MANAGEMENT OF CARIOUS LESIONS

Caries excavations are done during what stage of tx

Control phase

We do caries excavations when tooth tests _____ with signs of ________ OR __________

Vital

Healthy pulp or reversible pulpitis

When are control restorations placed during caries excavation (2)

Cost?

Time restraints or until final tx plan determined

None

Prior to beginning a caries excavation

Review ______

Evaluate and or update _______

______ Exam

____ diagnosis

______ diagnosis

______ plans

______ _____ ** most important

Medical history

radiographs

Clinical

Pulpal

Periapical

Treatment

Informed consent

What instruments are used in caries excavations (2)

Spoon excavator

Slow speed large round bur

The aim of carious tissue removal is to retain the ____ and _______ of its _____ for as long as possible

Tooth

Health - pulp

Should you do caries excavation on a tooth that is non vital

NO

Guiding principles of carious tissue removal

________ of dental tissues

Maintenance of _______ health

Avoidance of _______

Avoid _______

Provision of sound _______ to achieve an adequate _____

Preservation

Pulpal

Pulp exposure

Anxiety

Margins - peripheral seal

Selective removal is based on what

Lesion severity

Selective removal for moderate lesions (outer 1/3 of dentin)

To firm

Selective removal for extensive lesions (beyond outer 1/3 dentin)

To soft

Complete caries removal is considered what

Overtreatment

Restoration longevity is more important in what kind of lesions

Moderate

Preservation of pulpal health is prioritized in what kind of lesions

Extensive/deep

What is the best guide for reaching firm dentin in moderate lesion removal

Tactile sense

Involving inner pulpal third or quarter of dentin with clinically assessed risk of pulpal exposure

Extensive lesions

Will deform when hard instrument is pressed onto it and can easily be scooped up with sharp hand excavator with little force

Soft dentin

Dentin does not deform when instrument is pressed into it - can still be easily lifted without much force required, little difference between firm, more of a transition

Leathery dentin

Physically resistant to hand excavation, needs some pressure to be exerted through instrument to lift

Firm dentin

Pushing force needs to be used with hard instrument to engage, only sharp cutting edge or bur will lift it, scratchy sound or "cri dentinaire" can be heard with probe across it

Hard dentin

Sequence of Caries Excavation:

Access ____ and initiate _______

Establish ________ form

Establish _____ form

Re-evaluate ______ and ______

Place ______ as appropriate

Place _______

lesion - decay removal

external/periphery

internal

prep walls and cavosurface margins

pulpal protection

restoration

Peripheral walls should be extended into what kind of dentin

Sound / intact

The periphery of a lesion must be _____, ____ and free of ______

Clean

Hard

Discoloration

Prior to restoring:

remaining enamel should be ______ and allow for the most ____ restoration

Sound

Durable

Prior to restoring:

DEJ visibly free of _____ and _______

Enamel feels ____ with an explorer and cannot be removed with a _________

Stain and discoloration

Hard

Spoon excavator

If enamel is demineralized it is _____ and _____ NOT _____ or ______

Shiny and intact

Flaky or dull

Arrested Caries:

Dentin or cementum that is _____ but ____ and ____

Discolored

Hard and shiny

When do you treat arrested caries

Only if patient wants (esthetics)

What kind of restoration after excavation:

Sufficient remaning tooth structure

Lacking significant amount of tooth structure

Direct

Indirect

If there is not enough time to place a direct restoration after excavation, what should you place

GI

What do you need to place for indirect restorations before final restoration?

How long do you have to wait to place final restoration

Why?

Core build up

4-8 mo

Ensure pulp vitality

When does pulp need protection?

After ______ intervention for removal of _____ caries affected tissues leading to ____ or ___ preps

_____ preps

Presence of ________ pulp exposure

______ ______ exposure due to ____ or ______ foods

Surgical - enamel/dentin - medium/deep

Full crown

Mechanical

Cervical dentin - mechanical or acidic

No material provides better pulpal protection than what

Dentin

RDT >___mm provides little pulpal reaction to irritants

2

RDT < __mm has the greatest impact on pulp

.5mm

Provide a protective coating to the walls of a prepared cavity and a barrier to leakage at the interface

Sealers

Where are sealers placed

All walls in their entirety

Varnishes and adhesives are examples of what

Sealers

Varnishes and Adhesives:

Use when no ________

Provide a protective coating for freshly cut ______ with intent of preventing post op ______ and _______

Seals _________

Pulpal exposure

dentin - sensitivity and microleakage

dentinal tubules

Varnishes are made of what

Adhesives are made of what

Natural resin or synthetic resin

Bonding agents

Cement coating of minimal thickness to provide a therapeutic effect or a physical barrier to bacterial

Liners

Where are liners placed

How thick?

Placed between what two things

Bottom of cavity prep

<.5 mm

Tooth and restorative material

Where are liners never placed on

Enamel -> only place on walls adjacent to pulp

Examples of liners (3)

CaOH2, MTA (mineral trioxide aggregate) , RMGI

Consider placing liner if RDT is less than _____ but there is NO _________ evident and _____ caries is removed

2

Pulp exposure

All

What must be used in teeth with large carious lesions

Rubber dam :)

Use is not only critical to success of composite resin restorations

Rubber dam

When exposure site occurs in area of normal dentin usually as a result of misjudgement or operator error (aggressive handpiece use, explorer tips)

Mechanical pulp exposure

When exposure site is consequence of infected dentin extending into pulp

Carious pulp exposure

Indications for dycal

Direct pulp capping and indirect pulp capping

Main component of dycal

Calcium hydroxide

Dycal and vitrabond contraindications

Patients with severe allergy to methacrylate resins

Can you use vitrebond for direct pulp capping

no

What is vitrebond

Components?

Liner

RMGI

Vitrebond and dycal are both ___ setting and ___ in color

Minimally affected by ________

Contains ______

Only to be placed on ________

Rigid - white

Phosphoric acid

Monomers

Dentin

Vitrebond

Layer thickness

Curing time

2.5 mins

<1.5 mm

20 seconds

Dycal must not be placed where

Prep margin

Dycal requires the use of a _____

Only increments of ____mm

Rubber dam

1mm

A technique for treating NEAR pulp exposure with a material that promotes reparative dentin formation

Indirect pulp capping

Technique for treating pulp exposure with a material that seals over the exposure site and promotes reparative dentin formation

Direct pulp capping

Indirect pulp capping is indicated for what

Deep carious lesions

Procedure for indirect pulp capping:

____ and _______

____ tooth

Use ______ and ______ to remove caries

Place what material over remaining _______ dentin

Place what material over it, ensuring that margins are completely _____

Place ________

Anesthesia and RD

Prep

Slow speed and spoon exc.

Calcium Hydroxide (Dycal) - demineralized

RMGI (vitrebond plus), sealed

restoration

Procedure for direct pulp capping:

______ and _____

____ tooth

Use _____ and _______ to remove caries

When pulp is encountered, use what material first?

Then what material?

Light cure for how long

Place ________

Anesthesia and RD

Prep

Slow speed and spoon exc.

CaOH2 (dycal)

RMGI

20s

Restoration

When doing indirect pulp capping, you should leave demineralized dentin where?

Only in area immediately adjacent to pulp

Dycal:

Place layers in ____mm

Effect on pH?

Anti_____ properties

Stimulates _______

Poor _______ properties

.5

Neutralizes

Antibacterial

Pulp

Physical

RMGI (vitrebond plus)

Layer thickness?

___ release

What kind of bond?

Better _____ properties than CaOH2

.5

Fl

Chemical

Physical

During Direct pulp capping:

Where do you place Dycal?

Where do you place vitrebond?

Over and slightly beyond exposure site

Alternative capping material that is frequently used in endo

MTA (Mineral Trioxide Aggregate)

MTA:

____pH anti_____ effect

Good ____ properties

Protects against _______

Extended ____ time -> how long?

High - bacterial

Physical

microleakage

setting -> >2hrs

MUSoD protocols for carious pulp exposures

Immediately notify faculty

If ou experience a carious pulp exposure (not mechanical) >.5mm in diameter and cannot achieve hemostasis what should you do

extirpate pulp and plan endo

Direct Pulp Capping is most likely successful when:

Pulpal exposure is ______

Pulp is free of _____ contamination and exposure occurred in _____ and ________ field

Exposure was relatively _______ , little _________of tooth occurred with no evidence of ________ of blood into dentin (what is this called)

small

salivary

atraumatic - desiccation - aspiration

dentin blushing

Direct Pulp Capping is most likely successful when:

____________ from exposure is easily controlled

________- exposure is not evident

Tooth was _________ prior to cavity preparation

Patient is _______-

Hemorrhage

Carious

Asymptomatic

Young

Clinically, if a temp/control restoration has previously been placed over a pulp capping liner and the teeth is re-entered for a restorative procedure, should you remove the pulp capping material

NO

Temp material of choice at MUSoD for temporization of caries excavations

GI - equia forte

Benefits of using GI as a control restoration:

______ bond to tooth-> No ___________ required

Bonds to _____vtooth

_____ release

Good ______ seal (minimal ______)

________ ________ similar to natural dentin

Bio______

Direct - bonding

moist

Fl

Marginal -> shrinkage

Thermal expansion

Compatible

Sandwhich technique takes advantage of ___ properties with _____ of _____

GI

Esthetics - composite resin

Sandwhich technique is used for what caries risk classification?

High risk

Open Sandwhich:

Layer of ____- at base

_____,______ and _____

________ layer - should also be in what

CGI or RMGI

etch, prime, adhesive

resin - contact area

TRAUMATIC RESTORATIVE TREATMENTS (ART)

are based on sound concept of maximum ______, minimal _______ intervention and minimal ________ ____

Often used in what types of environments

Prevention

surgical

tooth prep

Field type - save teeth rather than extract

TRAUMATIC RESTORATIVE TREATMENTS (ART)

Only what kind of instruments?

Relies on pressing material into ______ or ____and _____

Seals off ______, uses _______ to aid in ________

Hand

Excavated or pits and fissures

Decay - fluoride - remineralization

Clinical steps of TRAUMATIC RESTORATIVE TREATMENTS (ART)

Isolate with

Obtain access to caries with _____ instruments

Caries removal with

Place what materail

Remove ____

Check _____

Cotton rolls

Hand

excavator

high viscosity GI (GCI or RMGI)

Excess

Occlusion