DENTAL CARIES

Dr Ranjini
Department of Conservative dentistry and endodontics
DSCDS
 Contents
• Definition of dental caries
• Etiology
• Clinical presentation
• Histopathology
• Classification
• Theories
• Diagnosis
• Caries risk assessment
• Methods of caries prevention
• FAQ
Caries – Latin means ‘dry rot’
Affects Enamel, dentin, cementum
Caries is name given to the process of slow
disintegration that may affect any of the
biological hard tissue as a result of bacterial
action.
Definition

It can be defined as the microbial disease of the

calcified tissues of teeth, characterized by
demineralization of the inorganic portion and
destruction of organic substances of the tooth.
Shafer
ETIOLOGY OF DENTAL CARIES
 Etiological Factors:
Primary Factors: Modifying Factors:
• Teeth • Saliva
• Diet • Other dietary factors
• Microorganisms • Vitamins & minerals
• Time • Hereditary factors
 TOOTH:

• Susceptible tooth surface

- accentuated pits and fissures → more prone

to caries

- enamel hypoplasia → increase caries

incidence
 SUSCEPTIBLES SITES FOR PLAQUE RETENTION

• Pits & fissures-molars & premolars

• Proximal smooth surface-gingival to contact

area

• Enamel at cervical aspect of teeth-near gingiva

• Exposed root surface following gingival

recession

• Margins of the restorations-if they are rough.

 Dental Plaque and Microorganisms:

• Sturdevant
“soft, translucent and tenaciously adherent material
accumulating on the surface of the teeth” is called plaque.

• Consist of
- salivary component- mucin
- desquamated epithelial cells
- microorganisms
- acquired pellicle
 Microorganisms in Dental Plaque-
• Streptococci- S.mutans, sanguis, salivarius

• Actinomyces- A. viscous, naeslundi, israeli

• Veillonellae- V.parvula
 BACTERIA:
– Pioneer / primary bacteria – initiate caries

• S.mutans (smooth surface caries)

• Lactobacillus acidophilus (pit & fissure caries)

• Actinomyces (root surface caries)

– Invaders / secondary bacteria

• Staphylococcus, Veillonellae
 Streptococcus mutans:
• Chief etiological agent in dental caries disease
1. It can produce low pH (acidogenic)

2. It can survive in low pH (acidouric)

3. Utilize sucrose at a faster rate than other

bacteria
4.Can metabolize sucrose to synthesize glucan

and fructan

5. It can store intracellular glycogen amylopectin

type polysaccharides that act as a reservoir of
substrate and prolongs its metabolic activity
 Other Bacteria
• Lactobacillus acidophilus
– Found in carious dentin & saliva of persons with high
caries activity
– Release lactic acid
• Actinomyces
– Found in root caries
– Acidogenic
DIET:-
• Third major factor
• Compared to primitive diet there are several changes in modern
diet these include:-
– Physically diet is less fibrous,more refined,soft & sticky
– Chemically diet composed of carbohydrates- cariogenic
• Modern diet lack phytates(organic phosphate)-which can protect
against caries.
• Diet rich in refined carbohydrates & low proteins
• Frequent snacking between meals promotes caries
• Protective factors-phosphates,calcium lactate,fluorides,Vit-D,Vit-
B6
 Fermentable Carbohydrates
• Most cariogenic component of the diet

• The cariogenic potential depends upon

- frequency of ingestion

- physical form
• Sucrose is called as an “ Arch criminal of caries ”

- it is utilized by bacteria as a source of energy

- it is metabolized by bacteria to form glucan and
fructan
- diffusion of sucrose in plaque is fast as compare to
other sugars
 Time:-
• During long intervals of plaque stagnation

The plaque pH is lowered favouring production of organic

acids- that demineralize tooth structure.
 Modifying factors
SALIVA-
• MAJOR MODIFYING FACTOR

• It has a protective role in preventing dental caries

 Protective functions of saliva

• Flushing action.
• Buffering capacity.
• Antimicrobial effect.
• Remineralization property.
 Vitamins
– Vitamin A & B are important in formation of
hard tissues. Thus if they are deficient, hypoplasia
of teeth is seen, teeth more prone to caries

– Fibrous food help in cleansing of teeth, removal

of lodged food
 Hereditary Influence
• Hereditary Fructose Intolerance

- autosomal recessive disorder

- deficiency of hepatic fructose-l -phosphate aldolase

- patient is kept on sucrose free diet

- absence of caries
 Saliva

Keyes rings
Clinical presentation of caries
Pit and fissure caries

Smooth surface caries

Root surface caries

Pit and fissure caries
These are originating in the pits and fissures found on
the lingual surfaces of maxillary anterior teeth and on
the buccal, lingual and occlusal surfaces of posterior
teeth.
• Pit and fissure caries “fans out” as it penetrates into enamel.
• The entry is over a small area but the occlusal enamel rods
bend down and terminate on the dentin immediately below the
developmental fault.
• This makes the carious lesion involve a wide area of enamel
after penetrating through a pit or fissure.
• In longitudinal sections of teeth, caries can be seen as a cone
shaped defect with its base towards the DEJ and apex towards
the pit.
• At the DEJ the caries spreads more laterally than pulpally.
• So the carious lesion in dentin also appears cone shaped with
the base of cone at DEJ and apex towards the pulp
Smooth surface caries
Carious lesions originating in and around all
surfaces without involving pits
Smooth surface caries
• Caries starting on smooth surfaces has a broad area of origin
and a conical extension towards the pulp.
• The path of origin is roughly parallel to the long axes of the
enamel rods in the region.
• In longitudinal section, the caries process is seen as a cone
shaped area with its base towards the enamel surface and its
apex towards the DEJ
• At the DEJ, it spreads laterally along the junction, rather than
pulpally.
• The base of the cone in dentin is again at the DEJ and its apex is
towards the dental pulp
Root surface caries( senile carious lesions)

Caries on the tooth root that has been both exposed

to the oral environment and habitually covered with
plaque( associated with aging process).
Root surface caries
• The cementum covering root surface is
relatively thin and provides little resistance to
caries attack
• Root surface caries begins directly on dentin.
• It is U shaped in cross section and spreads
more rapidly because dentin is less resistant to
caries attack
Histopathology of Dental Caries
 Demineralization:
When sugar and other fermentable
carbohydrates reaches the bacteria, they
form acids which start to dissolve the
enamel - an early caries lesion occurs due
to loss of Calcium and Phosphates

Remineralization:
When sugar consumption has ceased,
saliva can wash away sugars and
buffer the acids. Calcium and
Phosphates can again enter the tooth.

A CAVITY occurs if the Demineralization "wins" over the Remineralization over time
The zones seen in enamel caries
Zone 1: Translucent zone,
-lies at the advancing front of the lesion,
-slightly more porous than sound enamel,
-it is not always present

Zone 2: Dark zone,

-this zone is usually present and referred
to as positive zone
-formed due to demineralization.
Zone 3: Body of the lesion,
• found between the surface and the dark zone,
• it is the area of greatest demineralization,

Zone 4: Surface zone,

• relatively unaffected area,
• greater resistance probably due to greater degree of mineralization
and
• greater fluoride concentration.
ZONES OF DENTINAL CARIES
Zone 1; Zone of Fatty Degeneration of Tome’s Fibers(next to
pulp)
-due to degeneration of the odontoblastic process.

Zone 2; Zone of dentinal sclerosis

-deposition of Ca salts in the tubules.
.
Zone 3; Zone of decalcification of dentin

Zone 4; Zone of bacterial invasion

Zone 5; Zone of decomposed dentin due to acids

and enzymes
 Fusayama, 1979

Infected dentin Affected dentin

• Outer zone • Inner zone
• Irreversibly denatured collagen • Reversibly denatured dentin
• Infiltrated with bacteria • Not infiltrated with bacteria
• Not remineralizable • Remineralizable
Active lesion Inactive lesion

White spot lesions close to Shiny white or brown

gingival margin lesions, often well exposed
due to recession
Matt or visibly frosted
surface, these are often Lesions not plaque covered
plaque covered

Cavitated , plaque covered Cavitated lesions often dark

lesions with or without brown, with hard dentin at
exposed dentin their bases,

If dentin is exposed and soft, Lesions are not plaque

the dentin is heavily infected covered and are often
and the lesion is active. remote from gingival margin
• THEORIES Current concepts
Early concepts Acidogenic theory
Proteolytic theory
Worm theory
Proteolytic chelation theory
Humoral theory Sucrose chelation theory
Vital theory Phosphate sequestration theory
Chemical theory Auto immune theory
Septic theory Genetic theory
Acidogenic theory /chemicoparasitic
theory (w.d miller)
Caries is a chemico parasitic process

This states that oral bacteria act on sugars to

release acids that demineralize the inorganic
portion of enamel, resulting in development of
caries.

Draw backs
Phenomenon of arrested caries, caries on unerupted teeth is not
explained
Smooth surface caries was not accounted
Particular type of organisms causing caries was not explained
Presently, the chemicoparasitic theory is most
accepted, although not in the same form as that proposed
by Miller.

Research has shown the complex interrelationship

between enamel and plaque.

The factors that determine the movement of minerals

from saliva and plaque to enamel and vice versa have
been elaborated.
Proteolytic theory (Bodecker C.F.
1948)

This theory states that the organic

component of the enamel is first
broken down by proteolytic
enzymes, opening up pathways for
bacteria to attack the enamel by
other processes such as by acid or
chelation.
Chelation theory (schatz)
chelation; is a process involving the
complexing of a metallic ion to a
complex substance through a coordinate
covalent bond which results in a highly
stable, poorly disassociated or weakly
ionized compound.
this states that enamel is demineralized by
chelating agents at neutral pH. Protein
breakdown products and lactic acid are some
chelating agents present in nature.
Levin's theory
He emphasized that demineralization and
remineralization of the enamel is a
continuous process .
If in a given interval of time , more ions leave
the enamel than entering it, then there is a
net demineralization hence the carious
process starts.
Three Important Factors
1.pH of plaque
2Calcium and phospate ion concentration at the
interface between enamel and plaque
3.Fluoride ion concentration
 Classification
• Classified according to three major factors:
– According to morphology
– According to severity and progress of lesion
– According to age pattern
 Classification of caries

1. Based on location

• Pit and fissure caries

• Smooth surface caries

• Root surface caries

II. Based on whether it is new or recurrent lesion
1.Incipient, initial (reversible) caries
Is the first evidence of caries activity in the enamel.
2 cavitated caries

3.Recurrent (secondary) caries

Caries which occurs at the junction of a restoration
and the tooth and may progress under the restoration.
III. Based on the speed of caries progression
1.Acute(rampant) caries
Is a rapidly invading process that usually involves several
teeth.
The lesions are soft and light coloured and are usually
accompanied by severe pulpal reactions.
2.Chronic caries-
Slowly progressing, long standing and appears hard in
consistency and dark in color

3. Arrested caries-and is termed ‘sclerotic or eburnated

dentin. Dark brown in color and hard in consistency
IV- based on pathway of caries spread
1.Forward caries
Whenever the caries cone in enamel is larger or
atleast the same size as that in the dentin.
2.Backward caries
If the carious process in dentin progresses much faster
than it does in enamel ; in addition, the decay can
attack the enamel from its dentinal side.
V. Residual caries
Is the caries that remains in a completed tooth
preparation, whether by operator intention or by
accident.
VI. Based on number of surfaces involved
1.Simple carious lesion
It is the one that involves only one surface of the
tooth.
Compound Carious Lesion
It involves only two surfaces of a tooth.
Complex carious lesion
It involves three or more tooth surfaces.
VII. Depending upon structure involved
• Enamel caries
• Dentin caries
• Cemental/ root/ senile caries
 Pit &fissure
Smooth surface

Enamel caries
Dentin caries
Root caries
Incipient

Acute

Chronic

Recurrent
VIII. According to chronology
infancy/nursing bottle caries
adolescent caries
adult/ root surface caries

IX. According to dynamics

very mild(occlusal pits)
moderate
severe
very severe
X. According to depth of caries
class A: confined to enamel
class B: confined to dentin
class C: confined to 1/3 rd of dentin not involving pulp
class D: confined to pulp
XI.Based on the treatment and restoration – by
G.V.Black
class I
class II
class III
class IV
class V
class VI
Class I- caries occuring in pits, fissures or defective grooves
on the tooth surfaces
• Occlusal surfaces of molars and premolars
• Occlusal two thirds of the facial and lingual surfaces of
molars
• Lingual surfaces of maxillary anteriors
Class II caries- caries found on the proximal surfaces of molars
and premolars
Class III- caries occurring in the proximal surfaces of anterior
teeth without involving the incisal angle
Class IV – caries found on the proximal surfaces of anterior
teeth with involvement of the incisal angle
Class V- caries seen at the gingival third of the facial
and lingual surfaces of anterior and posterior teeth
Class VI caries- caries found on the incisal edges of
anterior teeth and cusp tips of posterior teeth
 Xii.New cavity classification
Graham mount’s classification

• Site 1: pit and fissure and enamel defects on the

occlusal surfaces of posterior teeth, on smooth
surfaces such as cingulum pits on anteriors.
• Site 2: approximal enamel immediately below
areas in contact with adjacent teeth.
• Site 3: the cervical 1/3 rd of the crown following
gingival recession of the exposed root.
• Size 1: minimal involvement of dentin just beyond
treatment by mineralization alone
• Size 2: moderate involvement of dentin following
cavity preparation, remaining enamel is sound well
supported by dentin and not likely to fail under
normal occlusal load.
• Size 3: the cavity enlarged beyond moderate, the
remaining tooth structure is weakened to the extent
that cusps or incisal edges are split or are likely to
fail if left exposed to occlusal or incisal load.
• Size 4: extensive caries with bulk loss of tooth
structure has already occurred.
 GRAHAM MOUNT’S CLASSIFICATION
CAVITY SITE SIZE 1 SIZE 2 SIZE 3 SIZE 4

MINIMAL MODERATE ENLARGED EXTENSIVE

SITE 1 1.1 1.2 1.3 1.4

PIT & FISSURE

SITE 2 2.1 2.2 2.3 2.4

APPROXIMAL
SURFACE
SITE 3 3.1 3.2 3.3 3.4
CERVICAL
XIII.WORLD HEALTH ORGANISATION (WHO) SYSTEM

The shape and depth of the caries lesion can be scored on a four point
scale.

D1- clinically detectable enamel lesions with intact ( non-cavitated)

surfaces
D2- clinically detectable cavities limited to enamel
D3-clinically datectable cavities in dentin
D4- lesions extending into the pulp
The International Caries Detection and
Assessment System (ICDAS)
• The International Caries Detection and
Assessment System (ICDAS) is a clinical
scoring system for use in dental education,
clinical practice, research, and epidemiology.
 The International Caries Detection and
Assessment System (ICDAS)
• The International Caries Detection and
Assessment System (ICDAS) is a clinical scoring
system for use in dental education, clinical
practice, research, and epidemiology.
• The ICDAS caries activity criteria are still part of
an expanding research agenda.
• Preliminary caries activity assessment criteria
have been developed using the ICDAS approach
of relying on visual assessment and the use of
the WHO/PSR probe
• Description of Codes(2)
0 Sound
1 First Visual Change in Enamel (seen only after
prolonged air drying or restricted to within the
confines of a pit or fissure)
2 Distinct Visual Change in Enamel
3 Localized Enamel Breakdown (without clinical
visual signs of dentinal involvement)
4 Underlying Dark Shadow from Dentin
5 Distinct Cavity with Visible Dentin
6 Extensive Distinct Cavity with Visible Dentin
• .
 The following general rules can be
applied
• In the case of inactive caries of stages ICDAS 1 and 2, basic
prophylaxis is sufficient, even given a radiographic extension into
the first third of the dentin.

• Active caries of stages ICDAS 1 and 2 with a radiographic

extension of E1-E2 should be treated noninvasively (floss,
fluoride), if the risk of caries is low.
• Active caries of stages ICDAS 1 and 2 with a radiographic
extension of E2-D1 should be infiltrated, the risk of caries is
moderate or high
• Active caries of stages ICDAS 3-6 should be filled in most cases.
• If the lesions are very deep, consider removing the caries in a
stepwise caries excavation process or incompletely.
 XIV. According to age pattern
• Nursing Bottle caries:
– Bottle fed babies develop this
– Maxillary incisors
– Sweetener to milk
– Prolonged breast feeding at night
• Adolescent Caries:
– Usually seen at 4-8 yrs of age

• Geriatric caries:
– Occurs in older adults
• Aged 50 or so
• Caries of cementum
 Infancy caries Adolescent caries Adult caries

Mild Moderate Severe Very severe

DIAGNOSIS OF CARIES
• “Drill and Fill” approach.

• Gradual shift towards a preventive approach

WHY IS DIAGNOSIS IMPORTANT ?

It forms the basis for treatment decision

It enables the dentist to inform the patient
As a population level it advises health service planners
Pre-requisites for detection and diagnosis of
caries:

– Relevance of clean teeth

– Use of drying

– Proper lighting

– Sharp eyes and magnification

– Use of an explorer or probe

– Tooth separation
 Visual and Tactile Diagnosis
• Widely used

• Dental mirror, a sharp probe and a 3-in-1 syringe

• Requires good lighting

• Clean/dry tooth surface.

(Hamilton, 2005).
DIAGNOSIS OF DENTAL CARIES

I.TRADITIONAL METHODS-

1. Patient’s complaint- sensitivity to thermal changes, mild to

moderate toothache, etc

2. Clinical examination- careful examination of teeth in clean

and dry conditions with good illumination

• brownish discolouration of pits and fissures.

• opacity beneath pits and fissures or marginal ridges

• frank cavitation of tooth surface

3. Tactile examination- use of a dental explorer
• softness at the base of a pit or fissure and
discontinuity of enamel surface
• binding or catch of the explorer tip
• Cavitation at base of a pit or fissure.
Benefits of Visual–Tactile Diagnosis
✓ Visual–tactile diagnosis is quick and easy to perform, does not need expensive
equipment, and can be completed without unnecessary radiation.
✓Currently, activity assessment according to the criteria suggested by Nyvad et al
(1999) is considered the best choice for performing a caries diagnosis, because these
are the only criteria that reflect the current evidence-based management options for
different phases of caries formation, and the only criteria with predictive value.
✓Surprisingly, data show that when non-cavitated lesions are included in
classification, the yield of visual–tactile caries examination is greater than that of
radiographic examination because minor mineral losses cannot be detected in
radiographs.

Limitations of Visual–Tactile Lesion Diagnosis

✓These include the fact that visual–tactile diagnosis requires subjective evaluations
to be made by the practitioner, lesions can go undetected because teeth are typically
examined by the naked eye, and there is need for supplemental analysis when faced
with clinical signs that will leave a dentist uncertain, including dark occlusal or
proximal shadows.2
• Tooth Separation

To detect initial proximal caries, separation of the contacting teeth

can be achieved using wedges or mechanical separators.

Once the proximal surface is

accessible, visual examination and
gentle probing may help in diagnosis
of the carious lesion.
• Dental floss or Tape

• It is used to detect proximal caries.

• Floss is inserted through the contact area and dragged

occlusally against one proximal surface.

• Whenever dental floss is sawed through the contact

areas between the teeth, if it frays or shreds, then it is
a sign of proximal caries.

• However, there should be no overhanging restoration.

Radiographi
c Methods
➢ Radiographic examinations include;
Bitewing radiographs
IOPA radiographs using paralleling technique
Dental panoramic tomography

➢ The most commonly used radiographic method for detecting caries lesions is the
bitewing technique.

➢It is meant to find lesions that are hidden from a clinical visual examination, such as
when a lesion is hidden by an adjacent tooth, as well as help the dental professional
estimate how deep the lesion is.
➢To get the radiographic images, a central beam of X-rays is positioned to pass at right
angles to the long axis of the tooth.

➢ If film is used, a beam-aiming device on the film holder guides the position, directing
the beam at right angles to the film.

➢However, digital radiography is replacing radiography based on film. It has been

proven as accurate as traditional radiography for detecting caries, but it comes with
additional advantages of using a lower radiation dose, being less time-consuming, and
does not require wet chemicals in the processing of the image.
Conventional radiography
• Discloses in-accessible sites.

• Depth of lesion

• Permanent record-
– allows assessment of progression or regression of
lesions,

– evaluation of disease activity,

– efficacy of preventive and therapeutic measures

• Non invasive
Bitewing radiography-

• Implies the use of a film-holder with a wing to bite

• Evaluation of caries lesions depth.
• Central ray is directed along the plane of the cervical
areas.

• Performance of bitewing radiography-

– High sensitivity (50-70%) to detect caries lesions in
dentin of both approximal and occlusal surfaces,
compared to clinical visual detection
 Incipient occlusal lesions

Moderate occlusal lesions

Severe occlusal lesions

 Incipient proximal lesions

Moderate proximal lesions

Advanced proximal lesions

 Facial & Lingual caries

Root surface caries

 Recurrent caries

Other radiographic shadows

• Limitations

– Accurate reproducibility- standardized geometric angulation,

exposure time, processing procedures, and analysing facilities
are necessary

– Does not disclose earliest stages of lesion development

– Does not distinguish approximal surfaces that are sound, have

subsurface lesions, or are cavitated.

– Underestimate the extent of demineralization

• Limitations (cont.)
– Overestimations - as a result of projection errors

– Subjective- interpretation of radiographic findings is subject to

inter-observer and intra-observer variations

– Approximal caries on the more apical part of a restoration may

not be detected

– Noncavitated lesions on the root are difficult to diagnose.

• Advantages
• 1. Non-invasive method.
• 2. Disclose sites inaccessible to other diagnostic methods.
• 3. Permanent record for monitoring progress or arrest of the carious
lesion.

• Disadvantages
• 1. Only a two dimensional image of a three dimensional object.
• 2. Do not reveal the earliest stages of caries development.
• 3. Radiolucency may be due to caries, wear, fracture, or cervical
burnout.
Enhanced visual techniques

Fibre optic transillumination (FOTI and DiFOTI)

• The intact tooth absorbs very little light allowing it free passage.
• In contrast areas of caries absorb and scatter light thus appearing
dark.
• The basis of visual inspection of caries is based upon the
phenomenon of light scattering.
• Fibre optic transillumination takes advantage of the optical
properties of enamel and enhances them by using a high intensity
white light that is presented through a small aperture in the form of
a dental handpiece.
Digital imaging fiber-optic transillumination
➢ This is a digitized and computed version of the FOTI.

➢While FOTI was designed for detection of approximal and occlusal caries, digital
imaging fiber-optic transillumination DIFOTI is used for detection of both incipient
and frank caries in all tooth surfaces.

➢DIFOTI can also be used to detect fractures, cracks, and secondary caries around
restorations.

➢DIFOTI uses white light to transilluminate each tooth and to instantly create high-
resolution digital images of the tooth. It is based on the principle that carious tooth
tissue scatters and absorbs more light than surrounding healthy tissue.

➢ Decay near the imaged surface appears as a darker area against the more translucent
brighter background of surrounding healthy anatomy.

➢ A single fiber-optics illuminator in the mouthpiece delivers light to one of the

tooth’s surfaces. As this light travels through layers of enamel and dentin, it scatters in
all directions toward the nonilluminated surface usually the opposite surface. The light
is then directed through the mouthpiece to a miniature electronic charge coupled
device CCD camera in the handpiece.
➢The camera digitally images the light emerging from either the smooth surface
opposite the illuminated surface or the occlusal surface.

➢ These images are displayed on a computer monitor in real time and stored on the
hard drive for easy retrieval for comparative review of images over time.

➢Image acquisition is controlled with software and a foot pedal.

➢ Images of the teeth can be viewed by both the clinician and patient, and therefore
can be used for patient education and motivation.

➢It is important to note that DIFOTI images the light emerging from surface closest to
the CCD camera. It does not image the tooth material between the light source and the
CCD camera, and therefore cannot indicate the depth of lesion penetration.

➢Schneiderman et al. demonstrated a method of using DIFOTI to quantitatively

monitor lesion progression and reported a successful result. Inherent with the high
sensitivity of the device, dark areas in DIFOTI images may sometimes be due to stains
or calculi on tooth surface; therefore it is suggested that prophylaxis should be carried
out prior to the use of the device in order to increase the specificity.
Laser fluorescence
DIAGNOdent System
Laser fluorescence—DIAGNODent
➢The DIAGNODent (DD) instrument (KaVo, Germany) is another device employing
fluorescence to detect the presence of caries.

➢Using a small laser the system produces an excitation wavelength of 655 nm which
produces a red light. This is carried to one of two intra-oral tips; one designed for pits
and fissures, and the other for smooth surfaces.

➢ The tip both emits the excitation light and collects the resultant fluorescence.

➢ Unlike the QLF system, the DD does not produce an image of the tooth; instead it
displays a numerical value on two LED displays.

➢The first displays the current reading while the second displays the peak reading for
that examination.

➢ A small twist of the top of the tip enables the machine to be reset and ready for
another site examination and a calibration device is supplied with the system.
➢DIAGNOdent was designed for the detection of caries lesions in occlusal and
smooth surfaces.

➢For this purpose, the method has been extensively studied and has demonstrated
the high reliability of the device in detecting occlusal caries lesions and a moderate
correlation with mineral loss in smooth-surface caries lesions.

➢With regard to validity, studies have demonstrated good sensitivity and specificity
values, but the magnitudes of these values have been variable due to different cut-off
points used in the different studies.

➢Another possible explanation for the high variability found in these studies could be
due to several possible factors that can alter the LF readings. The drying time of the site
before the LF assessment, presence of plaque or pigmentation, and some toothpastes
or prophylaxis pastes are possible factors that influence the LF readings.

➢The sensitivity values for detection of occlusal caries lesions have been higher than
the specificities, and the values have been usually described between 0.80 and 0.90.

➢The specificity values obtained in different studies have been between 0.60 and 0.70.
These results, therefore, indicate that the device could be used as an adjunct to visual
inspection, and could be an alternative for radiography.
DIAGNODent pen
➢Due to this limitation, a new version of the method was designed and introduced,
named DIAGNOdent pen.

➢ This new version permits the assessment of both occlusal and proximal surfaces.

➢The device works on the principles of the old version, but the design is different. The
tip is rotatable around the axis of its length, enabling the operator to assess mesial and
distal surfaces from both sides (buccal and lingual).

➢The tip designed for proximal surfaces is made of sapphire fiber with a prismatic shape,
and the light is directed laterally to the longitudinal axis of the tip.

➢Another cylindrical tip is recommended for occlusal surfaces, and the direction of its
light is perpendicular to the axis of the length of the tip. After excitation, the tip collects
the fluorescence and translates it into a numerical scale from 0 to 99.

➢This device could be used as an alternative to the radiographic method to aid the
dentist in the decision-making process after visual inspection.

➢ Nevertheless, the evidence concerning the use of the method in clinical practice is
limited, and further studies are necessary to evaluate whether the method could be useful.
 DIAGNODENT

• DIAGNOdent 2095 (KaVo, Biberach, Germany),

• 1998

• Non-invasive and quantitative method based on the laser

induced fluorescence.

• Measures the fluorescence of the cariogenic metabolites

and the fluorescent nature of the lesion.

• Red LASER light- 655nm

• Laser diode
• Emitted light reaches the dental tissues through a flexible tip

• Central core fibre running through the pen grip and tip is a red
laser

• Surrounding fibres being detectors to measure the returned

fluorescent light from the tooth surface.
Limitation:
• Need for the tooth surfaces and fissures being assessed to
be clean and dry.
• To date there is no evidence to support the use of
DIAGNODENT for the detection of approximal or
secondary caries adjacent to existing restorations.

• Good results shown in the detection of occlusal caries,

however, it might not be used as the only method for
treatment decision-making process

(Bader & Shugars, 2006; Rodrigues et al., 2008).

 CARIES ACTIVITY TESTS:

1. Lactobacillus colony count test

⚫ Saliva is collected by chewing paraffin

before breakfast
⚫ The specimen is vigorously shaken and
after that 0.1 cc of sample is withdrawn
⚫ Dilute and undiluted samples are then
spread evenly over a rogosa’s SL agar
plate
⚫ The plate is incubated for 4 days & no. of
lactobacillus colonies that developed are
counted.
No of organisms Symbolic Degree of caries
designation activity suggested

1-1000 + Little or none

1000-5000 + Slight

5000-10,000 ++ Moderate

More than 10,000 +++/++++ Marked

 SNYDER
TEST
⚫ This test measures the ability of salivary
microorganisms to form organic acid from a
carbohydrate medium.
⚫ The classical formula of Snyder’s agar per litre
of purified water is

pancreatic digest/ casein -13.5 gm

yeast extract -6.5 gm
dextrose -20 gm
sodium chloride -5 gm
agar -16 gm
Bromocresol green -0.029 gm
 24 hrs 48 hrs 72hrs

Color : yellow yellow yellow

Caries activity: marked definite limited

Color : green green green

Caries activity: continue test continue test caries inactive

ALBAN’S TEST

• Alban modified the Snyder test to make it easier and for use in
regular dental office.
• In this method lesser amount of agar is used.
• The agar is taken from the refrigerator but is not heated. To this
saliva is added and incubated for 4days.
• Color observations are same as that of Snyder test.

SWAB TEST

⚫ Advantage is no collection of saliva is necessary

⚫ Valuable in evaluating caries activity in very young children
⚫ Principle is same as Snyder test
⚫ The oral flora is sampled by swabbing the buccal surface of
tooth with cotton.
 REDUCTASE TEST
⚫ This test measures the activity of reductase enzyme present in salivary bacteria
⚫ The sample is mixed with fixed amount of diazo-resorcinol
⚫ The change in color after 15 min is taken as a measure of caries activity

color Time score Caries activity

Blue 15min 1 Non conductive

Orchid 15 min 2 Slightly conductive

Red 15 min 3 Moderately

conductive
Red Immediately 4 Highly conductive

pink Immediately 5 Extremely conductive

 ENAMEL SOLUBILITY TEST

⚫ It is based on the fact that when glucose is added to saliva containing

powdered enamel, organic acids are formed
⚫ Organic acid decalcifies the enamel, resulting in an increase in the amount
of soluble calcium
⚫ The extend of increase of calcium is a direct measure of caries activity

SALIVA FLOW TEST

⚫ Flow rate is determined by collecting paraffin stimulated saliva in a test tube

over 5 min
⚫ Severely decreased flow is related to caries susceptibility
⚫ As salivary flow rate decreases viscosity increases
 PATIENT EDUCATION WITH METHYL RED

⚫ A simple and effective technique that may be of assistance in

educating child patient to the problem of dental caries control
involves the use of aqueous solution of methyl red
⚫ Indicator dye changes colour in the pH range from 6.3(distinct
yellow) – 4.2(red)
⚫ Aqueous methyl red is then applied to the surface of the tooth
with dropper
⚫ Red colour is developed in the area of plaque accumulation
⚫ This is interpreted to patient as evidence of continuous acid
formation
Caries-Detecting Dyes
• In 1972, a technique using a Basic fuchsin red stain was introduced.

• Because of potential carcinogenicity, the basic fuchsin stain was

subsequently replaced by another dye, Acid red solution.

• Dye was used to stain only infected tissue and was advocated for a
“painless” caries removal technique without local anesthetic.

• The technique was laborious, as it was guided by staining, involved

multiple dye application-and-removal repetitions and required the use
of a slow-speed bur.
Diagnosis of incipient caries
and hidden caries
Clinical characteristics:

• Loss of normal translucency of enamel

• Fragile surface layer susceptible to damage

from probing

• Increased porosity, particularly the subsurface

• Reduced density- detected with radiographs,

transillumination, modern laser detecting
devices

• Potential for remineralization

Diagnosis of occlusal
caries
Active lesion Inactive lesion
White spot lesions with matt or visibly White or brown spot lesions with a
frosted surface shiny surface.

Cavitated lesion including micro

cavities and cavities exposing the
dentin

Fundamentals of operative dentistry- Summit

Third edition
Diagnosis of approximal lesions
Active lesion Inactive lesion
White spot lesions close to gingival Shiny white or brown lesions, often
margin well exposed due to recession

Matt or visibly frosted surface, these Lesions not plaque covered

are often plaque covered

Cavitated lesions often dark brown,

Cavitated , plaque covered lesions with with hard dentin at their bases,
or without exposed dentin
Lesions are not plaque covered and
If dentin is exposed and soft, the are often remote from gingival margin
dentin is heavily infected and the
lesion is active.
Diagnosis of root caries
Active lesion Inactive lesion
Close to gingival margin and plaque At some distance from gingival margin
covered and not covered by plaque

Soft and leathery in consistency As hard as surrounding healthy root

surface
NEWER METHODS
• Endoscope/videoscope
• Ultrasound techniques
• Multi-photon imaging
• Infrared thermography
• Infrared fluorescence
• Optical coherence tomography
• Terahertz imaging
MANAGEMENT OF CARIES

I. PREVENTIVE MANAGEMENT- to prevent new

lesions from forming and to encourage
remineralization of incipient caries

II. OPERATIVE MANAGEMENT- appropriate

restorations must be placed to restore the integrity of
the tooth
• Remove infected dentin
• Protect pulp and avoid pain
• Remove habitat for cariogenic bacteria
• Facilitate plaque control
• Restore the esthetics and integrity of the tooth.
PREVENTION OF DENTAL CARIES
Approaches to Prevention and control of
Caries
1. Diet modification
2. Personal oral hygiene measures
3. Use of fluoride
4. Use of antimicrobials.
5. Pit and Fissure sealants.
6. Use of ACP-CPP
7. Use of Lasers
8. Use of Ozone
9. Caries vaccine
 Methods of caries prevention

1. Nutritional measures

2. Chemical measures

3.Mechanical measures

Shafer’s textbook of oral pathology. 5th edition

 NUTRITIONAL MEASURES

• Nutrition: The sum processes concerned in the growth,

maintenance and repair of living body as a whole or its
constituent parts. (Oxford Dental Dictionary)

• "Diet refers to the customary allowance of food and drink taken

by any person from day to day." (Newbrun, E. Cariology. Third
ed. 1989).
Dietary Analysis

Objectives

o Overall picture of diet

o Modification of dietary habits
o Record for study and future comparison
 SUGAR SUBSTITUTES

• Lower calorie substitute for sugars

• Less cariogenic or non-cariogenic.

• Plaque pH raises, mobilizes calcium and phosphates

for remineralization.
 Sweeteners
Bulk sweetners
Intense non calorific sweetners

Polyols & Related

Saccharine,
Sorbitol, Mannitol,
Aspartame,
Lactitol, Xylitol, Erythritol,
cyclamate
Alternative Sugars Acesulfame –K Etc
Neosugar, Isomaltulose &
Certain L Sugars

Starch Derivatives
Glucose Syrups, Corn Syrups,
High Fructose Syrups
 Polyols
– Sugar alcohols

– Sugar-free

– Low-digestible sweeteners

– Sugar replacers, a more consumer-friendly

“DO NOT PROMOTE TOOTH DECAY”

Polyols are not readily converted to acids by bacteria in

the mouth.
 Xylitol – What It Does
Inhibits acid production by S. mutans
Slows the growth of mutans streptococci
Formation of dental plaque
No. of mutans streptococci in saliva

(Caries Res, 1997; Vaccine, 2000; Caries Res, 2001; Caries Res, 2003)
Food items preventing dental caries
• Cheese
• Fats
• Vitamins
• Proteins
• Tea
• Fruits
• Chocolate
 Cheese
• Alkaline nature
• Salivary flow is increased
• High calcium and phosphorus content – remineralization
• Casein - cheese proteins reduces enamel solubility and aid in
remineralization

Herod EL. The effect of cheese on dental caries: A review of the literature.
Austr Dent J 1991; 36: 120-5
 FATS

• Form a protective barrier on tooth surface

• Rapid clearance of carbohydrates from oral cavity.
• Antimicrobial effect
• Oleic & lenolic acid – protective against decalcification
 Proteins
• Shaw 1970 & Navia 1979-
protein deficiency during dental development in rats -
caries susceptibility

• Mechanism
Post-eruptively :
- Replace carbohydrates by weak proteolytic activity
 Tea

• Poly-phenols
• Fluorides
• Flavinoids

Inhibits Salivary Amylase….

 Fruits

• Fruits & vegetables are prefered than fruit juices

• Non-starchy polysaccharide

• Good salivary stimulator

 Chemical methods

1) Substances which alter the surface of tooth structure

a. Fluoride.
b. Iodides.
c. Bis-biguanides.
d. Silver nitrate.
e. Zinc chloride
f. Potassium ferrocyanide.

2) Substances which interfere with carbohydrate

degradation through enzymatic reaction/alterations
a. Vitamin K.
b. Sarcoside.
3) Substance which interfere with bacterial growth and
metabolism
a. Urea and ammonium compounds
b. Chlorophyll
c. Nitrofurans
d. Caries vaccine
 Properties of chemical measures

1. Safe
2. Rapid bactericidal
3. Agent must be able penetrate plaque and retained
4. Acceptable taste
5. Easy to handle and apply
6. Should be inactivated or destroyed in GIT
Substances which alter the surface of
tooth structure
 FLUORIDES
• Essential nutrient- FDA

• WHO- Normal growth and development of human beings

• Halogen family , AW – 19, AN – 9

• Latin word Fluore – to flow

• Fl was identified as the essential element for reducing dental

caries and this led to intro of various methods of application
 Mechanism of action

• Increase enamel resistance / reduction in enamel solubility

• Increased rate of post eruptive maturation

• Remineralization of incipient lesions

• Interference with plaque MO

• Modification in tooth morphology

 FLUORIDE DELIVERY METHODS
Topical Systemic
1.Professionally Applied 1. Dietary Fl
Fl Vehicles
supplement
Solutions
Gels
Thixotropic solutions 2. Water
fluoridation
Fluoridated pastes
Foam
Varnish Community water
Fluoridation
Mouth rinses
School water Fluoridation
3. Salt Fluoridation
Dentrifices 4. Milk Fluoridation
2.Self Applied Fl Mouthrinses
Fl gels
 Methods of Application of Topical Fl
1. Paint on technique
2. Tray technique
Characteristic NaF SnF APF
Fl % 2% 8% 1.23%
Ppm Fl 9200 19500 12300
Frequency 4 at weekly intervals 1or 2 yrs 1 or 2 yrs

Taste Bland Disagreeable Acidic

Stability Stable Unstable Stable in plastic
container

Tooth pigmentation No Yes No

Gingival irritation No Occasional transient No

Avg effectiveness 29% 30% 28%

 Low Caries Risk Fl tooth paste applied for atleast 1min twice
daily

Fl tooth paste applied for at least 1min twice

Medium Caries Risk each day
One high Fl application at home once a day or
a professional Fl application once a year

Multiple application using custom made trays

High Caries Risk or Fl varnish & or one high Fl application at
home once a day
 Systemic Fl
I) Dietary Fl supplements
1. Fl drops with/without vitamins
2. Fl tab with/without vitamins
3. Lozenges intended to be sucked slowly or permitted to dissolve in
mouth
4. Oral rinse ( Swished and swallowed)

Fl compound used – NaF

APF

Not more than 1mg of Fl should be ingested each day

water Fluoridation

Salt Fluoridation

Milk Fluoridation
Method Avg % reduction on DC

Community water fluoridation 50-65%

School water fluoridation 40%

Dietary Fl supplementation 50-65%

Professional applied 30-40%

Self-applied 20-50%
 Toxicity of Fl
• Acute
GIT Nausea, vomiting, diarrhea, abdominal pain and cracks

Neurological Paresthesia, paresis,tetany,CNS depression and coma

CVS Weak pulse, hypotension,pallor,shock,cardiac irregularities

and ultimately failure

Blood chemistry Acidosis, hypocalcemia and hypomagnenesia

• Chronic
Dental fluorosis 2times optimal)
Skeletal fluorosis (10-25mg/day)
Kidney damage (5-10mg/day)
 Bis-biguanides:

• Commercially available forms -

a) Chlorhexidine
b) Alexidine

• Effective antiplaque agents and thus potential anticaries agents.

• Have both hydrophobic and hydrophilic constituents and possess a net

positive charge at physiologic pH.
 Chlorhexidine

➢Diguanidohexane (Cationic)
➢Broad specturm antimicrobial “G+ve; G-ve; yeast and fungi”.
➢Used as Chlorhexidine digluconate
➢Use : Daily Twice (0.2% aqueous in 10ml) (1 min)
➢ Reduces bacterial count by 85-95%
➢Antiplaque and antibacterial properties.
Mode of action:
• Ionic adsorption of negatively charged bacterial surface

• Interfere with normal membrane function causing

leakage and precipitation of cell constituents

• Inhibits enzymes essential for microbial accumulation

i.e. glucosyltransferase and metabolic enzymes like
phosphoenol pyruvate phosphotransferase
Advantages :
1. Low irritancy
2. Unlikely to produce sensitization.
3. Absorption after oral ingestion is decreased.
4. Long term use : No changes in hematological and biochemical
parameters.
5. Prolonged use : No carcinogenty.

Disadvantage:

1. Bitter taste
2. Brownish discoloration of soft & hard tissue.
3. Painful desquamation of mucosa.
 II. Substances which interfere with carbohydrate
degradation through enzymatic reaction/alterations

Vitamin K-
2-methyl-1,4-naphthoquinone was suggested by Fosdick as a anticaries
agent.
• Invitro studies have found it prevents acid formation in incubated mixtures
of glucose & saliva.

Sarcosides- may act as a enzyme inhibitor.

 PIT AND FISSURE SEALANTS
• Attributed to the physical obstruction of the pits and grooves

• Prevents penetration of fermentable carbohydrates

 Pit & Fissure sealants

• Pit & Fissure- likely sites

• Mechanically fills & prevents caries in newly erupted teeth

• Prevents cariogenic bacteria from occupying preferred habitat

• Arrests incipient lesion

• Self-cure & light-cure resins

• RMGIC
180
Classification
(Mark siegal 1996)
• Filler particles

• Fluoride

• Method of polymerization

• Color
- clear
- opaque
- tinted

181
 Types

Based on Types characteristics

Generations First Activated by UV- light, no more used, as

UV is harmful to the body

second Chemical curing resins, based on catalyst-

accelerator system (concise-3M)

Third Activated by visible light ( Fissurit-voco,

Delton (johnson &johnson)

Fl containing Double protection

sealantss
 Types
• Fillers
1. Free of fillers- Flow is better

2. Semifilled – more resistant to wear

• Colour of the sealant

1. clear –Esthetic but difficult to detect at recall
examination
2. Tined – can be easily identified
3. Opaque - can be easily identified
 Indications
• A deep or irregular fissure, fossa, or pit

• The fossa selected for sealant placement is well isolated

from another fossa with a restoration present

• An intact occlusal surface is present where the contra

lateral tooth surface is carious or restored

• If there is no radiographic evidence

 Contraindications
• Patient behavior does not permit use of adequate dry field
(isolation) techniques throughout the procedure

• There is an open occlusal carious lesion

• Caries, particularly proximal lesions, exist on other surfaces

of the same tooth (radiographs must be current)

• A large occlusal restoration is already present

• If pits and fissures are well coalesced and self-cleansing

 Preventive resin restoration

Simonsen & Stallard 1977

• Ultraconservative modified preparation

• Minimal removal of tooth

• Use of composite/sealant

• Cavitation – composite / amalgam

186
 Caries vaccine

• Vaccine – Latin word- suspension of attenuated /

killed org administered for the prevention /
treatment of infectious diseases

• Vaccine – Immuno biological substances

To produce specific protection against diseases

• Stimulates production of protective antibody

• Live modified organisms
• Inactivated / killed
• Extracted cellular fractions, toxoids
• Subunit vaccine and recombinant vaccines
 Mechanism of Action

• Cannot be mounted via enamel

• Liberated into the saliva
• Migrate over the tooth surface
 Mechanism of Action

1. Production of secretory IgA secreated in the saliva

2. Production of antibodies that travel through

gingival epithelium into crevicular fluid that
bathes tooth and plaque
 Routes of Administration
Active Passive

Oral and systemic inoculation Direct introduction of specific

pretargeted Ab
Synthetic s.mutans peptides
Monoclonal Ab topically
Coupling s.mutans antigens to applied
cholera toxin
Immune bovine milk & whey
Fusing s.mutans genes with Egg yolk Ab , transgenic plant
avirulent salmonella Ab

Liposome delivery system

 Draw back

• Anti body cross reaction with heart and kidney

tissue, ruling out the use of such preparations in
humans

• Inflammation of gingival tissue

• Target only on S.Mutans

 Salivary substitutes
• Usually used in patients with xerostomia

Contents:
• Carboxymethyl cellulose or hydroxyethyl cellulose –
increases viscosity
• Calcium and phosphate ions and flourides – minerals
• Preservatives such as methyl- or propylparaben
• Flavoring agents
Casein Phosphopeptides-amorphous Calcium Phosphate
Nanocomplexes (CPP-ACP)

• Have anticariogenic activity as shown in laboratory, animal and human

in situ experiments
[Reynolds et al., 1999, 2003., Shen et al., 2000]

• CPP containing the amino acid cluster sequence - Ser(P)-Ser(P)-Ser(P)-

Glu-Glu- have a remarkable ability to stabilize ACP in metastable
solution.

• CPP stabilizes amorphous calcium phosphate and also localizes it at

the tooth surface thus leading to increased rate of remineralization
than with ACP alone.
• Promotes remineralization of enamel
subsurface lesions with hydroxyapatite
[Reynolds, 1997]

• Improves crystallinity and lowers

microstrain than normal tooth enamel.

• 18.8 mg of CPP-ACP complex significantly

remineralizes 2 times better than control
sugar-free gums (Shen et al 2001)
 GC Tooth mousse
• Water based, sugar free crème
• Binds to biofilms, hydroxyapatite and surrounding soft tissue
localizing bio-available calcium and phosphate.
• Saliva enhances effectiveness of CPP-ACP and its flavour will
help to stimulate saliva flow.
 Ozone
• Prof Dr Edward Lynch

• Natural gas surrounding earth

• Prevents caries process- remineralization

• Oxidising agent – dissipates in water kills m/o

rupture of cell membrane

• Healozone

197
• Total procedure – 25 sec

• Home care - dentifrices, mouthwash

• 4 phases of treatment

– Diagnosis

– Treatment phase- application of ozone

– Healing phase – remineralization

– Repair phase – permanent restoration

198
 ….Ozone
Advantages

• No injections

• No drilling

• No discomfort

• Conservative preparation

• Less time consuming

Adverse Effects

• In increased concentration it can cause respiratory distress.

199
Mechanical approach

ART
Sealants
Preventive resin restorations
Rotary
CMCR
Air abrasion
Air polishing
Ultrasonics
Sono abrasion
Lasers

200
 ART
• Pioneered Tanzania- 1980

Caries removal

Hand
instruments

Adhesive
Restoratives

201
 …..ART
Indicated

• Young patients

• Odontophobia

• Mentally/physically handicapped

• High caries risk individuals – immediately

stabilize

• Population with lack of resources 202

 ….ART
Limitations
• Long term survival rate not available
• Limited to small & medium sized lesions

GIC
• Fuji VIII- anterior teeth
• Fuji IX- posterior teeth
• Chem-Flex, Ketac Molar
203
 Rotary – high/low speed

• Fissurotomy system

1. Carbide burs

2. Caries detector

3. Flowable composite

• Smartprep burs

204
 Rotary – system
• Fissurotomy bur - new approach to ultra conservative
dental treatment

• Bur - treating pits and fissure lesions that are

superficial

• Avoids unnecessary loss of enamel and dentin

• Fine carbide tip

- strip < tooth than diamond
– pain free near DEJ 205
Smartprep burs
• SS White, USA

• Special polymer material

• Cutting edges- shovel-like straight

• Size- 010, 014, 018

• KHN – 50
• Carious dentin- 30
• Healthy dentin- 70-90 206
 Smartprep bur

• Selectively removes carious dentin

Excavation – centre to periphery

Fewer tubules cut < pain

Single use

speed – 500-800rpm

Polymer wears off on contacting harder dentin

Expensive
207
 Chemo-mechanical caries removal

• Chemical softening of carious dentin – gentle

excavation

• Sodium hypochlorite

• Sorensen’s buffer (glycine, NaCl, NaOH)

• Caridex 1980
208
 Caridex

• Delivery system

- reservoir

- heater & pump

- handpiece & applicator tip

• 100-500 ml required

• Carisolv 1998
Advantages

• Conservation of sound tooth str

• No LA

• Medically compromised & children

Disadvantages

• Requirement of rotary & hand instruments

• Unpleasant taste

• Expensive than hand excavation 210

 Air abrasion
• Dr Robert Black 1940
Dr J Tim Rainey 1950

• E = ½ mv2
• Highly energized AlO – tooth -
kinetic energy absorbed – cuts/abrades
• Kinetic cavity preparation

• Airdent (SS White company)

211
 40psi- fissure sealing
Pressure 40-140psi 80psi- extensive caries
removal

Large tips- large prep

Tip size 0.015”-0.027” Small tips- resin restn
diameter

Tip angle 40-120o

Tip distance < 2mm from target

Dwell time Long exposure >prep

27.5µ - intraoral
Particle size – Al2O3 27.5-50µ 50µ - extra oral –
cleaning restn

212
Particle flow rate 0-8 g/min
 Clinical parameters for cutting

Type & size of abrasive particle Large size & hard particles >
kinetic energy – rough finish

Air pressure Directly related to cutting

power

Distance from tooth surface 2mm

Large – higher cutting rate,

Angle of tip to surface narrow deep cuts
Small – shallow, wide cavity
Wide – fast cutting – large cut
Nozzle diameter Narrow – slow cutting – small
cut
High – great enamel removal
Powder flow Increase dust
213
 Advantages Disadvantages

Less invasive , conservative lack of tactile sensation – risk of

overprep

Ideal for adhesive restoration Messy procedure & damages mouth

mirrors, intraoral lenses
Adequate protection for operator &
patient

Rounded internal contours > longetivity Cannot remove infected dentin

of restn

< discomfort for patients CI – asthmatic, chronic pulm dis, remove

amalgam restn, crown prep
214
 Air polishing

• Sodium bicarbonate+ water + tricalcium

phosphate

• Jet of compressed air to sandblast tooth surface

• Cleaning tooth before sealant application ,

remove stains, plaque & calculus

215
 Ultrasonics
• Neilsen 1950

• Magnetostrictive instrument – 25KHz oscillating

frequency – in conjunction with AlO & water slurry

• High speed oscillations of cutting tip transfers kinetic

energy of water mol to tooth

• Cuts hard tissue / cannot remove soft caries

216
 Sono-abrasion

• High frequency (6.5KHz) , sonic, air-scalers with

modified abrasive tips- sono abrasion

• Tip oscillates – elliptical motion

• Diamond coated (40mm grit) – one side

217
 Lasers

• Light Amplification by stimulated emission of radiation

• Erbium: yttrium aluminium garnet lasers and

• erbium, chromium: yttrium-scandium-gallium-garnet lasers

are being used to cut dental hard tissues.

218
 Advantages

• Conservative and more precise.

• Less traumatic to patients and operative time is reduced.

• No LA

• Multiple restorations in different quadrants can be done

easily.

• No vibrations, no smell, maximum patient co-operation

219
 Disadvantages

• Expensive

• Cannot be used for amalgam restn

• Lasers cannot be used to repair existing amalgam fillings

either, because they vaporize mercury, making it highly
toxic.

220
 Tunnel preparation

• GIC, RMGIC. Occlusal 1.5mm - composite

• Round bur – occlusal surface – remove caries – inspect

proximal enamel Weak enamel – remove

Intact enamel - remineralize

221
Indication
• Small, proximal carious lesion

• Low caries index

Contraindicated
• Large carious lesion & access difficult

• Overlying marginal ridge subjected to heavy

occlusion

222
 Advantages Disadvantages

Preserves the marginal ridge Conservative approach- vision reduced

– inadequate caries removal

Outer surface of interproximal caries Highly tech sensitive & angulation

is removed if cavitated - < potential passes close to pulp
for overhang

Reduce damage to adj teeth –

minimal prep proximally

223
 Repair vs replacement restoration

Advent of adhesion, minimal intervention cavity

design- repair as treatment modality over
replacement

• Replacement results in

- larger cavity

- damage to adj teeth

- new defects introduced

224
 Indications for replacement

• Extensive secondary caries

- cannot be removed in repair procedure

• Esthetic need

• Pulpal pathology

225
 Conclusion

Extension for
prevention

Prevention of
extension

226
 Frequently asked questions
• Define dental caries
• Explain most accepted theory explaining dental
caries
• Etiology of caries
• S mutans
• Classification
• Diagnostic method of caries
• Role of fluorides in caries prevention
• CPP ACP