmotic changes) – Duration of symptom – Spontaneous pain
  15. 15. Decision making in the use of sealers, liners and/or bases  Cavity sealers: protective coating on the cavity walls creating a barrier to leakage – Resin bonding systems (i.e.OptiBond Solo)  Cavity liners: cement or resin coating of minimal thickness (less than 0.5 mm) placed as a barrier to bacteria or to provide a therapeutic effect (pulpal sedative or antimicrobial effect). Applied to cavity walls adjacent to pulp ( calcium hydroxide liners:Life,Dycal;glass-ionomer liners:VitreBond; Jonosit,)  Cavity bases: placed to replace missing dentin, placed in thicknesses of 0.5-1 mm; these are :glass- ionomers: VitreBond, Fuji IILC, modified glass-ionomers: Jonosit; zinc-phosphate cements, carboxylate cements
  16. 16. Calcium hydroxide  Calcium hydroxide has been used as a lining material since the 1920s.  Because of the basic pH of about 11, calcium hydroxide is both antibacterial and can neutralize the acidic bacterial byproducts.  The high pH creates an environment conducive to the formation of reparative dentin.  In addition, calcium hydroxide has the capacity to mobilize growth factors from the dentin matrix, causing the formation of new dentin.  Calcium hydroxide is an ideal lining material for the very deep cavity preparation and also continues to represent an option for both the indirect and direct pulp capping.
  17. 17. Merits of calcium hydroxide cement over adhesive cements  Adhesive resins can be acidic and cause pulpal irritation.  Many dentin bonding agents and resin- reinforced glass ionomers are actually detrimental to the pulpal tissues.  In contrast, calcium hydroxide has been shown to provide a significantly improved potential for pulpal repair compared to adhesive resins
  18. 18. Demerits of calcium hydroxide  Unfortunately, the self-setting calcium hydroxide liners are highly soluble and subject to dissolution over time.  Traditional calcium hydroxide liners are easily lost during acid etching.  Dentin bonding agents that contain water, acetone, or alcohol can also detrimentally affect the properties of calcium hydroxide.  A hermetic seal of the cavity may stabilize the lesion and arrest caries progression.  Therefore, when a restoration of composite resin is planned, glass ionomer cement should line the cavity preparation, sealing over the calcium hydroxide material, if used.
  19. 19. Resin modified GIC  Restorative materials that exhibit antimicrobial benefits are useful in minimal intervention and other types of dentistry.  Some studies show that RMGIs were about equal to conventional calcium hydroxide liners.  Remaining softened, demineralized dentin covered by glass ionomer becomes remineralized, presumably under the influence of the fluoride release and the presence of calcium and phosphate ions from the cement.  This phenomenon is also referred to as the “healing of affected dentin.”  However, in other studies, RMGIs were found to cause the greatest reduction in odontoblast numbers.  It is frequently recommend that a thin liner of calcium hydroxide be applied to the cavity floor of deep preparations before RMGI is placed.  This appears to provide improved pulpal protection from injury and bacterial microleakage.
  20. 20. Mineral trioxide aggregate (MTA  In recent years, mineral trioxide aggregate (MTA) preparations have been introduced (ProRoot MTA [DENTSPLY Tulsa Dental Specialties]).  These silicate cements are antibacterial, biocompatible, have a high pH, and are able to aid in the release of bioactive dentin matrix proteins.  MTA is a powder consisting of fine hydrophilic particles of tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide.  It also contains small amounts of other mineral oxides, which modify its chemical and physical properties.  Hydration of the powder results in formation of colloidal gel with a pH value equal to 12.5 (similar to calcium hydroxide) that solidifies to form a strong impermeable hard solid barrier in approximately 3 to 4 hours.  It is hypothesized that the tricalcium oxide reacts with tissue fluids to form calcium hydroxide.
  21. 21. Merits and demerits of MTA  The material has a low solubility and a radiopacity slightly greater than that of dentin.  Because it has low compressive strength, it should not be placed in functional areas.  Another significant disadvantage for the restorative dentist is that the setting times may take several hours. As a result, 2- step procedures are frequently necessary, requiring interim restorations.  As previously discussed, recent evidence indicates that an indirect pulp cap should be performed in a single treatment appointment.  Any immediate restoration will require coverage with a layer of RMGI cement.  MTA is an excellent material for direct vital pulp exposures and numerous endodontic applications.  The material has good long-term sealing capabilities, and some studies show greater success than conventional calcium hydroxide.
  22. 22. Biodentine  Biodentine is a relatively more user-friendly material for the restorative dentist as compared to traditional MTA preparations.  Biodentine is an active biosilicate material useful in direct and indirect pulp capping, and it also has endodontic applications.  In addition, it is different from the usual MTA formulations. The manufacturing process of the active biosilicate technology eliminates the metal impurities.  The setting reaction is a hydration of tricalcium silicate, which produces a calcium-silicate gel and calcium hydroxide.  In contact with phosphate ions, it creates precipitates that resemble hydroxyapatite.  “An evaluation of the dentin-Biodentine interface demonstrated an increase in the carbonate content of interfacial dentin, which suggested intertubular diffusion and mineral tags of Biodentine hydration products creating a hybrid zone.”  Biodentine resists microleakage similar to RMGI cements21 and also has an antibacterial effect.
  23. 23.  Biodentine reaches a final set in about 10 to 12 minutes.  This is much faster than the time required for MTA and also demonstrates higher compressive strength.  Therefore, it can serve as an excellent interim restoration.  As of yet, the manufacturer recommends the material be used in a 2-step procedure.  At a subsequent appointment, the clinician cuts the ideal cavity preparation, leaving the Biodentine as a liner or a dentin substitute base under the definitive restorative material
  24. 24. TheraCal LC  TheraCal LC, another recently introduced material, is in simplistic chemical terms, a material that offers the pulpal/dentin benefits of both calcium hydroxide and RMGI in one product.  The material demonstrates strong physical properties with low water solubility and can be light-cured up to a thickness of 1.0 mm.  TheraCal LC is FDA approved as an apatite stimulating liner with the ability to induce apatite crystal formation, similar to commercially available self-curing MTA products.
  25. 25.  Dentinal fluid absorbed by TheraCal LC results in a sustained release of calcium and hydroxide ions.  Calcium is necessary for rapid apatite stimulation, and hydroxide ions are required for providing an “alkalinizing effect” for wound healing propagation.  TheraCal LC is intended for use as an internally placed pulpal protectant liner over both occlusal and axial dentin.  When performing a direct pulp cap, use of a rubber dam to reduce bacterial contamination, apex development, and control of pulpal hemorrhage are among the essential factors for success.  This material will appeal to the clinician who wants the ease of placement of conventional calcium hydroxide liners along with the biological benefits of the newer calcium silicates.  TheraCal LC allows for the one-step indirect pulp cap.
  26. 26. Indirect Pulp Capping When caries is thought to extend close to, or into the pulp, excavation of the pulpal caries can be stopped at soft affected but not infected dentine (affected dentine could be remineralised if the acid production was halted). Medication is then applied over the pulpal dentine prior to placement of the definitive restoration.
  27. 27. Medication is left for 6 – 8 weeks . During this waiting period :  The carious process is arrested  Soft caries hardened  A protective layer of reparative dentine is laid down
  28. 28. However the difficulty with this tecnique is knowing:  how rapid the carious process has been  how much tertiary dentine has been formed  knowing exactly when to stop excavating to avoid pulp exposure.
  29. 29. Materials used for indirect pulp capping :  Calcium Hydroxide Although CaOH is the most commonly used it has been argued that its effect occurs only in case of its direct contact with pulp tissues . Therefore a material with better sealing ability should be used .  Zinc oxide and Eugenol  Recently adhesive resin has been used
  30. 30. Direct Pulp Capping Technique for treating a pulp exposure with a material that seals over the exposure site & promotes reparative dentin formation.. Requirements of direct pulp capping:  Asymptomatic vital tooth  Pin-point exposure (0.5mm or less in diameter)  Non-hemorrhagic or easily controlled.  Dry, sterile filed  Non-carious atraumatic exposure
  31. 31. Direct Pulp Capping Techniques Calcium Hydroxide Technique Total etch technique hemostasis hemostasis Disinfect cavity Disinfect cavity CaOH primers Resin modifieed glass ionomer adhesives IRM Resin modifieed glass ionomer Restoration Restoration
  32. 32. Calcium Hydroxide Technique: 1. Bleeding must be controlled. This control may be achieved by :  Washing the area with sterile saline and drying it with either paper points or cotton pellets,  Using cotton pellets soaked with hydrogen peroxide or 5.25% sodium hypochlorite, OR  Using a hemostatic agent . If bleeding fails to stop after two or three attempts, then endodontic therapy should be considered.  A disinfectant should be placed on the cavity floor.
  33. 33. 2. The area is then air dried 3. Calcium Hydroxide is placed directly in contact with pulp tissue. This step is very important, for the better the contact of the calcium hydroxide dressing with the pulpal wound, the better the healing. 4. The calcium hydroxide should then be covered with a resin-modified glass ionomer extended onto dentin. 5. A permanent restoration is placed, with a dentin bonding system used to seal the margins of the restoration.
  34. 34. An alternative is to place a zinc oxide-eugenol restoration over the calcium hydroxide cap. Zinc oxide-eugenol provides an excellent seal and, with its anti-microbial properties, makes for a very good temporary restoration. After three months, assuming pulp vitality and no symptoms, the zinc oxide-eugenol can be removed and a more permanent sealed restoration placed.
  35. 35. Total Etch Technique : 1. Enamel and dentin are etched with 32% phosphoric acid for 15 seconds. 2. The acid is rinsed off and the preparation is lightly dried. 3. The entire preparation , including enamel, dentin and pulpal tissue , is treated with a dentin bonding system. 4. Adhesive resin is applied onto the enamel, dentin and pulpal tissue and light cured, and a thin layer of resin- modified glass ionomer is also applied over and around the exposure site ( mechanically protect the perforation from intrusion of the restorative material during packing or condensation) and then cured. 5. The restoration is subsequently completed in conventional fashion.
  36. 36. Chemo-mechanical caries removal  An alternative to mechanical means of caries removal .  The need for local anesthetic is reduced or eliminated.  It is an effective alternative means of caries removal because it brings together atraumatic measures and bacterostatic/bactericidal action.  Chemicals used can be in the form of liquid (Caridex ) or gel (Carisolv).
  37. 37. Caridex  Caridex was developed by C.M.Habib from a formula N-monochloroglycine and amino butyric acid and is called as GK 101 E.  It gained FDA approval in 1984.  It was initially introduced in US market in 1985.  The system involved the intermittent appilication of preheated N-monochloro DL 2 aminobutyric acid to the carious
  38. 38. CARIDEX  The solution was claimed to cause disruption of collagen in the carious dentin and facilitating its removal.  The mechanism of softening involved chlorination of remaining partially degraded dentinal collagen and tha conversion of hydroxyproline to pyrrole -2- carboxylic acid which initially disrupted altered collagen fibres in the caries.
  39. 39. Disadvantages: -Expensive -large quantity required -solution has to be heated -short self life -hand instuments were optimum.
  40. 40. Carisolv Carisolv™ is a chemo-mechanical method for minimally invasive caries removal . The system comprises :  a gel that selectively attacks denatured collagen in the carious dentine, thus making the carious dentine softer.  a set of specially designed instruments used for removal of the softened material.
  41. 41. Carisolv gel consists of two carboxymethylcellulose based gels:  a red gel containing : 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
  42. 42.  The two gels are thoroughly mixed in equal parts at room temperature before use . The solution has a pH 11.  The positively and negatively charged groups on the amino acids become chlorinated and further disrupt the collagen crosslinkage in the matrix of the carious dentine.  The gel is then applied onto the exposed carious dentine and left for 30 to 60 seconds then the softened dentine is gently but firmly abraded away leaving a hard, caries-free cavity .
  43. 43. A soft caries lesion Gel application. Let gel slide onto the lesion. Wait 30 seconds. The lesion is gently scraped with a star instrument Re-applied gel stays clear. Cavity is hard with a probe.
  44. 44. The gel is removed with a dry pellet Complete caries removal is checked with an explorer The cavity is cleaned with wet pellets Finished cavity
  45. 45. Advantages of carisolv  The patients perceive the method as much more comfortable than drilling and anaesthetics are seldom needed.  Saves time  Avoids removal of unnecessary healthy dental tissues Action of excavator. Healthy dentine is also removed. Selective removal of softened dentine caries with the Carisolv™ instrument. Healthy dentine is not affected.
  46. 46. Papain gel  IN 2003 a research project in brazil led to a new formula to universalise the use of chemo –mechanical method for caries removal and promote its use in public health.  the new formula was commercially known as papacarie.  It basically consists of papaine,chloramine,toluidine blue,salts,thickening vehicle which together are responsible for its bactericide ,bacterostatic and anti inflammatory properties.
  47. 47. Smartprep instrument  The SMARTPREPTM Instrument is a polymer instrument that safely and effectively remove decayed dentin, leaving healthy dentin intact.  It is a self-limiting instrument and is not hard enough to penetrate healthy dentin. As it gently removes decay and contacts the healthy dentin, the instrument's edges become rounded and unable to cut healthy tooth structure.  A high-speed carbide bur is first used to gain access to the decay. After access has been created, the SMARTPREPTM Instrument is used in a slow speed handpiece (500-800 rpm) to complete caries removal.  They are single-patient-use rotary instruments.
  48. 48. Advantages :  Conserve healthy tooth structure,  Virtually no risk of inadvertent pulp exposure,  Reduce the need for anesthesia and allow for same-visit cavity preparations on multiple quadrants,  Designed to reduce post-operative sensitivity.
  49. 49. The restorative treatment doesn't cure the caries process, so identifying & eliminating the causative factors for caries must be the primary focus, in addition to the restorative repair of damage caused by caries.