2. WHAT ARE DEEP CARIOUS LESIONS?
Deep carious lesion is a clinical diagnosis that is given when the
caries process has penetrated deep into the dentin with possible
pulpal exposure. Deep carious lesions cause pulpal
inflammation( i.e. pulpitis); if not managed ,they may result in
pulp necrosis and involvement of the periradicular tissues, with
possible pain requiring endodontic treatment or extraction.
3. DENTINAL CARIES
When enamel caries reaches the dentinoenamel junction it spreads rapidly
laterally because it is least resistant to caries.
Caries advancement in dentin proceeds through three changes:
1. Weak organic acids demineralize the dentin
2. The organic material of dentin ,particularly collagen , degenerates and
dissolves
3. The loss of structural integrity followed by invasion of bacteria
4. FIVE DIFFERENT ZONES IN CARIOUS DENTIN
ZONE 1: NORMAL DENTIN
o Deepest area
o Have tubules with odontoblastic processes
o Intertubular dentin with normal cross banded collagen
ZONE 2 : SUBTRANSPARENT DENTIN
o Zone of demineralization of intertubular dentin
o Damage to odontoblastic process evident
o Dentin capable of remineralization
ZONE 3 : TRANSPARENT DENTIN
o Zone of carious dentin softer than normal dentin
o Collagen cross linking remains intact
5. o Pulp remains vital
ZONE 4 : TURBID DENTIN
o Zone of bacterial invasion
o widening and distortion of dentinal tubules
o Collagen irreversibly denatured
o Not self repair zone
ZONE 5 : INFECTED DENTIN
o Outermost zone
o Consists of decomposed dentin
o No recognizable structure to dentin teeming with bacteria
o Great numbers of bacteria dispersed in granular material
6. Affected and infected dentin
In operative procedures , it is convenient to term dentin as either
infected or affected dentin
AFFECTED DENTIN- softened, demineralized dentin that is not
yet invaded by bacteria- inner carious dentin(does not require
removal)
INFECTED DENTIN- outer carious dentin and bacterial plaque –
both softened and contaminated with bacteria ( requires
bacteria)
9. CAUSES OF PULPAL
INFLAMMATION Bacterial cause
Can damage pulp through toxins secreted by bacteria from
caries
Accidental exposure
Mechanical cause
Traumatic accident
Attrition
Abrasion
Luxation or avulsion of tooth
10. Thermal cause
Uninsulated metallic restoration
During cutting
Bleaching
Electrosurgical procedures
Laser beam
Periodontal curettage
Periapical curettage
Idiopathic cause
Aging
resorption: internal or external
12. 2. PULP DEGENERATION:
a) calcific ( radiographic diagnosis)
b) Other ( histopathological diagnosis)
3. NECROSIS
13. REVERSIBLE PULPITIS
Reversible pulpitis is a mild to moderate inflammatory condition
of the pulp caused by noxious stimuli in which the pulp is
capable of returning to the normal state following removal of
stimuli.
SYMPTOMS
Characterized by sharp pain lasting for a moment , commonly
caused by cold stimuli
May result from incipient caries and is resolved on removal of
caries
Pain does not occur simultaneously
14. TREATMENT
Best treatment is prevention
No endodontic treatment is needed
Periodic care to prevent caries , desensitization of hyperactive
teeth and use of cavity varnish or base before insertion of
restoration is recommended
If pain persists despite of proper treatment then it should be
considered as reversible
15. IRREVERSIBLE PULPITIS
It is a persistent inflammatory condition of the pulp , symptomatic
or asymptomatic , caused by a noxious stimulus. It has both acute
and chronic stages in pulp
CLINICAL FEATURES
EARLY STAGE
Paroxysm of pain caused by: sudden temperature changes like
cold , sweet, acid foodstuffs
Pain often continues when cause has been removed
May come and go spontaneously
Pain: sharp, piercing, shooting, generally severe
16. LATE STAGE
Pain more severe and throbbing
Increased by heat and sometimes relieved by cold , although
continued application of cold may intensify pain
DIAGNOSIS
Visual examination and history : on inspection may see deep
cavity involving pulp or secondary caries under restorations
Radiographic findings : may show depth and extent of caries
Percussion: tender on percussion(due to increased intrapulpal
pressure)
17. Vitality tests:
Thermal test: hyperalgesic pulp responds more readily to cold
stimulation than for normal tooth , pain may persist even after
removal of irritant.
Electric test: less current is required to initial stages . As tissue
becomes more necrotile more current is required to generate
the response
18. The results of diagnosis
No exposure Pulp exposure
Conventional
cavity
preparation
and
restoration
Indirect
pulp
capping
Vital
(traumatic)
exposure
Non-vital
(carious)
exposure
Direct pulp
capping
RCT
19. 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
20. 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-
2mm
Deep cavity depth- depth of preparation with less than 1.0mm of
remaining dentin over pulp
21. REACTIONARY DENTIN DEPOSITION
Reactionary dentin deposition observed beneath cavities with
RDT above 0.5mm as well as beneath cavities with a RDT below
0.25mm
Maximal reactionary dentin appeared to be beneath cavities with
an RDT between 0.5 to 0.25mm
Area of reactionary repair influenced by the choice of
restoration material
(from greatest least calcium hydroxide ,composite ,resin
modified glassionomer [RMGI] cement, and zinc oxide- eugenol)
Odontoblast numbers maintained beneath cavities with a RDT
above 0.25mm
22. INDIRECT PULP CAPPING
It is a procedure performed in a tooth with deep carious lesions
adjacent to pulp. In this procedure , all infected carious dentin is
removed leaving behind the softened carious dentin adjacent to
pulp. Caries near the pulp left in place to avoid pulp exposure
and preparation is covered with a biocompatible material
23. DECISION MAKING IN 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
• Osmotic changes
• Duration of symptom
• Spontaneous pain
24. INDICATIONS
Deep carious lesions near the pulp tissue but not involving it
No mobility of tooth
no history of spontaneous toothache
No tenderness on percussion
No radiographic evidence in pulp pathology
No root resorption or radicular disease
CONTRAINDICATIONS
Presence of pulp exposure
Radiographic evidence of pulp pathology
History of spontaneous toothache
Tooth sensitive to percussion
25. CLINICAL TECHNIQUE
Band the tooth if tooth is grossly decayed
Remove soft caries either with spoon excavator or round bur
A thin layer of dentin and some amount of caries is left to
avoid pulp exposure
Place calcium hydroxide paste on the exposed dentin
Cover the calcium hydroxide with zinc oxide eugenol cement
Teeth should be evaluated after 6 to 8 weeks
After 2 to 3 months , remove the cement and evaluate the
tooth preparation
26.
27. During this waiting period :
The carious process is arrested
Soft caries hardened
A protective layer of reparative dentin is laid down
Success of indirect pulp capping depends upon
Age of patient
Size of exposure
Restorative procedure
Evidence of pulp vitality
28.
29. DIRECT PULP CAPPING
Procedure that involves the placement of biocompatible material
over the site of pulp exposure to maintain vitality and promote
healing
30. INDICATIONS
Small mechanical exposure of pulp during :
tooth preparation
traumatic injury
No or minimal bleeding at exposure site
CONTRAINDICATIONS
Wide pulp exposure
Radiographic evidence of pulp pathology
History of spontaneous pain
Presence of bleeding at exposure site
31. CLINICAL PROCEDURE
Administer local anesthesia
Isolate the tooth with rubber
dam
When vital and healthy pulp
exposed , check the fresh
bleeding at exposure site
Clean the area with distilled
water or saline solution and
thin dry it
Apply calcium hydroxide over
the exposed area
32. Give interim restoration such as zinc oxide eugenol for 6 to 8
weeks
After 2 to 3 months , remove the cement very gently to
exposure site .
If secondary dentin formation takes place over the exposed site
, restore the tooth permanently with protective cement base
and restorative material.
If favorable prognosis not there, pulpotomy or pulpectomy is
done
34. FACTORS AFFECTING SUCCESS OF DIRECT PULP
CAPPING
Age of the patient
Type of exposure
Size of exposure
History of pain
35. MATERIALS USED FOR PULP
PROTECTION
These materials help to:
Insulate the pulp
Protect the pulp in case of deep carious lesion
Act as barriers to micro leakage
Prevent the bacteria and toxins from affecting the pulp
36. PULP PROTECTING AGENTS
CAVITY SEALERS: protective coating on the cavity walls
creating a barrier to leakage, to seal dentinal tubules
ADVANTAGES:
Used to reduce micro leakage
Reduces postoperative sensitivity
Prevents discoloration of tooth by checking migration of ions
into dentin
In case of amalgam restoration , it improves the sealing ability
of amalgam
37. RESIN BONDING AGENTS: an adhesive sealer is commonly
used under compound restorations for application, cotton tip
application is used to apply sealer on all areas of exposed
dentin
INDICATIONS:
To seal dentinal tubules
To treat dentin hypersensitivity
LINERS: cement or resin coating of minimal thickness (less
than 0.5mm) 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, zinc oxide eugenol )
it also stimulate formation of reparative dentin
38.
39. CAVITY BASES: placed to replace missing dentin , placed in
thicknesses of 0.5-1mm
Provide thermal insulation
Encourage recovery of injured pulp from thermal,
or chemical trauma, galvanic shock and micro leakage
MATERIALS USED AS BASES:
Zinc oxide eugenol
Zinc phosphate cement
Zinc polycarboxylate cement
Glass ionomer cement
40. CALCIUM HYDROXIDE CEMENT
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
of new dentin
Biocompatible in nature
41. 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
42. DEMERITS OF CALCIUM HYDROXIDE
Unfortunately , the self-setting calcium hydroxide liners are
highly soluble and subject too 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
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
43. MINERAL TRIOXIDE
AGGREGATE(MTA)
In recent years, mineral trioxide aggregate (MTA) preparations
have been introduced
These silicate cements are antibacterial, biocompatible, have a
high pH, and are cable 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
44. 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 tricalcium oxide reacts with tissue fluids
to form calcium hydroxide
45. MERITS AND DEMERITS OF MTA
The material has a low solubility and a radiopacity slightly greater than that
of dentin
Because of its low compressive strength , it should not b placed in
functional areas
Another significant disadvantage for the restoration is that the setting time
may take several hours. As a result , 2 step procedures are frequently
necessary , requiring interim restorations
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