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MANAGEMENT OF DEEP
B. GLADSON SELVAKUMAR
Dental caries is an infectious micro-biologic
disease of the teeth that results in localized
dissolution & destruction of the calcified
tissues. requiring restorative intervention &
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 ).
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
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
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.
The objective is to focus on the:
Management of deep caries
The results of diagnosis :
No exposure Pulp Exposure
Recent advances of caries removal :
Direct pulp capping
and restoration RCT
We must remember that no material
can provide better protection for the pulp
The remaining dentin thickness, from
the depth of cavity preparation to the
pulp, is the most important factor in
protecting the pulp from insult.
Shallow cavity depth
– Preparation 0.5 mm into dentin (ideal
Moderate cavity depth
– Remaining dentin over pulp of at least
Deep cavity depth
– Depth of preparation with less than 1.0
mm of remaining dentin over pulp
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
It helps us to make a decision
concerning the use of bases and liners.
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
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
o Odontoblast numbers were maintained beneath
cavities with a RDT above 0.25 mm.
Decision making in the use
of sealers, liners and/or
Remaining dentin thickness in tooth
Thermal conductivity of restorative
Presence or absence of pulpal symptoms-
pain to stimuli
– Sweets (osmotic
– Duration of symptom
– Spontaneous pain
Decision making in the use
of sealers, liners and/or
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
Cavity bases: placed to replace missing dentin,
placed in thicknesses of 0.5-1 mm; these are :glass-
VitreBond, Fuji IILC, modified glass-ionomers:
Jonosit; zinc-phosphate cements, carboxylate
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
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
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
Demerits of calcium hydroxide
Unfortunately, the self-setting calcium hydroxide
liners are highly soluble and subject to dissolution
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.
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
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
This appears to provide improved pulpal protection from injury
and bacterial microleakage.
Mineral trioxide aggregate (MTA
In recent years, mineral trioxide aggregate (MTA) preparations
have been introduced (ProRoot MTA [DENTSPLY Tulsa Dental
These silicate cements are antibacterial, biocompatible, have a
high pH, and are able to aid in the release of bioactive dentin
MTA is a powder consisting of fine hydrophilic particles of
tricalcium silicate, tricalcium aluminate, tricalcium oxide, and
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.
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
As previously discussed, recent evidence indicates that an
indirect pulp cap should be performed in a single treatment
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
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
“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.
Biodentine reaches a final set in about 10 to 12
This is much faster than the time required for
MTA and also demonstrates higher compressive
Therefore, it can serve as an excellent interim
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
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
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
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
TheraCal LC allows for the one-step indirect pulp cap.
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
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
However the difficulty with this tecnique is
how rapid the carious process has been
how much tertiary dentine has been
knowing exactly when to stop excavating to
avoid pulp exposure.
Materials used for indirect pulp capping :
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
Direct Pulp Capping
Technique for treating a pulp
exposure with a material that
seals over the exposure site &
promotes reparative dentin
Requirements of direct pulp
Asymptomatic vital tooth
Pin-point exposure (0.5mm or
less in diameter)
Non-hemorrhagic or easily
Dry, sterile filed
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
A disinfectant should be placed on the cavity
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
4. The calcium hydroxide should then be covered
with a resin-modified glass ionomer extended
5. A permanent restoration is placed, with a
dentin bonding system used to seal the
margins of the restoration.
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
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
An alternative to mechanical means of
caries removal .
The need for local anesthetic is reduced
It is an effective alternative means of
caries removal because it brings
together atraumatic measures and
Chemicals used can be in the form of
liquid (Caridex ) or gel (Carisolv).
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
The system involved the intermittent
appilication of preheated N-monochloro
DL 2 aminobutyric acid to the carious
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
-large quantity required
-solution has to be heated
-short self life
-hand instuments were optimum.
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
Carisolv gel consists of two
carboxymethylcellulose based gels:
a red gel containing :
amino acids (glutamic acid, leucine and lysine),
Erythrosine (added in order to make the gel
visible during use ).
and a second containing sodium hypochlorite
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
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.
The gel is removed with a
Complete caries removal is
checked with an explorer
The cavity is cleaned with
Advantages of carisolv
The patients perceive the
method as much more
comfortable than drilling and
anaesthetics are seldom
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.
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
It basically consists of
blue,salts,thickening vehicle which together
are responsible for its bactericide
,bacterostatic and anti inflammatory
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.
Conserve healthy tooth structure,
Virtually no risk of inadvertent pulp
Reduce the need for anesthesia and
allow for same-visit cavity preparations
on multiple quadrants,
Designed to reduce post-operative
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.