Management of dental caries

2.  Cariology is a science which deals with the study of etiology, histopathology,
epidemiology, diagnosis, prevention and treatment of dental caries.
 Dental caries is defined as a microbiological disease of the hard structure of
teeth, which results in localized demineralization of the inorganic portion and
destruction of the organic substances of the tooth.

3.  Dental plaque is an adherent deposit of bacteria and their products, which
forms on all tooth surfaces.
 Dental plaque is important for beginning of caries because it provides the
environment for bacteria to form acid, which causes demineralization of hard
tissue of teeth.

4. Susceptible tooth surface
↓
Formation of biofilm and microbial deposits
↓
Acid production and PH change
↓
Shift in dynamic equilibrium of minerals
↓
Dissolution of minerals
↓
Initiation of caries

5.  Dental caries is a multifactorial disease of tooth which has been explained by
many theories. Though there is no universally accepted theory of the etiology
of dental caries, but following three theories are considered in etiology of
dental caries:
1. Acidogenic theory: (WD Miller in 1882). Its most accepted and supported
theory.
fermentation of dietary
carbohydrates by oral
bacteria
acid
decalcification of tooth substance
with subsequent disintegration of
organic matrix.

6. 2. Proteolytic theory: (Heider and Bodecker in 1878) and (Abbott in 1879).
Microorganism attack the organic part of enamel leaving the generated acid
responsible for further decalcification of inorganic part.
3. Proteolysis-Chelation theory: (Schatz and his coworkers).
Organic part of the enamel is attacked first then followed by chelation process
that removes calcium from enamel and dentine without acid.
Chelation is independent of the pH of the medium.

7. Normal tooth
↓
White chalky spot
↓
Incipient lesion
↓
Cavitation
↓
If not treated
↓
Involvement of dentine and pulp
↓
Pulp inflammation
↓
Pulp necrosis
↓
Periradicular lesion

9.  According to the caries balance theory, caries does not result from a single
factor; rather, it is the outcome of the complex interaction of pathologic and
protective factors.

15. A. Dietary Measures:
1. Sugar substitutes: Xylitol, Sorbitol.

16. 2. Fibrous food: Intake of fruits, vegetables and grains helps in:
A. Increasing the salivary flow.
B. Increases caries protective mechanism because these foods contain natural
phosphates and non-digestable fibers, moreover they do not stick to teeth.
3. Fats: Fats form a protective barrier on enamel or carbohydrate surface so that
it is less available for bacteria. They also speed up the clearance of carbohydrate
from oral cavity, thus decreasing cariogenic potential.
4. Cheese: Cheese is considered as responsible for:
A. Increasing the salivary flow.
B. Increasing the PH.
C. Promoting the clearance of sugar.

17. B. Methods to improve oral hygiene:
1. Dental prophylaxis: Polishing of roughened tooth surfaces and replacement of
faulty restorations is done so as to decrease the formation of dental plaque,
therefore, resulting in less incidence of caries.
2. Tooth brushing.
3. Interdental cleaning.

18. C. Chemical Measures:

19. A. Methods to improve flow, quantity and quality of saliva:
In patients with hyposalivation, baking soda may help to neutralize acids. The
mouth rinse is prepared by mixing two teaspoons of baking soda in eight oz of
water. This solution is used for mouthrinsing after eating.
B. Chemicals altering the tooth surface or tooth structure:
 Fluorides: It found as clinical fluoride products such as (professional topical
fluorides, fluoride varnishes, mouthrinses, dentifrices, supplements in the form
of fluoride tablets and drops, fluoridated salt). Also, it found in human diet:
 Silver nitrate
 Zinc chloride

20. C. Application of remineralizing agents:
Remineralizing agents are available in various forms like dentifrices,
mouthwashes, chewing gums, and foods and beverages. Various approaches have
been employed to enhance the remineralization of teeth.
D. Use of pit and fissure sealants:

21. A. Genetic modalities in caries prevention: In an attempt to produce the strains of
S. mutans which can not cause caries.
1. Genetically modified foods (probiotics): Modified fruits and vegetables are
being developed by incorporating antagonist peptides to work against glycosyl
transferase.
2. Genetically modified organisms: A new strain of S. mutans has been created
which lacks lactodehydrogenase gene, thus unable to produce lactic acid.
3. Lactobacillus zeae: Theses are genetically modified bacteria which produce
antibodies so as to attach to surface of S. mutans resulting in their death.

22. B. Caries vaccine:
 Vaccine is an immunological substance designed to produce specific protection
against a given disease. It stimulates production of protective antibody and
other immune mechanism.
 Although many trials have been carried out on experimental animals in the
laboratories, no such vaccine is commercially available till date. Vaccine should
be given before eruption of deciduous teeth so as to achieve maximum benefits.

23.  Three routes have been tried to achieve caries immunity in animal studies:
 Induction of mucosal immune system: by stimulating the production of
specific SIgA.
 Induction of systemic immune system: by stimulating the production of
seric antibodies.
 Passive immunization: through topical application of antigen-specific
antibodies on the teeth surface against virulence factors in S. mutans.

24.  Caries vaccines have commonly been tested in mice and rats although they
presented dental morphology and pattern of caries different from humans, not
being colonized by S. mutans.
 Animal models ideal for experimental studies on caries are the monkeys for
having colonization pattern similar to humans in occlusal fossa and fissures and
proximal sites, in addition to S. mutans be the primary etiological agent.

25.  Disadvantages of caries vaccine in animal:
 Great difficulty in producing vaccines on large-scale, requiring large
investments and increasing the cost.
 Short duration of the experiments in animals compared to the time scale of
caries development in humans.

26. o The invention and application of engine driven or rotary instruments in
operative treatment of carious lesions has resulted in removal of considerable
tooth structure. But now a days other procedures have also been used for
removal of caries like Air abrasion, Ozone treatment of dental caries,
Chemomechanical caries removal and Lasers.

27.  The study of the use of air abrasion technology for dental applications initiated
by Dr. Robert Black in the 1940's was successfully introduced in 1951 with the
Airdent air abrasion unit (S.S. White).
 Kinetic energy is used to remove carious lesion. In this method, a powerful fine
stream of aluminum oxide particles is targeted against the surface to be
removed.

28.  There are 2 sizes of aluminum oxide particles:
 27µm (more comfortable, less effective cutting).
 50µm (more abrasive cutting, but more discomfort).
 The abrasive particles hit the tooth with high velocity and remove small
amounts of tooth structure. Tip distance must be (0.5 to 2 mm) from carious
lesion.
 Nowadays, a number of variations in tip angulations and nozzle diameters are
available. Smaller nozzle diameters can be used for areas that are difficult to
access. The various tip angulations allow easy placement and orientation of the
handpiece thus easing the strain off the operator's hands.

29. 1. Lack of tactile sensation.
2. Risk of cavity over preparation and inadequate caries dentine removal.
3. Spread of aluminum oxide around dental operatory.
4. Danger of air emphysema.
5. Impaired indirect view.
6. Damaged of dental mirror, optical devices like magnifying lopes.
1. Non-traumatic.
2. No micro chipping or micro fracturing.
3. Less discomfort.
4. No anesthesia.
5. Decreased thermal buildup.

30. 1. Cavity preparation.
2. Internal cleaning of tunnel preparation.
3. Micro abrasion of while spot enamel hypoplasia.
4. Stain removal.
1. Crown preparation.
2. Large caries defect.
3. Amalgam removal.

31.  Use surgical mask, dry vacuum systems to reduce respiratory exposure.
 Use rubber dam, protective eyeglass and metal matrix to protect adjacent
tooth structure.
 Use disposable mirrors.
1. Patients with dust allergy, asthma.
2. Patients with advanced periodontal disease.
3. Patients with fresh extraction.
4. Patients with recent placement of orthodontic appliances.

34.  Within the past few years, ozone therapy has been launched as a new method
for treating caries by Edward LyGh.
 Ozone (O3) is a gas with a characteristic, penetrating odor that is present in
small amounts in atmospheric air.
 Ozone reacts with numerous inorganic and organic compounds. It bleaches
dyes and kills bacteria.
 Ozone destroys the bacterial cell membrane, where after the bacteria die. As
bacteria cause caries, it was natural to investigate whether ozone could be used
to treat caries.

35.  The ozone unit for dental use was initially developed by CurOzone Inc.
(Canada) and subsequently manufactured under license and distributed by
KaVo-Dental GmbH & Co. (Germany) under the name ‘HealOzone’.
 The new version of HealOzone (Mark3) was launched in July 2004. According
to the manufacturer previous models can be upgraded to the most recent
technical functions.
 Oxygen delivery unit (Ozone unit - HealOzone) consists of:
1. Polyurethane console:
A. Ozone generator.
B. Vacuum pump.
C. Desiccant.
D. Hydrophobic filter.

36. 2. Handpiece:
 Stainless steel, contra angle handpiece.
 Disposable polymer sealing cup attaches to the head (differently
shaped silicone cups are available that correspond to the form of
various teeth and their surfaces; 5 sizes from 3 to 8 mm in diameter).
This ensures close contact between the silicone cup and the carious
area of the tooth so that the ozone does not escape).
3. Patient kit: tooth paste, oral rinse.
 Handpiece attaches to the
console by detached hose.
 Delivers ozone at a rate of
13:33ml/sec.

37.  Polymer cup adapted to carious lesion and air sucked to create a vacuum.
 Ozone gas delivered for 10 seconds at minimum into the cup around the tooth
surface.
 The ozone in the silicone cup is collected again and reconverted to oxygen by
the apparatus (suction activated for 10 seconds while cup is still attached to
carious lesion to remove residual).

38.  The procedure usually takes between 20 and 120 seconds per tooth.
Immediately after ozone application the tooth surface is treated with a
remineralizing solution (reductant) containing fluoride, calcium, zinc,
phosphate and xylitol dispensed from a 2ml ampoule.
 Patients are also supplied with a patient kit, which consists of toothpaste, oral
rinse and oral spray, all containing fluoride, calcium, zinc, phosphate and
xylitol, and aims to enhance the remineralization process.

39.  One of the study to assess the effect of ozone therapy in combination with the
daily use of remineralizing products on root caries. The control period was up
to 18 months, and the patients were recalled for examination and repeat
treatment after 3, 6, 12 and 18 months.
 The trial showed that 69-100% of the ozone-treated lesions (duration of
treatment 40 sec) became harder during the 18-month trial and none became
softer.

40. 1. Primary root carious lesions.
2. Primary pit and fissure caries.
1. Kills more than 99% of microorganisms in carious lesion at a concentration of
2,200 ppm.
2. Oxidizes caries and speeds up remineralization.
3. Helps to remove organic debris on carious lesion.
4. Potentially whitens discolored caries.
5. Decreased treatment time.
6. Treatment painless and noiseless.
7. Does not cause any allergic reaction.
8. Microorganisms do not developed resistance to Ozone.

41.  Chemomechanical caries removal (CMCR) involves the selective removal of
carious dentine. The reagent is prepared by mixing solutions of amino acids
and sodium hypochlorite (NaOCl).
 Reagents commonly available in market are Caridex and Carisolv.

42.  The idea of chemo-mechanical caries removal has been developed in 1970s by
Goldman who was primarily an Endodontist, while using sodium hypochlorite
(NaOCl) in removing organic materials in the root canals. This chemical has
got the ability to dissolve carious dentine and since that time, the idea of
removing caries chemically was borne.
 Caridex was introduced in the US market in 1984 by National Patent Medical.
 Carisolv was introduced in 1997 by Swedish Medi Team.
 Papacarie was developed in Brazil in 2003, by Bassadori et al, (Papacarie: a
word that means “eating caries”).

44.  The delivery system of Caridex consisted of:
 Reservoir for the solution.
 Heater: warmed liquid to the body temperature.
 Pump: passed the warmed liquid through a tube to a hand piece and
applicator tip (20 gauge hypodermic needle, the tip of which had been
modified into spoon shape).
 It involves the chlorination and disruption of the partially degraded collagen
fibers in carious dentine with N-monochloro-D-2 aminobutyrate (NMAB).
 The carious dentine then becomes easier to remove by excavation using the
modified needle tip.

45. 1. No need for local anesthesia.
2. Conservation of sound tooth structure.
3. Reduced risk of pulp exposure.
1. Instruments may still be needed for the removal of caries or material.
2. It leaves a surface with many overhangs and undercuts.
3. Large volumes of solution are needed.
4. Procedure is slow.
5. It is ineffective in the removal of hard eburnated parts of the
lesion.
6. It requires heating or a delivery system which is not available commercially.

46.  The contents of the two syringes should be mixed immediately before use as its
effectiveness begins to deteriorate after 20 minutes.
 The mixed gel is applied to the carious lesion for 30 seconds and then the
carious dentine can be gently removed, using Carisolv specially designed, non-
traumatic hand instruments.
 The same procedure is continuously repeated until removing clear gel is
achieved.

48. 1. No need for local anesthesia.
2. Conservation of sound tooth structure.
3. Reduced risk of pulp exposure.
4. Volume required is less.
5. Does not require heating or a delivery system.
6. Since it involves gel not liquid, it is much easier to use than caridex.
7. Better contact with the carious lesion.
1. Instruments may still be needed for the removal of caries or material.

52.  Papacarie when applied to the contaminated dentine has proteolytic,
chlorinating and oxidating properties on the affected collagen, without acting
on the sound dentine.
 It is able to remove the smear layer, which facilitates the penetration of
adhesives, thereby enhancing the adhesional properties of restorative materials,
without compromising on the shear bond strength.

53. 1. It does not require special instruments or equipments.
2. Easy to manipulate.
3. Fast acting.
4. Ideal consistency.
1. Instruments may still be needed for the removal of caries or material.

55.  The use of lasers for cavity preparation and caries removal is based on the
ablation mechanism, in which dental hard tissue can be removed by thermal
and/or mechanical effect during laser irradiation (Keller et al., 1998).
 Lasers have shown to remove caries selectively while leaving the sound enamel
and dentin. They can be used without application of local anesthetics.
 Commonly used lasers for caries removal are Er:YAG and Er.Cr:YSGG lasers.
 Carious material contains a higher water content compared with surrounding
healthy dental hard tissues. Consequently, the ablation efficiency of caries is
greater than for healthy tissues.

56. Er:YAG
Laser

57. • Lasers have photomechanical effects, Laser light is highly energetic and when
exposed causes fast heating of dental tissues in small area.
• Fast mechanical shock waves occur due to photo-vaporization of water within
the tooth.
• This change creates high pressure, removing and destroying selective areas of
adjacent tooth.

58. • Recommended setting for Er:YAG laser:
 Caries : 100-200mj.
 Dentin : 150-200mj.
 Enamel, 200-250mj.
• Gently touch target tissue with tip end.
• Direct water stream to the target tissue.
• Always keep operation area wet.
• Keep tip moving to provoke effective ablation and better cooling.
• For deep cut move the tip constantly up and down (pumping action).

59. 1. Pulp vitality not compromised.
2. Can remove caries effectively.
3. Can perform cavity preparation effectively.
4. Quality of cavity preparation equivalent to that with the handpiece.
5. Less anxiety, pain free and anesthesia free.
6. Little or no post-operative discomfort.
7. Ideal for children and adults (comforting for both patient and parent).
1. Limitation of ErYAG: do not ablaze amalgam, gold and porcelain.

60. References
• Al-Rubaye HEA. Evaluation of carisolv in the chemico-mechanical removal of carious dentine in primary molars (In vivo study).
Tikrit Journal for Dental Sciences 2013. 61-70.
• Banarjee et al. Dentin caries excavation: a review of current clinical techniques. BDJ 2000. 188(9): 476-482.
• Beeley JA et al. Chemomechanical caries removal a review of the techniques and latest developments. BDJ 2000. 188(8):427-430.
• Brazzelli M, McKenzie L, Fielding S, Fraser C, Clarkson J, Kilonzo M, Waugh N. Health Technology Assessment 2006; 10(16).
• Ganesh M, Parikh D. Chemomechanical caries removal (CMCR) agents: Review and clinical application in primary teeth. Journal
of Dentistry and Oral Hygiene, 2011; 3(3), Page:34-45.
• Garg N and Garg A. Textbook of operative dentistry, 2nd ed. Jaypee Brothers Medical Publishers (P) LTD Ltd, New Delhi, India,
2013; chapter 5: Dental caries.
• Goldstein E et al. Air-Abrasive technology: New role in restorative dentistry. JADA 1994. 125: 551-557.
• Hegde VS, Khatavkar RA. A new dimension to conservative dentistry: Air abrasion. J Conserv Dent. 2010; 13(1): 4-8.
• Heymann HO, Swift EJ, Ritter AV. Art and science of operative dentistry, 6th ed. 2013; chapter 2:Dental caries: etiology, clinical
characteristics, risk assessment, and management.
• Kadtane SS, Bhaskar DJ, Chandan AR, Singh V, Bumb SS. Chemico-mechanical caries removal: a revolutionary alternative for
conventional method. TMU J 2014, 1(1): 1-4.
• Khullar S, Mittal A, Kumar M, Perwez E, Kumar A. Ozone therapy in pediatric dentistry: An alternate approach. The Internet
Journal of Dental Science 2012, 10(2):1-8.
• Koort HJ, Frentzen M. Laser effects on Dental hard tissues, Lasers in Dentistry.
• Laser Dentistry Amarillo TX-Laser Dentistry. Ken Comer, D.D.S., P.C. http://www.kencomerdds.com.
• Mhatre S, Kumar KSV, Sinha S, Ahmed BMN, Thanawala EA. Chemo-Mechanical method of caries removal: a brief review. IJCDS
20011. 2(2): 1-7.
• Ozone therapy for the treatment of dental caries. Danish Center for Evaluation and Health Technology Assessment-Health
Technology Alert 2005,4(1): 1-4.
• Poonam Bogra. Ozone therapy for dental caries-A revolutionary treatment for the future. JIDA 2003 74: 41-45.
• Pratap KM, Nandakumar K, Sambashivarao P, Sandhya PS. Chemo mechanical caries removal - A New horizon. Indian J Dent Adv
2011; 3(4): 668-672.
• Silva ACB, Silva DR, Silva IG, Oliveira PAP, Agripino GG, Marinho SA. Caries vaccine: current reality or remote future. 2013; P:1-
5.
• Rainey JT. Air-Abrasion: an emerging standard of care in conservative operative dentistry. Dental clinics of North America 2002.
46:185-209.
• Reyto R. Lasers and Air-abrasion new modalities for tooth preparation, Dental clinics of North America 2001. 45(1):189-213.
• Venkataraghavan K, Kush A, Lakshminarayana CS, Diwakar L,Ravikumar P, Patil S, Karthik S. Chemomechanical caries removal:
A review & study of an indigenously developed agent (Carie Care™ Gel) in children. J Int Oral Health 2013; 5(4):84-90.
• Waston TF, Kidd EAM. The Caridex caries removal system. Brit Dent J. 1986; 20: 461-462.
• Yip HK, Beeley JA. Studies on the reaction of NaOCl and NMAB with collagen J Dent Res. 1989; 68: 982.