Operative Dentistry

department

Motamiz OPRD 42

Lecture 2

WED 18-3-2020

Management of deep

carious lesions

- Success of vital pulp therapy depends on the proper

diagnosis and estimation of the prognosis of the pulp

condition.

- In order to conduct a proper diagnosis of the pulp

condition and extension of the carious lesion. There are

several evaluating means are performed to form complete

picture of the P-D organ and reaching the correct line of

treatment by proper diagnosis using:-

- Patient history, clinical examination, radiographic

examination, other clinical tests and pulp sensitivity and

vitality tests.

Management of deep decay

Patient history should be obtained in terms of:-

Presence or absence of pain.

Incidence of pain ( sudden, intermittent, continuous).

Type of the stimulus ( hot , cold, sweets, on biting,

without stimulus).

Duration.

Severity (mild, moderate, severe).

1-History of pain

The presence of pain guide the operator about the pulp condition:-

- Sensation of short pain with sweet, cold and hot in the presence of bare dentine surface due to caries or fractured restoration is indicative of pulp vitality. (reversible pulpitis / pulpal hyperemia)

- Pulpal hyperemia---decrease in the pain threshold is due to the increased vascularity and widening of endothelial spaces which cause accumulation of edema in the interstitial tissue at the pulp. It stops on removal of stimulus and inflammatory state resolve following treating the cause.

- Acute irreversible pulpitis---lingering sharp shooting, lancinating pain which may be spontaneous or precipitate by a stimulus but does not disappear after removal of the irritant.

Thermal: By application of hot or cold may denote pulp vitality

Electric: It is one of the most accurate methods. It detects nerve sensation of the pulp. Electric pulp tester must be applied to the neighboring and the contralateral side for comparison

Response—vital

Not responding—degenerated or necrotic

Limitations with sensitivity pulp tests:-

1-Not measure the blood flow.

2-False-positive or false-negative especially in teeth presenting traumatic injuries or incomplete maturation or large restoration.

3- Being subjective because depend on responses provided by the patient.

2-Pulp sensitivity and vitality testing

a -Thermal and Electric pulp testing:

New advanced methods have been developed measuring

pulp vascularization

B- Pulse Oximetry----Measuring pulpal blood oxygen

saturation.

- It is effective and reliable method giving objective

results

- Useful in testing traumatized teeth.

C- Laser Doppler flowmetry ( LDF) --- measure blood

flow even in very small blood vessels.

- Presence of pulp exposure during excavation of carious

lesion usually indication of the progression of the lesion

faster than the rate of P-D reaction.

- Reparative reactions of P-D organ depends on the extent of

exposure and the conditions at which this exposure occurred.

Pin point exposure with peripheral sound dentin and no or

minimal hemorrhage denoting mild to moderate pulp

inflammation with possibility of reparative ability.

On the other hand, presence of a carious pulp exposures with

peripheral soft decay surrounding and profuse bleeding are

indicative of advanced pulp inflammation and poor

prognosis and immediate root canal treatment is the line of

treatment.

3-Presence of pulp exposure

4- Percussion test:- - Tenderness of tooth to percussion is of a

little value indetermination of pulpal state.

In cases of extensive inflammation of pulp

with periapical involvement the sensitivity

becomes severe indication of radical

treatment should be carried out. 5- Radiograph

It cannot detect any pulp exposure, but it constitutes a

valuable diagnostic tool to give an idea about:

♦ The proximity of the lesion to the pulp.

♦ Reparative calcific changes.

♦ Size of the pulp.

♦ Thickening of the periodontal membrane space.

- The tooth must be vital and have no history of spontaneous pain. Pain not longer after stimulus removal.

- A periapical radiograph should show no evidence of periradicular lesion of endodontic origin.

- Bacteria must be excluded from the site

TECHNIQUES FOR MANAGEMENT OF THE

DEEP CARIOUS LESION

The classical way (extension for prevention)

Remove all carious dentin leaving hard sound dentin---is very radical and invasive technique (increase risk of pulp exposure especially with very deep lesions).

Conservative way (incomplete caries removal)---to preserve the viable tooth St.

This new concept of carious dentin excavation based on the idea that:-

1-Caries is a pathological reversible disease.

2-Not all carious dentin is infected with cariogenic microorganism.

3- good peripheral seal is very crucial for long term success as it deprive the bacteria from the nutrient.

- Infected carious dentin:-

The outer carious infected dentin, soft brownish and filled with

bacteria.

- Affected carious dentin:-

The inner carious affected dentin, soft yellowish and bacterial

sterile.

- It is not easy clinically to discriminate the border line between

them to stop at even with use of caries detection dyes.

- With very deep carious dentin ( deeper than 2mm from DEJ) it is

not mandatory to remove all soft carious dentin ????

Any left dentin even it is infected at the base of cavity did not

progress to the failure of the restorations, as long as good

peripheral seal was established and maintained.

First step (visit)

1- complete caries and undermined enamel removal from peripheries and walls of the cavity is done.

2- Removal of gross mass of soft infected dentin in a direction parallel to recessional line of the pulp by sharp excavator leaving what is close to pulpal floor.

3- Sealing of tooth by a provisional restoration e.g. glass ionomer

4- Followed up for several months(at least 3 moths)→ remineralization and development of tertiary dentin

N.B: When medicament liner (e.g. calcium hydroxide or mineral trioxide aggregate)this technique called indirect pulp capping.

Second step (Re–entry visit)

After confirming the vitality of pulp and laid down of dentin bridge by the x ray. Complete excavate the residual caries which will be harder then sealing the cavity by a final restoration.

A- Stepwise excavation

B- Partial caries removal (one step) technique

It omits the re-entry visit by sealing the tooth with a

final restoration in the same visit.

One step technique reported a higher clinical success

rate compared to two-step technique??? because

pulp exposure may occur in the second visit

during caries removal.

The procedure of lining the exposure site with

medicament liner e.g. calcium hydroxide or MTA and

sealing the cavity by well sealed restoration to

stimulate reparative dentin bridge with subsequent

follow up periods.

- Pulp exposure can occurred either (pathological or

traumatic).

- Also, there is what called microscopic exposure ( when

the dentin bridge is less than 0.5 mm) size and

number of open D.T increase pulp is relative to a

true pulp exposure.

Direct pulp capping

Indication

1- There are no sign or symptom of degeneration of P-D organ

2- The field of operation is completely aseptic. ( preferred to use

rubber dam)

3- The exposure has the following characteristics:-

- Size— exposure is pin point

- There is either no hemorrhage from the site or if there is

hemorrhage, immediately coagulate in the form of small point

at the site.

- Dentin at the periphery is repairable

- Traumatic pulp exposure.

Procedure

1- All undermined enamel and unsound dentin should

be removed.

2- The cavity floor and exposure site should be gently

cleaned with sterile water and dried with sterile

cotton pellet not air spray.

3- Use either MTA or calcium hydroxide as capping

material.

4- The permanent restoration should be placed

5- Follow up

The general considerations in prognosis of

management of deep caries should be noted:-

- The basic idea for treating deep caries is to enhance the

reparative capacity of the pulp-dentin organ ant to prevent

further irritation.

- Minimal traumatic procedure.

- Proper capping.

- Proper sealing of the permanent restoration.

- Periodic follow up.