1 - Selective Caries Removal and Cavity Preparation: Feitosa

Caries lesions initiates a cascade of re-treatment with increasing loss of ______ _____ ______

dental hard tissue

The death spiral (picture)

To reduce the speed of the death spiral process we must make the preparation as _____ as possible

make minimal preparation.

- Do the prep as small as possible

What type of caries removal do we practice

Selective caries removal

_____ ____ is the name of the disease

dental caries

is the consequence and manifestation of the disease- the signs or symptoms of the disease

carious lesion

Involves control of the disease through prevention and noninvasive means at a patient level

dental caries management

Controls the disease symptoms at the tooth level

carious lesion management

Clinical and radiographic classifications are by ____ and _____

severity and activity

Managing caries can be patient specific (as learned in cariology), or lesion specific and can be ____ or ___-_____

- Surgical

- Non-surgical

intital caries are surgical or non surgival

non-surgical

first visual changes in the enamel - can be remineralized

Based on Lesion Severity- Visual

initial caries description

Class I or II

first visual changes in the enamel (white spot lesion or brown carious discoloration)

no dentin shadowing

moderate carious lesion

Class III or IV

can be localized enamel breakdown with no dentin shadowing (III)

OR
underlying dentin shadowing (IV)

no dentin is exposed

extensive carious lesion

Class 5 or 6

a distinct cavity with visible dentin

Based on Radiographic Assessment

RA 1 - initial

radiolucency in the outer ½ of the enamel

RA 2 - intitial

radiolucency in the inner ½ of the enamel + DEJ

RA 3 - initial

radiolucency in the outer 1/3 of dentin

RA 4 - moderate

radiolucency in the middle 1/3 of dentin

RA 5 - extensive

radiolucency reaching inner 1/3 dentin, clinically cavitated

RA 6 - extensive

radiolucency into the pulp

Before reaching for a handpiece the dentist must also consider _______ options

non-invasive

with carious tissue removal we want to retain the tooth and the healthy/vitality of its ____ for as long as possible

pulp

To retain the tooth and the healthy/vitality of its pulp for as long as possible

Reversible Pulpitis

Sensibility/Vitality - noraml responses to:

- Thermal tests

- Electric Pulp tests

in caries removal we want to avoid ____ exposure

pulp

in caries removal we want provision of sound cavity margins to achieve an adequate _____ _____

peripheral seal

in caries removal we want to control the lesion and inactivate remaining _____

bacteria

For moderate lesions (not reaching inner third of dentin) - the restoration ______ may be more important

longevity

outer 1/3 dentin and enamel = restoration

Extensive- Deep lesions (radiographically involving inner pulpal third or quarter of dentin or with clinically assessed risk of pulpal exposure) preservation of _____ _____ should be prioritized

pulpal health

inner 1/3 dentil + pulp = vitality of tooth main priority

When I do a selective caries removal can I leave caries (soft stained dentin) on the margin

NO

On the margin you need to have the best ______

bonding

centrally you can leave some of the _____ ____

affected dentin

4 characteristics of dentin

Soft

Leathery

Firm

Hard

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

Soft Dentin

Although dentin does not deform when an instrument is pressed onto it this dentin can still be easily lifted without much force being required

Leathery Dentin

May be little difference between leathery and firm dentin, with leathery being a transition on the spectrum between soft and firm dentin

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

Firm Dentin

A pushing force needs to be used with a hard instrument to engage the dentin, and only a sharp cutting edge or a bur will lift it. A scratchy sound or "cri dentinaire" can be heard when a straight probe is taken across the dentin

Hard Dentin

Most external area of the preparation: in coronal areas is the enamel and DEJ, in gingival areas only dentin

periphery

in coronal areas the periphery is the _____ and ____, in gingival areas only _____

enamel and DEJ

dentin

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

clean, hard and free of discoloration

Once restored the periphery is closest to the oral environment, so it is imperative to have a good restoration ____ in these areas

seal

Caries removal steps: 1. Access

If lesion is NOT sufficiently cavitated, removal of enamel is necessary (High speed, with water)

Where there is enamel, extend the periphery depth and width to the depths of the 330 until the dentin at the DEJ is no longer

soft/stained.

(Halo of yellow/hard dentin exposed)

some caries lesion are accessible and initial enamel removal is ____ ______

not necessary

Remove the remaining firm caries and demineralization along the DEJ with a small round bur using slow speed ______ [with/without] water?

Without

Ideally the dentin at the DEJ should be ____ and _____

hard and clean

The dentin along the DEJ should have a ____ _____ apprearance in the shape of a halo of approximately __mm

light yellow

1mm

Pictures

Caries removal instrument/ aids

Appropriate radiographs and current pulpal status

Clean dry tooth- avoid repeated or forceful drying to prevent pulpal damage

Adequate illumination and magnification

Spoon excavator, small and large round burs on slow speed

Mirror- most commonly missed areas are under cusp tips and at DEJ, always check with a mirror for these access-limited areas using multiple mirror angulations

For best visualization during caries removal turn your handpiece water

off

Intermittently spray water from the air/water syringe to keep the dentin _____ will help with preserving the _____

moist, pulp

Do not _____ the tooth, keep it moist

desiccate

Moist dentin allows for visualization of the ______

lesion

Margins should be ____ and _____. It is important to remove undermined ______

smooth and uniform

enamel

prior to restoring the remaining enamel should be _____ allowing for the most durable sealing of the restoration

sound

Final enamel presentation: DEJ should visibly free of ____ and _____

stain and discoloration

Final enamel presentation: Enamel feels ____ with an explorer

hard

Final enamel presentation: Enamel cannot be removed with a _____ _____

spoon excavator

Final enamel presentation: if enamel is little demineralized, it is _____ and ____, not ____ or _____

shiny and intact, Not flaky or dull

Selective removal is based on _____ ____

Lesion severity

what constitutes moderate lesion severity

caries limited to the outer 1/3 of dentin

what constitutes extensive lesion severity

Caries extending into inner 1/3 of dentin

Moderate severity is selective to

FIRM dentin

Extensive severity is selective to

SOFT Dentin

Pulpally remove carious tissue until ____ or _____ dentin is reached or until it is resistant to ____ _____

leathery or firm dentin, spoon excavation

- using a larger bur on slow speed or gently with a spoon

- Firm dentin on the pulpal floor, rather than aiming for hard dentin

The periphery of cavity should be ____/___

clean/hard (sound dentin)

Tissue removal to allow adequate ____ _____ and ____ for a durable restoration

marginal sealing and bonding

In a moderate lesion we are centrally leaving affected (soft) dentin to

stay far from pulp

Extensive lesions: Selective caries removal steps

Evaluate the lesion- visually and radiographically

Access- remove enamel to obtain a clear DEJ. High speed with water

Caries removal at DEJ with smaller round bur, e.g #2 or #4 on Slow speed without water, so you can visualize what is being removed

If needed, remove soft wet disorganized carious tissue to leathery (experience required)