Cariology II Martina Kukletová Caries classification (BLACK – 5 CLASSES) I. class - molars, premolar, occlussal surfaces - fissures, foramina (pits) II. class - molars, premolars - approximal surfaces III. class - frontal teeth - appproximal surfaces IV. class - frontal teeth - incisal corners lost V. class - cervical region - oral, vestibular Source: www.dent.ucla.edu Mount-Hume classification system (SiSta) SizeThe 12-way guidance grid 1 Minimal 2 Moderate 3 Enlarged 4 Extensive 1 Fissure 1.1 1.2 1.3 1.4 2 Proximal 2.1 2.2 2.3 2.4Site 3 Cervical 3.1 3.2 3.3 3.4  Primary  Secondary  Recurrent  Arrested Caries localization  Coronary  Fissures and pits  Free smooth surfaces  Approximal surfaces  Root  Caries in enamel  Caries in dentine  Caries in cement Diagnosis of dental caries What is diagnosis? Diagnosis is the art or act of identifying a disease from its signs and symptoms (Webster´s Dictionary) Diagnosis of dental caries Caries diagnosis the intellectual course that integrates information obtained by clinical examination of teeth, use of caries diagnostic aids, conversation with the patient and biological knowledge consists of inspecting the teeth immediate surrounding additional aids Diagnosis of dental caries Significance 1. forms basis for a treatment decision (D1,D2,D3,D4) 2. enables the professional to advice and inform the patient (and parents) 3. at a population level it advises health service planners Caries in enamel Detection of white spot lesion Progression of enamel caries Caries reaches the amelodentinal junction Caries of the dentine-pulp complex  Detect  Diagnose  Record The caries diagnostic examination Clinical visual examination 1. Systematic 2. Clean 3. Illumination 4. Dry 5. Push the sharp probe away 6. Radiographs 7. Caries risk assessment The caries diagnostic examination 1. Systematic according the system of charting 2. Clean tooth cleaning before examination, or tooth polishing in surgery, plaque removal in surgery after its disclosing 3. Illumination good operating light dental mirror transillumination : operating light reflected through the contact points of anterior teeth using dental mirror – caries = dark shadow (demineralized area has a lower index of light transmission than sound tooth structure) Magnifying glasses (systems) The caries diagnostic examination 4. Dry relative refractive indices: air 1.0 water 1.33 enamel 1.62 White spot lesion dried – air replaces the water in the porous tissue. The refractive index of air is farther away from enamel – lesion becomes easier to see. 5. Push the sharp probe away Probing can cause traumatic defects in lesions that can be arrested by plaque control alone (conversion of a subsurface defect to a frank cavity. Probe – indispensable part of the caries diagnostic armamentarium but The tip of the probe – very delicate tactile instrument – used gently, without pressure, then valuable information about the consistency and texture of the surface. 6. Radiographs orthopantomogram periapical bitewing When bitewing radiography for caries diagnosis is justified. How long the intervals between radiographic examinations should be. International Commission on Radiological protection (ICPR): No practice involving exposure to radiation should be adopted unless it produces sufficient benefit to the exposed individuals and the magnitude of individual doses should be kept as low as reasonably achievable, economic and social factors being taken into account Radiography must not be routinely used for all patients Individual grounds Clinical indications for every radiograph Conventional versus digital radiography digital radiography – radiation dose is reduced substantionally but little documentation on its utilization number of retakes, improved diagnostic effectivness, economic benefits Bitewings – for diagnosis of approximal caries not very reliable for occlusial caries (combination of more methods) false-positive diagnosis in the enamel-dentin area (Mach band effect, cervical burn-out)) The caries diagnostic examination 7. Caries risk assessment Previous disease : presence of restorations previous extractions new disease Dietary factors Social factors Fluoride use and plaque control Medical history Saliva Bacteria Fissure shape Risk categories high, moderate low Cariogram Advanced methods for caries diagnosis 1. Magnification 2. Temporary tooth separation (TTS) 3. Diagnostic methods based on applied physical properties Temporary tooth separation Placement of an orthodontic separator to move the teeth apart – direct visual access to a surface for diagnosis (for 3-4 days) advantage: the avoidance of exposure to ionizing radiation the ability to detect whether the surface is cavitated Diagnostic methods based on applied physical properties An overview of advanced caries diagnostic methods related to the applied physical principles Physical principle Application in caries diagnosis X-ray Digital image enhancement Digital subtraction radiography Tuned aperture computed tomography Visible light Optical caries monitor (OCM) Quantitative fibre-optic transillumination (QOTI, FOTI)) Quantitative light-induced fluorescence (QLF) Laser light Laser-fluorescence measurement (Diagnodent) Electrical current Electrical conductance measurement (ECM) Electrical impedance measurement Ultrasound Ultrasonic caries detector Coronal caries Diagnosis Visual examination, x-ray examination, FOTI, Diagnodent (laser) On following pictures you can observe the changes in caries development, white spot in the fissure (2) dark line in the fissure system (3,4), development of cavitation, from hardly visible (5), to medium and extensive (6, 7), to destructive (8). White discoloration approximally involving the marginal ridge is signalizing caries pulp. proxima or pulpal involvement (bite-wing 2, slide No.32). Visible caries (3), extent of cavitation not very large, the X-ray (bitewing) revealed caries pulp. prox. (4). Slide No 35 demonstrates caries development occlusially from intact surface to extensive cavitation. Approximal caries Diagnosis – bite-wing, OPG, Temporary tooth separation, FOTI, Diagnodent (laser) Approximal caries Approximal caries can easily be diagnosed in case of missing neighbours. Slide 42 demonstrates the radiolucency approximally reaching into the pulp vicinity on the bite-wing x-ray . The extent of caries is visible on the prepared teeth. Caries destructs the whole approximal wall and is in the close vicinity to the dental pulp. Root surface caries Diagnosis Shallow area, less than 2 mm deep mostly non cavitated, ill-defined, softened discolorated lesion destruction of cementum penetrating dentine Classification of root caries Classification (Billings 1986) Grade I (incipient) Surface texture: soft, can be penetrated with a dental explorer No surface defect Pigmentation: variable, light tan to brown Grade II (shallow) Surface texture: soft, irregular, rough, can be penetrated with a dental explorer Surface defect (<0.5 mm in depth) Pigmentation: variable, light tan to brown Grade III (cavitation) Surface texture: soft, can be penetrated with a dental explorer Penetrating lesion, cavitation present, (> 0.5 mm in depth) Pigmentation: variable, light tan to brown Grade IV (pulpal) Deeply penetrating lesion with pulpal or root canal involvement Pigmentation: variable, light tan to brown Classification according to Nyvad and Fejerskov (1982, 1987) Generally accepted at the present time 1. Active root surface lesion Any area that is well defined and shows a yellowish or light brown discoloration. The lesion is most likely covered by visible plaque and/or presents a softening or leathery consistency on probing with moderate pressure. 2. Inactive (arrested) root surface lesion Any root surface area that shows a well defined, dark brown or black discoloration. The surface of the lesion is smooth and shiny and appears hard on probing with moderate pressure. Diagnosis and Characteristics of the root caries Diagnosis clinical examination, including gentle probing primary caries secondary caries cementum dentine soft leathery hard yellow, light brown, dark brown black differentiation between active and inactive caries both active and inactive may exhibit cavitation tendency to spread circularly (Sharpey´s fibres) Histopathological features – very similar to caries in enamel and dentine demineralization, remineraliration, hypermineralized strip Treatment of the root caries – no preparation. The lesion is circular – danger of the tooth fracture. The approach is prophylactic The aim is to change the acute caries to arrested one (slide 49) 1. Motivation 2. Instruction and training of proper oral hygiene 3. Improvement of the oral hygiene 4. Change of dietary habits (nutrition) 5. Fluoridation (tooth paste, rinses, gels and mainly - varnishes Root caries, detection of the dental plaque both on the tooth and gingiva ( 1,2). Shallow cavitation approximally ( 3) Lesion is changing its appearance and colour (brown-to black), gingiva without inflammation, the lesion is glossy (4) Lesion almost heaaled, the surface is hard, glossy and discolorated to brown-black, gingiva without inflammation (5, 6) Successive changes on the root surface in case of root caries treatment localized on an incisor (7-10) and in the premolar region (1-4). Notice the change of gingiva. Oral hrealth state before the treatment and after the prophylactic approach – calculus removal, proper hygiene, changes of gingival inflammation and changes of root surface (5,6) _ the same patient. Secondary caries Sequence of changes along the cervical margin of the filling – secondary caries development Non carious lesions  Fluorosis ( see slides 69 – 74, severity of a different degree)  Tetracyclines  Amelogenesis imperfecta  Dentinogenesis imperfecta  Erosions erosion – dissolution od enamel by chemical process  idiopatic erosion – composition of saliva (citric acid)  dietetic erosion – citrus fruits, coca – cola  Profesional erosion – exposition to acids Non carious lesions Traumatic defects of enamel A. physiologic attrition – consequence of natural tooth contacts B. pathologic attrition – intensification - bruxism, use of teeth as tools Exposure of the dental pulp – rarely (secondary dentin formation) C. abrasion – pathologic loss of enamel ( and dentin) as the consequence of physical forcel other than that of occlusion (mastication). Wedge defects,plaing woodwings instruments, tooth brushing, pipe smoking Tetracyclines Tetracyclines Tetracyclines Discoloration of teeth - in dentine Amelogenesis imperfekta Amelogenesis imperfekta After plaque removal –large erosions ,penetration into the enamel Finding Primary canine –erosive loss of enamel in the whole extent