Deep carious lesions Deep carious lesions managementmanagementDeep carious lesions Deep carious lesions managementmanagement

Remaining dentin Remaining dentin thicknessthickness

�� Shallow cavity depthShallow cavity depth

–– Preparation 0.5 mm into dentin (ideal Preparation 0.5 mm into dentin (ideal depth)depth)depth)depth)

�� Moderate cavity depthModerate cavity depth

–– Remaining dentin over pulp of at least 1Remaining dentin over pulp of at least 1--2 mm 2 mm

�� Deep cavity depthDeep cavity depth

–– Depth of preparation with less than 1.0 Depth of preparation with less than 1.0 mm of remaining dentin over pulpmm of remaining dentin over pulp

�� BeforeBefore placingplacing a a restorationrestorationintointo cavitycavity youyou mustmust decidedecideifif a a cavitycavity basebase oror cavitycavitylinerliner shouldshould be be placedplaced. . ThisThisdecisiondecision isis not not alwaysalways easyeasydecisiondecision isis not not alwaysalways easyeasybecausebecause of of typestypes and and numbernumber of of basesbases and and lininiglininigmaterials. materials. NowadaysNowadaysresearchresearch givesgives newnewprotocolsprotocols -- basesbases areare not not necessarynecessary to to protectprotect thethepulp pulp

DENTIN THICKNESSDENTIN THICKNESS

�� We must remember that no We must remember that no material can provide better material can provide better protection for the pulp than protection for the pulp than dentindentin

�� The remaining dentin The remaining dentin �� The remaining dentin The remaining dentin thickness, from the depth of thickness, from the depth of cavity preparation to the cavity preparation to the pulp, is the most important pulp, is the most important factor in protecting the pulp factor in protecting the pulp from insultfrom insult

Remaining dentin Remaining dentin thicknessthickness

�� The studies have shown The studies have shown that 0.5 mm thickness of that 0.5 mm thickness of dentin reduces the effect of dentin reduces the effect of toxic substances on the toxic substances on the pulp by 75%, 1.0mm pulp by 75%, 1.0mm thickness of dentin reduces thickness of dentin reduces thickness of dentin reduces thickness of dentin reduces the effect of toxins by 90%, the effect of toxins by 90%, little if any pulpal reaction little if any pulpal reaction occurs when there is a occurs when there is a remaining dentinal remaining dentinal thickness of 2mm or morethickness of 2mm or more

�� It helps us to make a It helps us to make a decision concerning the use decision concerning the use of bases and linersof bases and liners

Why do we use bases Why do we use bases and liners?and liners?

�� to to preservpreservee pulpal healthpulpal health

�� to to creatcreate e barrier to external irritationbarrier to external irritation

�� toto seal seal thethe marginal gaps between tooth marginal gaps between tooth �� toto seal seal thethe marginal gaps between tooth marginal gaps between tooth and restorationand restoration

Causes of pulpal inflammationCauses of pulpal inflammation

�� Bacterial toxins penetrating the dentinal Bacterial toxins penetrating the dentinal tubulestubules

�� Bacterial can causeBacterial can cause

–– Pulpal irritationPulpal irritation

–– Pulpal necrosisPulpal necrosis

–– Recurrent cariesRecurrent caries

�� Leakage at the restorationLeakage at the restoration--tooth interface tooth interface due to gaps at that interfacedue to gaps at that interface

�� Trauma of tooth preparationTrauma of tooth preparation

Bacterial penetrationBacterial penetration--pulpal inflammationpulpal inflammation

Bacterial invasionat gap between

restorative-

Restorativematerial

Bacteriapenetratinggap, invadingdentinal

MutansStreptococci

restorative-tooth interface

inflammation

dentinaltubules

Sensitivity after Sensitivity after treatmenttreatment

�� Recent evidence demonstrates that pulpal Recent evidence demonstrates that pulpal inflammatory reactions to dental materials inflammatory reactions to dental materials are mild and significant adverse pulpal are mild and significant adverse pulpal responses occur more as the result of pulpal responses occur more as the result of pulpal responses occur more as the result of pulpal responses occur more as the result of pulpal invasion by bacteria or their toxinsinvasion by bacteria or their toxins

�� But instrumentation techniques elicit pulpal But instrumentation techniques elicit pulpal responses as well: rotary instrumentsresponses as well: rotary instruments--overheating, desiccation, pressure.overheating, desiccation, pressure.

Sensitivity after Sensitivity after treatmenttreatment

�� The explanation of pulpal pain in the The explanation of pulpal pain in the absence of inflammation is the absence of inflammation is the hydrodynamic theory, in a vital tooth with hydrodynamic theory, in a vital tooth with exposed dentin , there is a slow constant exposed dentin , there is a slow constant exposed dentin , there is a slow constant exposed dentin , there is a slow constant movement of fluid outward through the movement of fluid outward through the dentilal tubules.dentilal tubules.

�� When a stimulus causes the slow fluid When a stimulus causes the slow fluid movement to become more rapid, nerve movement to become more rapid, nerve endings in the pulp are deformed and the endings in the pulp are deformed and the response is interpreted as painresponse is interpreted as pain

Decision making in the use Decision making in the use of seof seaalers, liners and/or lers, liners and/or basesbases�� Remaining dentin Remaining dentin

thickness in tooth thickness in tooth preparationpreparation

�� Thermal conductivity of Thermal conductivity of restorative materialrestorative materialrestorative materialrestorative material

�� Presence or absence of Presence or absence of pulpal symptomspulpal symptoms--pain pain to stimulito stimuli

–– ThermalThermal

–– Sweets (osmotic Sweets (osmotic changes)changes)

–– Duration of symptomDuration of symptom

–– Spontaneous painSpontaneous pain

Materials to seal the tooth Materials to seal the tooth for pulpal protectionfor pulpal protection

�� Cavity sealersCavity sealers: protective coating on the cavity walls : protective coating on the cavity walls creating a barrier to leakagecreating a barrier to leakage–– Resin bonding systems (Resin bonding systems (i.e.i.e.OptiBond Solo)OptiBond Solo)

�� Cavity linersCavity liners:: cement or resin coating of minimal thickness cement or resin coating of minimal thickness (less than 0.5 mm) placed as a barrier to bacteria or to (less than 0.5 mm) placed as a barrier to bacteria or to (less than 0.5 mm) placed as a barrier to bacteria or to (less than 0.5 mm) placed as a barrier to bacteria or to provide a therapeutic effect (pulpal sedative or provide a therapeutic effect (pulpal sedative or antimicrobial effect). Applied to cavity walls adjacent to antimicrobial effect). Applied to cavity walls adjacent to pulp (pulp ( calcium hydroxide liners:Life,Dycal;glasscalcium hydroxide liners:Life,Dycal;glass--ionomer ionomer liners:liners:VitreBondVitreBond; Jonosit,; Jonosit,))

�� Cavity basesCavity bases:: placed to replace missing dentin, placed in placed to replace missing dentin, placed in thicknesses of 0.5thicknesses of 0.5--1 mm; 1 mm; these are :glassthese are :glass--ionomers: ionomers: VitreBond, Fuji IILCVitreBond, Fuji IILC, modified glass, modified glass--ionomers: Jonosit; ionomers: Jonosit; zinczinc--phosphate cements, carboxylate cementsphosphate cements, carboxylate cements))

Cavity SealersCavity Sealers

�� Provide protective coating for freshly Provide protective coating for freshly cut tooth structure in a cavity cut tooth structure in a cavity preparationpreparationpreparationpreparation

�� Cavity sealers provide a transition Cavity sealers provide a transition between cut tooth and restorative between cut tooth and restorative materiamateriall

�� In cavities of shallow or medium depth In cavities of shallow or medium depth aadhesive sealerdhesive sealers may be used without s may be used without the use of bases nor linersthe use of bases nor liners

Cavity sealersCavity sealers--bonding bonding systemssystems

Cavity linersCavity liners

�� Materials placed as thin coatingsMaterials placed as thin coatings�� Function:barrier against chemical irritationFunction:barrier against chemical irritation�� Not thermal isulatorsNot thermal isulators�� Materials laid down in a thin layer (less than 0.5 Materials laid down in a thin layer (less than 0.5

mm)to protect the pulp tissue from irritation from mm)to protect the pulp tissue from irritation from mm)to protect the pulp tissue from irritation from mm)to protect the pulp tissue from irritation from chemical insultchemical insult

�� These materials are generally not strong and are These materials are generally not strong and are not intended to be placed in thick amounts not intended to be placed in thick amounts

�� Materials that can be used as cavity liners: calcium Materials that can be used as cavity liners: calcium hydroxide liners:dycal,life; glasshydroxide liners:dycal,life; glass--ionomer liners, ionomer liners, resinresin--modified glassmodified glass--ionomers: Jonosit, Interfaceionomers: Jonosit, Interface--Kerr; zincKerr; zinc--oxide and eugenol liner,oxide and eugenol liner,

�� Liners should be applied with a minimal Liners should be applied with a minimal thickness (less than 0.5 mm)thickness (less than 0.5 mm)

�� Use minimal amount of liner to achieve Use minimal amount of liner to achieve resultresult

Guidelines for liningGuidelines for lining

resultresult

�� Calcium hydroxide should be placed only Calcium hydroxide should be placed only where needed adjacent to pulpwhere needed adjacent to pulp

WHY do we use that small amount WHY do we use that small amount of calcium hydroxide liners? of calcium hydroxide liners?

Many studies have shown that Many studies have shown that calcium hydroxide liners calcium hydroxide liners have poor physical have poor physical properties and their high properties and their high solubility may result in solubility may result in softening of the liner and softening of the liner and softening of the liner and softening of the liner and material loss under the material loss under the restoration that is not restoration that is not properly sealed. properly sealed.

These unfavorable properties These unfavorable properties of Ca(OH)2 materials of Ca(OH)2 materials restrict their use to restrict their use to application over the application over the smallest area that would smallest area that would suffice to aid in the suffice to aid in the formation of reparative formation of reparative dentindentin

Cavity basesCavity bases

�� Barrier against chemical irritationBarrier against chemical irritation

�� Provide thermal insulationProvide thermal insulation

�� Resist forces of condensationResist forces of condensation

�� Restore internal formRestore internal formRestore internal formRestore internal form

�� Are intended to form a thick layer of material to protect Are intended to form a thick layer of material to protect the pulp tissue from irritation from chemicals or thermal the pulp tissue from irritation from chemicals or thermal insult, and to provide a solid base to resist condensation insult, and to provide a solid base to resist condensation forcesforces

�� Commonly used base materials include: glass ionomer Commonly used base materials include: glass ionomer cement: Kavitan, Photac Fil, Fuji, Ketac Molar; cement: Kavitan, Photac Fil, Fuji, Ketac Molar; polycarboxylate cement, resinpolycarboxylate cement, resin--modified glassmodified glass--ionomer ionomer cement, zinc phosphate cementcement, zinc phosphate cement

Guidelines for basingGuidelines for basing(best base is always the tooth (best base is always the tooth structure itself)structure itself)

�� Do notDo not remove healthy, sound tooth remove healthy, sound tooth structure to provide space for basestructure to provide space for base

�� Use base as buildUse base as build--up and blockup and block--out for out for cemented restorationscemented restorationscemented restorationscemented restorations

�� If using base for amalgam or composite If using base for amalgam or composite restorations minimize extent of base. restorations minimize extent of base. Always try to leave a dentin seat for the Always try to leave a dentin seat for the restorative materialrestorative material

�� Do notDo not base a preparation to create an base a preparation to create an “ideal depth.” This is contraindicated and “ideal depth.” This is contraindicated and can lead to increased risk of restoration can lead to increased risk of restoration fracture.fracture.

Recommendations for Recommendations for composite resincomposite resin

Shallow cavity depth

adhesive composite resin

Moderate cavity depth

Deep cavity depth

glass ionomer liner adhesive composite resin

Calcium glass adhesive composite resinHydroxide ionomer

Deep cavities Deep cavities

�� Indirect pulp cappingIndirect pulp capping �� Direct pulp cappingDirect pulp capping

Direct and Indirect Pulp Direct and Indirect Pulp CappingCapping

�� The tooth must be vital and have no The tooth must be vital and have no history of spontaneous painhistory of spontaneous pain

�� The result of pulp tesing should not The result of pulp tesing should not �� The result of pulp tesing should not The result of pulp tesing should not linger linger

�� A periapical XA periapical X--ray should show no ray should show no evidence of pathologyevidence of pathology

�� Bacteria must be excluded from the Bacteria must be excluded from the side by permanent restorationside by permanent restoration

Indirect pulp cappingIndirect pulp capping

�� Placing calcium hydroxide liner over a thin layer of Placing calcium hydroxide liner over a thin layer of remaining dentin over the pulp, this procedure remaining dentin over the pulp, this procedure concerns most of deep carious lesions with thin concerns most of deep carious lesions with thin layer of remaining healthy dentinlayer of remaining healthy dentin

�� Involves the partial or total removal of carious Involves the partial or total removal of carious �� Involves the partial or total removal of carious Involves the partial or total removal of carious dentindentin--removing the carious tooth structure to a removing the carious tooth structure to a pointpoint-- demineralized dentin may be left only over demineralized dentin may be left only over the pulp to avoid the exposurethe pulp to avoid the exposure

�� Demineralized dentin not near the pulp should be Demineralized dentin not near the pulp should be completely removedcompletely removed

�� Setting calcium hydroxide liner placed over the Setting calcium hydroxide liner placed over the (Dycal,Life)(Dycal,Life)

Indirect pulp capIndirect pulp cappingping

Restorative

Glass-ionomerLife

Glass-ionomer

Leathery dentin

Direct pulp cappingDirect pulp capping

�� in case of accidental or carious pulp in case of accidental or carious pulp exposureexposure

nonnon--setting calcium hydroxide is placed on setting calcium hydroxide is placed on exposed pulp (Biopulp) and setting calcium exposed pulp (Biopulp) and setting calcium exposed pulp (Biopulp) and setting calcium exposed pulp (Biopulp) and setting calcium hydroxide (Dycal,Life) on nonhydroxide (Dycal,Life) on non--settingsetting

�� it stimulates pulp to form odontoblasts it stimulates pulp to form odontoblasts which can produce a layer of reperative which can produce a layer of reperative dentindentin-- dentin bridgedentin bridge

�� Direct pulp exposures can heal normally but Direct pulp exposures can heal normally but a bacteriaa bacteria--free environment is requiredfree environment is required

Direct pulp capDirect pulp cappingping

Glass-ionomer

Restorative

LifeBiopulp Glass-ionomerBiopulp

Direct pulp cappingDirect pulp capping--the the prognosisprognosis

The chance that direct pulp capping will cause the formation of a The chance that direct pulp capping will cause the formation of a dentin bridge and the tooth will become vital is only under the ideal dentin bridge and the tooth will become vital is only under the ideal conditions:conditions:

--small mechanical exposure has better prognosis comparing to carious small mechanical exposure has better prognosis comparing to carious --small mechanical exposure has better prognosis comparing to carious small mechanical exposure has better prognosis comparing to carious exposureexposure

--young pulpyoung pulp

--no bacterial contamination of the exposureno bacterial contamination of the exposure

--the degree of bleedingthe degree of bleeding-- increased bleeding is associated with increased bleeding is associated with increased likelihood of failureincreased likelihood of failure

--the tooth must be isolated and a proper hemostasis achievedthe tooth must be isolated and a proper hemostasis achieved

--the tooth has to be restored with well sealed restorationthe tooth has to be restored with well sealed restoration

Technique forTechnique for direct and direct and indirect indirect pulp cappingpulp capping

Deep cavity depth

Carious pulpal exposure Life G-i over Life

Caries ControlCaries Control

When to do treatment with caries control:When to do treatment with caries control:�� Deep caries without pulpal invasion as determined Deep caries without pulpal invasion as determined

by radiographs, symptoms and vitality testing. by radiographs, symptoms and vitality testing. Note: deep caries with pulpal involvement requires Note: deep caries with pulpal involvement requires Note: deep caries with pulpal involvement requires Note: deep caries with pulpal involvement requires total caries removal to evaluate tooth restorability total caries removal to evaluate tooth restorability and endodontic therapy if tooth is restorableand endodontic therapy if tooth is restorable

�� Multiple teeth with extensive caries requiring Multiple teeth with extensive caries requiring placement of temporary restorations to stabilize placement of temporary restorations to stabilize active diseaseactive disease

�� As a diagnostic tool, will pulp survive treatment; As a diagnostic tool, will pulp survive treatment; tooth may be become symptomatic after treatmenttooth may be become symptomatic after treatment

Caries control treatmentCaries control treatment

Removal of gross caries (very soft consistency caries) from the Removal of gross caries (very soft consistency caries) from the pulpalpulpal,,axial and lateral walls; leathery carious dentin adjacent axial and lateral walls; leathery carious dentin adjacent to the pulp on the pulpal and axial wall may remain.to the pulp on the pulpal and axial wall may remain. In order In order to cause remineralization and reperative dentin formation we to cause remineralization and reperative dentin formation we place materials that stimulate odontoblasts for production of place materials that stimulate odontoblasts for production of reperative dentin.reperative dentin.reperative dentin.reperative dentin.

Treatment:Treatment:

Calcium hydroxide Calcium hydroxide oror ZincZinc--Oxide Oxide

and and GlassGlass--iionomersonomers Eugenol Eugenol

Reevaluation of the cavity after 3 months and replacing Reevaluation of the cavity after 3 months and replacing temporary material for the permanent restoration. temporary material for the permanent restoration.

Caries control with glass Caries control with glass ionomerionomer

Not all Caries removedOn axial wall

Deep caries

Glass ionomer placement