Deep caries / dental implant courses

INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
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Dental caries is an infectious micro-Dental caries is an infectious micro-
biologic disease of the teeth that results inbiologic disease of the teeth that results in
localized dissolution & destruction of thelocalized dissolution & destruction of the
calcified tissues. requiring restorativecalcified tissues. requiring restorative
intervention & even extraction..intervention & even extraction..
Definition :

EtiologyEtiology
food bacteri
a
tooth

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Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental courses

Dentine CariesDentine Caries
Affected & Infected Dentin:Affected & Infected Dentin:
In operative procedures, it is convenient toIn operative procedures, it is convenient to
term dentin as either..term dentin as either..
 Affected dentin:Affected dentin: is softened, demineralizedis softened, demineralized
dentin that is not yet invaded by bacteriadentin that is not yet invaded by bacteria  innerinner
carious dentin ( does not requires removal ).carious dentin ( does not requires removal ). OROR
 Infected dentin:Infected dentin:  outer carious dentin &outer carious dentin &
Bacterial plaqueBacterial plaque is both softened &is both softened &
contaminated with bacteria ( requires removal ).contaminated with bacteria ( requires removal ).

Caries Detecting DieCaries Detecting Die
 Caries detection solutions have been usedCaries detection solutions have been used
by clinicians to distinguish betweenby clinicians to distinguish between
affected and infected dentin.affected and infected dentin.
 These are protein dyes that stainThese are protein dyes that stain
denatured callagen of carious dentinedenatured callagen of carious dentine

Response to dental cariesResponse 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 .

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:The objective is to focus on the:
 DiagnosisDiagnosis
 ttt modalitiesttt modalities
Management of deep caries

Treatment ModalitiesTreatment Modalities
The results of diagnosis :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

Indirect Pulp CappingIndirect Pulp Capping
When caries is thought to extend closeWhen caries is thought to extend close
to, or into the pulp, excavation of theto, or into the pulp, excavation of the
pulpal caries can be stopped at softpulpal caries can be stopped at soft
affected but not infected dentine (affected but not infected dentine (affectedaffected
dentine could be remineralised if the aciddentine could be remineralised if the acid
production was halted)production was halted). Medication is then. Medication is then
applied over the pulpal dentine prior toapplied over the pulpal dentine prior to
placement of the definitive restoration.placement of the definitive restoration.

Medication is left for 6 – 8 weeks .Medication is left for 6 – 8 weeks .
During this waiting period :During this waiting period :
 The carious process is arrestedThe carious process is arrested
 Soft caries hardenedSoft caries hardened
 A protective layer of reparative dentine is laidA protective layer of reparative dentine is laid
downdown

However the difficulty with this tecnique isHowever the difficulty with this tecnique is
knowing:knowing:
 how rapid the carious process has beenhow rapid the carious process has been
 how much tertiary dentine has beenhow much tertiary dentine has been
formedformed
 knowing exactly when to stop excavatingknowing exactly when to stop excavating
to avoid pulp exposure.to avoid pulp exposure.

Materials used for indirect pulp capping :Materials used for indirect pulp capping :
 Calcium HydroxideCalcium Hydroxide
Although CaOH is the most commonly used itAlthough CaOH is the most commonly used it
has been argued that its effect occurs only inhas been argued that its effect occurs only in
case of its direct contact with pulp tissues .case of its direct contact with pulp tissues .
Therefore a material with better sealing abilityTherefore a material with better sealing ability
should be used .should be used .
 Zinc oxide and EugenolZinc oxide and Eugenol
 Recently adhesive resin has been usedRecently adhesive resin has been used

Direct Pulp CappingDirect Pulp Capping
Technique for treating a pulpTechnique for treating a pulp
exposure with a material thatexposure with a material that
seals over the exposure site &seals over the exposure site &
promotes reparative dentinpromotes reparative dentin
formation..formation..
Requirements of direct pulpRequirements of direct pulp
capping:capping:
 Asymptomatic vital toothAsymptomatic vital tooth
 Pin-point exposure (0.5mm orPin-point exposure (0.5mm or
less in diameter)less in diameter)
 Non-hemorrhagic or easilyNon-hemorrhagic or easily
controlled.controlled.
 Dry, sterile filedDry, sterile filed
 Non-carious atraumaticNon-carious atraumatic
exposureexposure www.indiandentalacademy.comwww.indiandentalacademy.com

Direct Pulp Capping TechniquesDirect 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

Calcium HydroxideCalcium Hydroxide
TechniqueTechnique::
1.1. Bleeding must be controlled.Bleeding must be controlled.
This control may be achieved by :This control may be achieved by :
 Washing the area with sterile saline and dryingWashing the area with sterile saline and drying
it with either paper points or cotton pellets,it with either paper points or cotton pellets,
 Using cotton pellets soaked with hydrogenUsing cotton pellets soaked with hydrogen
peroxide or 5.25% sodium hypochlorite, ORperoxide or 5.25% sodium hypochlorite, OR
 Using a hemostatic agent .Using a hemostatic agent .
If bleeding fails to stop after two or threeIf bleeding fails to stop after two or three
attempts, then endodontic therapy should beattempts, then endodontic therapy should be
considered.considered.
 A disinfectant should be placed on the cavityA disinfectant should be placed on the cavity
floor.

2.2. The area is then air driedThe area is then air dried
3.3. Calcium Hydroxide is placed directly in contactCalcium Hydroxide is placed directly in contact
with pulp tissue. This step is very important, forwith pulp tissue. This step is very important, for
the better the contact of the calcium hydroxidethe better the contact of the calcium hydroxide
dressing with the pulpal wound, the better thedressing with the pulpal wound, the better the
healing.healing.
4.4. The calcium hydroxide should then be coveredThe calcium hydroxide should then be covered
with a resin-modified glass ionomer extendedwith a resin-modified glass ionomer extended
onto dentin.onto dentin.
5.5. A permanent restoration is placed, with aA permanent restoration is placed, with a
dentin bonding system used to seal thedentin bonding system used to seal the
margins of the restoration.margins of the restoration.

An alternative is to place a zinc oxide-eugenolAn alternative is to place a zinc oxide-eugenol
restoration over the calcium hydroxide cap.restoration over the calcium hydroxide cap.
Zinc oxide-eugenol provides an excellent sealZinc oxide-eugenol provides an excellent seal
and, with its anti-microbial properties, makesand, with its anti-microbial properties, makes
for a very good temporary restoration.for a very good temporary restoration.
After three months, assuming pulp vitality andAfter three months, assuming pulp vitality and
no symptoms, the zinc oxide-eugenol can beno symptoms, the zinc oxide-eugenol can be
removed and a more permanent sealedremoved and a more permanent sealed
restoration placed.restoration placed.

Total Etch Technique :Total Etch Technique :
1.1. Enamel and dentin are etched with 32% phosphoricEnamel and dentin are etched with 32% phosphoric
acid for 15 seconds.acid for 15 seconds.
2.2. The acid is rinsed off and the preparation is lightly dried.The acid is rinsed off and the preparation is lightly dried.
3.3. The entire preparation , including enamel, dentin andThe entire preparation , including enamel, dentin and
pulpal tissue , is treated with a dentin bonding system.pulpal tissue , is treated with a dentin bonding system.
4.4. Adhesive resin is applied onto the enamel, dentin andAdhesive resin is applied onto the enamel, dentin and
pulpal tissue and light cured, and a thin layer of resin-pulpal tissue and light cured, and a thin layer of resin-
modified glass ionomer is also applied over and aroundmodified glass ionomer is also applied over and around
the exposure site ( mechanically protect the perforationthe exposure site ( mechanically protect the perforation
from intrusion of the restorative material during packingfrom intrusion of the restorative material during packing
or condensation) and then cured.or condensation) and then cured.
5.5. The restoration is subsequently completed inThe restoration is subsequently completed in
conventional fashion.conventional fashion.

Chemo-mechanical caries removalChemo-mechanical caries removal
Carisolv™ is a chemo-mechanical method forCarisolv™ is a chemo-mechanical method for
minimally invasive caries removal .minimally invasive caries removal .
The system comprises :The system comprises :
 a gel that selectively attacks denatureda gel that selectively attacks denatured
collagen in the carious dentine, thus makingcollagen in the carious dentine, thus making
the carious dentine softer.the carious dentine softer.
 a set of specially designeda set of specially designed
instruments used forinstruments used for
removal of theremoval of the
softened material.softened material.

Carisolv gel consists of twoCarisolv gel consists of two
carboxymethylcellulose based gels:carboxymethylcellulose based gels:
 a red gel containing :a red gel containing :
amino acids (glutamic acid, leucine and lysine),amino acids (glutamic acid, leucine and lysine),
NaClNaCl
NaOHNaOH
Erythrosine (added in order to make the gelErythrosine (added in order to make the gel
visible during use ).visible during use ).
 and a second containing sodium hypochloriteand a second containing sodium hypochlorite

 The two gels are thoroughly mixed in equal partsThe two gels are thoroughly mixed in equal parts
at room temperature before use .at room temperature before use . The solutionThe solution
has a pH 11.has a pH 11.
 The positively and negatively charged groups onThe positively and negatively charged groups on
the amino acids become chlorinated and furtherthe amino acids become chlorinated and further
disrupt the collagen crosslinkage in the matrix ofdisrupt the collagen crosslinkage in the matrix of
the carious dentine.the carious dentine.
 The gel is then appliedThe 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
dry pellet
Complete caries removal is
checked with an explorer
The cavity is cleaned with
wet pellets
Finished cavity

Advantages of carisolvAdvantages of carisolv
 The patients perceive theThe patients perceive the
method as much moremethod as much more
comfortable than drilling andcomfortable than drilling and
anaesthetics are seldom neededanaesthetics are seldom needed..
 Saves timeSaves time
 Avoids removal of unnecessaryAvoids removal of unnecessary
healthy dental tissueshealthy 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.

Smartprep instrumentSmartprep instrument
 The SMARTPREPTM Instrument is a polymerThe SMARTPREPTM Instrument is a polymer
instrument that safely and effectively removeinstrument that safely and effectively remove
decayed dentin, leaving healthy dentin intact.decayed dentin, leaving healthy dentin intact.
 It is a self-limiting instrument and is not hardIt is a self-limiting instrument and is not hard
enough to penetrate healthy dentin. As it gentlyenough to penetrate healthy dentin. As it gently
removes decay and contacts the healthy dentin,removes decay and contacts the healthy dentin,
the instrument's edges become rounded andthe instrument's edges become rounded and
unable to cut healthy tooth structure.unable to cut healthy tooth structure.
 A high-speed carbide bur is first used to gainA high-speed carbide bur is first used to gain
access to the decay. After access has beenaccess to the decay. After access has been
created, the SMARTPREPTM Instrument iscreated, the SMARTPREPTM Instrument is
used in a slow speed handpiece (500-800 rpm)used in a slow speed handpiece (500-800 rpm)
to complete caries removal.to complete caries removal.
 They are single-patient-use rotary instruments.They are single-patient-use rotary instruments.

Advantages :Advantages :
 Conserve healthy tooth structure,Conserve healthy tooth structure,
 Virtually no risk of inadvertent pulpVirtually no risk of inadvertent pulp
exposure,exposure,
 Reduce the need for anesthesia and allowReduce the need for anesthesia and allow
for same-visit cavity preparations onfor same-visit cavity preparations on
multiple quadrants,multiple quadrants,
 Designed to reduce post-operativeDesigned to reduce post-operative
sensitivity.sensitivity.

The restorative treatment doesn'tThe restorative treatment doesn't
cure the caries process, socure the caries process, so
identifying & eliminating theidentifying & eliminating the
causative factors for caries mustcausative factors for caries must
be the primary focus, in additionbe the primary focus, in addition
to the restorative repair ofto the restorative repair of
damage caused by caries.damage caused by caries.

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