Management of deep
caries
By
Dr / Belal Saleh
Management of deep caries
• introduction :
In general , management and dealing with simple and
moderate caries , regarding diagnosis, caries removal, and
restoration does not have any challenges .
• Contrary, the deep carious lesion encountered a real
challenge in diagnosis and treatment, it should be examined
thoroughly to differentiate between different treatment
modalities that could be expected:
- Direct pulp capping.
• - Indirect pulp capping.
• - Root canal treatment.
• - Deep cavity with sub-base and G.I. base cement
( conventional treatment).
Introduction:
The severity of the carious lesion
is determined by :
1) The decay type, whether acute or chronic.
2) The amount of loss tooth structure.
3) The extent of lesion in enamel and dentin.
Tooth chronic caries
Exposed pulp in proximal deep caries
The main types of caries
• We can classify the caries according to behavior and severity of
attack into two main types; acute and chronic caries.
Acute caries:
- It is a rapidly progressive caries.
- The acid penetration occurs before bacterial
invasion ,so the last layer is aseptic .
- For this reason indirect pulp capping is mostly
success.
- Clinically it appears yellow.
- The caries is usually goes rapidly in the apical direction
toward the pulp and may cause pulp exposure without destruct
a large area of enamel and dentin.
chronic caries:
- It is slowly progressive caries.
- In this type the acid penetration is coincides
with bacterial invasion , so the last layer is both infected and
affected .
- Clinically it appear dark brown.
- It usually destruct the enamel and dentin in lateral direction
more than toward the apical one, so it may destroys large area of
tooth before causing pulp exposure, specially if it not treated
early.
Notice : patient with a long-term deep chronic caries is usually
come to your clinic with necrotic pulp (non vital tooth )
regardless does it clinically exposed or not.
Chronic caries
Chronic caries under old amalgam
Class I cavity with lingual spots
Badly decay tooth with chronic caries
Carious process may cause irritation to
the pulp through three distinct causes:
1) Biological irritation from bacteria and their
toxins.
2) Chemical irritation from acids.
3) Physico-mechanical irritation resulting from
thinning of the remaining dentin bridge.
Examination and Diagnosis of deep caries:
The examination of tooth with deep caries to determine is
it exposed or not, and to distinguish the pulp condition
are not easy . Therefore, collective data and thorough
examination should be follow to create a proper
treatment plane.
Examination of deep caries
1) Personal data: e.g.
young age → High pulp horn with huge size of the
pulp→ pulp exposure is mostly expected
2) Past dental history:
- Old amalgam filling with recurrent caries → is usually
produces mild to moderate irritation → stimulates pulp
to lay down reparative dentine.
- Bad oral hygiene with multiple carious teeth → pulp
exposure is expected in tooth with deep caries→
specially when there is endodontic ttt before.
3) Patient’s complain: (mostly is pain)
It gives an idea about the degree of pulp damage .
- Pain on thermal stimuli disappears after removal
of the stimuli → pulp hyperemia.
- Throbbing , sharp and dull pain, continuous and
standing after removal of stimulus → irreversible
pulpitis.
- Pain elicited with hot and fading gradually by cold
→ last stage of pulpitis and beginning of pulp
degeneration.
- pain with sweets, it usually indicate
hypersensitivity.
4- Radiograph examination:
Because the x-ray give only two dimensional for a three
dimensional objects, it can not detect the pulp
exposure accurately. But it constitutes a valuable
diagnostic tool to give an idea about:
a) The proximity of the lesion to the pulp.
b) Reparative calcific changes in and around the pulp
whether circum-pulpal aging or localized against
caries lesion.
c) Size of the pulp.
d)Thickening of the periodontal membrane space,
intactness of lamina Dura and closure of the apical
foramen.
5) Clinical inspection of cavity floor.
Clinical inspection should be done after excavate & remove
all carious dentin except the last layer, and then inspect the
floor of the cavity by tactile and optical sensations (to detect
the change in color and surface texture).
- If the last layer of remaining carious dentin is
deeply dark stained and large, it should be removed
even if it hard.
- If it hard and ranging from dark yellow to light brown color
and by exploration not catches, it should not be skipped,
particularly in very deep cavity where if it removed the pulp
will be exposed.
On the other hand , if the remaining caries is soft ,
excavation should be done, care must be taken and the
excavation should be parallel to the recessional line of the
pulp . In this case three probabilities of diagnosis could be
expected:
1) Wide infected exposure particularly with chronic caries
→ indicated for→ thorough RCT.
2) Deep cavity with sub clinical microscopic pulp exposure (
the remaining dentin thickness is less than o.5 mm.)
3) If the remaining caries is
skipped , the tooth will surely be clinically exposed . In this
case, careful examination must be done to assess pulp
vitality and defined the following :
a) Whether the pulp exposure is still surrounded
with peripheral decay or not ,
- if it surrounded → pulp is surely infected → bad
prognosis → RCT is the line of treatment.
On the other hand , if it not surrounded with
carious dentin , further excavate of caries
particularly from the area which closely related to
the pulp → assuring pulp vitality →indirect pulp
capping → follow up by radiographs, pt. complain,
and diagnostic aids.
N.B: Treatment plane for deep cavity with sub- clinical
pulp exposure is usually root canal treatment.
b) After excavation of all carious dentin
( peripherally and which closely related to the
pulp), pin point pulp exposure with red oozing
blood may discovered → if the field is aseptic
( acute caries) → direct pulp capping→ follow up
c) The last expectation is: After excavation , the
pulpal floor is sound and free from any type of
exposure → diagnosed as deep cavity without pulp
exposure → sub-base + + base +permanent rest.
Direction of caries removal
Direct pulp capping
Pulpal floor with dark black dentin
( This dentin should be removed)
Dark black dentin
( this dentin should be removed)
Finished cavity with remaining hard
discolored dentin
Soft caries had removed, with remaining
hard discolored dentin
6) pulp tester:
It may give idea about the pulp condition (vital or non vital only)
Thermal : pain on hot or cold application may denote pulp vitality but
negative reactions do not mean devitalized pulp, specially if it
compared to the adjacent tooth or contra lateral one.
Electric : The electric pulp tester must be applied to the neighboring
and the contra lateral side for comparison.
The minimum current needed to elicit response must be
recorded and compared to the condemned tooth.
If higher or lower current is needed than the control .
this denotes pulp affection . But if the tooth not response to electric
current , it may indicate devitalized tooth.
7) percussion:
If the tooth is tender , it usually referred to sever pulp
inflammation with periodontitis.
3 canal orifices in mandibular molar
Tooth with hidden chronic caries
Fate and effect of microorganisms under
restoration of deep caries :
• After totally removing of superficial & peripheral carious
dentin ,several types of microorganisms may still
exist ,particularly with chronic caries.
• The biological testing for these restorations were reported
the following findings:
1) There was a sharp decrease in the number of
microorganisms .
2) The residual microorganisms (mainly streptococci &
staphylococci ) had under gone morphological changes.
3) No caries activity in the form of de-mineralized was
observed.
* These findings could be explained on the
basis of two mechanisms:
a) Depriving these aerobic microorganisms
from air after sealing the cavities ,would
definitely have an affect on their life, behavior
and activity .
b) Absence of one of the basic factors of the
caries triad(diet) , therefore the parameter or
etiology of caries process has ruptured.
Treatment plan of deep caries:
The basic idea in treatment of deep carious lesion is to
promote or enhance the calcific reparative capacities
of the pulp and prevention of further irritation of the
P-D organ . This is can realized by :
1- Minimal traumatic procedure through proper
operative technique and smart selection of the
restorative material
2) Proper pulp medication through the application of
suitable insulating base material .
3) Proper sealing of the final restoration.
4) Periodic follow up by radiograph and other
diagnostic tool, to assess the condition of the pulp
tissues.
General steps of treatment:
1- Excavation of caries in direction parallel to recessional lines of the pulp
especially when the exposure is expected and in case of indirect pulp capping
technique.
2- Removing of undermined enamel using hand instruments better than rotary
one.
3-Finishing the enamel wall and c.s.m to be smooth and according to the type of
restoration.
4- Select suitable capping material such as ca-hydroxide to be placed into floor of
the cavity and then covered by basecement.
5- perfectly sealed permanent restorations.
N.B. Zinc oxide/eugenol cement may use as temporary
filling (T.F) when there is no direct contact with the pulp
tissue specially with multiple carious teeth(deep cavity
without exposure). In this case the patient come in the
next visit (not more than one week) to remove a layer
of T.F. and left a reasonable layer of cement to be used
as a base and sub-base material.
Ca. hydroxide application
• Ca hydroxide should be applied on exposed
area only.
Mechanism of action of Ca. hydroxide on deep
carious dentin :
The exact mechanism action of Ca. hydroxide is not
known. However two theories are accepted:
a) Precipitation of reparative dentin. studies using
labeled calcium hydroxide with radioactive isotopes
revealed that the source of ca ions is not from
calcium hydroxide.
b) Calcium hydroxide create good environment and
provide smooth surface to the area of exposure to
attracts U.M.Cs where it differentiate into
odontoblasts cells to form reparative dentin.
General steps of direct pulp capping
• 1) After assuring the vitality and healthy of the pulp, local anesthesia
is administered .
• 2) Isolation of the operative field by rubber dam.
• 3) Excavation of the all carious dentin.
• 4) Control of bleeding by sterile warm water.
• 5) Application of calcium hydroxide at the site of exposure without
pressure.
• 6) Banding the tooth with a properly sealed restoration.
• N.B: it is prefer to use permanent restoration without pressure. If
the restoration is temporary, it should be changed after one weak
without disrupt the capping layer.
• 6) Follow up , (reparative dentin could be formed within 2-3 weeks).
• .
comments:
1) When the
caries extend apically more than 2.5 mm. from DEJ towards the
pulp (nearly all working head of the fissure bur is invested) ,the
pulp is mainly exposed.
2) Also, when the caries in proximal surface extend towards the
pulp more than 2mm.(1.5mm for premolar), the pulp is
considered exposed.
the above 2 comments are for acute caries.
3) The tooth with deep chronic caries , it mostly has a necrotic
pulp, specially when it standing for long time without treatment.
Criteria of successful direct pulp
capping
• Requirements of direct pulp capping:
• Good prognosis of D.P.C:
• Asymptomatic tooth with normal response to normal
vitality test.
• Pin-point exposure (0.5mm or less in diameter)
• Non-hemorrhagic or easily controlled.
• Dry, sterile field (using a R.dam ).
• A traumatic exposure with minimal manipulation of
cavity floor.
The success or failure of direct pulp capping
depends on :
a) Size and site of the exposure .
b) Salivary contamination .
c) Sterilization of the instruments .
d) Pulp condition and general health of the
patient
e) Excellent marginal seal restorations
