MANAGEMENT OF DEEP CARIES

How Deep Is a Deep Caries Lesion?

2

Deep caries lesions point toward the potential

exposure of the pulp.

Lesions that penetrated to within three fourths of

the entire dentin thickness or more as evaluated on

x-rays.

FACTORS INFLUENCING THE SUCCESS

OF PULP THERAPY
3

Depth of
penetration
of bacteria

Type and
amount of
pulpal
damage

Spread of
carious
attack

(Oper. Dent. 2002; 27: 2117 ; Dentin Caries,Progression &

Management)

pain - not reported even when caries invades dentin

except when deep lesions bring the bacterial

infection close to the pulp.
Episodes of short-duration pain - occasionally

during earlier stages of dentin caries. pain stimulation of pulp tissue by movement of fluid
through dentinal tubules.

When bacterial invasion of the dentin is close to the

pulp, toxins and a few bacteria enter the pulp .

Initial pulpal inflammation is evident clinically by
production of sharp pains - lingering only a few
seconds (10 seconds) in response to a thermal
stimulus.
A short, painful response to cold suggests reversible
pulpitis .

Reversible pulpitis - limited inflammation of the

pulp - the tooth can recover if the caries producing

the irritation is eliminated by timely operative
treatment.
When the pulp becomes more severely inflamed, a

thermal stimulus produces pain that continues after

termination of the stimulus, typically longer than 10
seconds - irreversible pulpitis.

TYPES AND LAYERS OF DENTINAL

CARIOUS LESIONS
TWO TYPES : ACUTE AND CHRONIC
FIVE LAYERS OR ZONES

ZONES OF DECAY
8

DECAYED ZONE
9

Devoid of minerals
Collagen fibers have lost

their cross striations

High concentration of

micro-organisms
Clinically similar in acute

& chronic lesion

Has to be removed.

SEPTIC ZONE
10

Highest concentration of

microorganisms
Collagen fibers have fewer

cross striations
Dentinal tubules are

widened
Softer in an acute lesion

than in chronic
Has to be removed.

DEMINERALIZED ZONE
11

Dentin is only

demineralized &
dentinal matrix still
intact
Destructive & repair

activities takes place.

TRANSPARENT ZONE
12

Area of disturbed

mineralization repair
Zone of dentinal sclerosis

& calcific barrier

More pronounced in

chronic decay
Extremely hard than

normal dentin
Should not be excavated.

OPAQUE ZONE
13

Transparent zone
Characterized by intra-

tubular fatty
degenaration
Sclerosis of dentinal

tubules
More pronounced in

acute lesions

14

Carious dentin has been identified by two layers

The outer carious layer is infected un-

remineralizable with irreversible deteriorated

collagen fibers, with no odontoblastic processes,
insensitive and therefore, should be removed.

15

The inner carious layer is un-infected,

remineralizable with reversibly denatured

collagen fibers, sensitive, and so should be
preserved.

The dye stains only the infected outer carious

dentin.

AFFECTED & INFECTED DENTIN

16

ENAMEL

DEJ

DENTIN

PULP

Infected dentin
1.Softened demineralized
dentin teeming with
bacteria
2.Collagen is irreversibly
denatured
3.Cannot remineralize

Affected dentin
1.Softened deminerlized dentin
not yet invaded by bacteria
2.Collagen cross linking remains
3.Acts as a template for
remineralization
4.Softer than normal dentin,
discoloured but does not flake
easily

4.Soft necrotic tissue,

followed by dry leathery
dentin flakes away with
an instrument
5.Dyes: 1% Acid red in
5.Does not stain
propylene glycol stains
only irreversibly denatured
collagen

EFFECT OF CARIES ON THE P-D ORGAN

18

Type of decay

Duration of
decay

No . Of
microorganisms

Depth of
involvement

Tooth resistance

TYPE OF DECAY
19

Acute decay
Chronic decay

Less effective
defensive
reparative mech.
Substantial
repair
Destructive
reaction

DURATION OF DECAY PROCESS

20

ACUTE DECAY
- more massive destruction of tooth structure

CHRONIC DECAY

Greater chances for repair

DEPTH OF INVOLVEMENT
21

Deeper the caries

Nearer the sources of
irritation to the pulp
Pulpal destruction

NUMBER & PATHOGENECITY OF MICROORGANISMS

22

Greater
the
virulence

population

Greater
pulpal
reaction

TOOTH RESISTANCE
23

Thickness of
involved dentin

Susceptibilty of
tooth

F & Ca content
of the involved
dentin

Permeability of
dentin

Solubility of
dentin

24

EFFECTIVE DEPTH(RDT)
Is the area of minimum thickness of sound dentin
separating the pulpal tissue from carious lesions

Importance of Remaining Dentin Thickness (RDT)

25

Dentin is the best insulator for the pulp. Therefore, it is

better to conserve remaining sound tooth structure rather

than replace lost tooth structure with an artificial
material.

RDT , from the depth of the cavity prep. to the pulp is the

single most imp. factor in deciding the best method of

pulp protection.

Role of RDT
26

RDT

0.5mm

1 mm

2 mm

Effect of toxic
substances on
pulp
25%

10%

minimal or nil

CARIES EXCAVATION
METHODS
27

CATEGORY

METHOD

Mechanical Rotary

Handpiece + burs

Mechanical Non Rotary

Hand excavators, Air abrasion. Air

polishing. Ultrasonic. Sono abrasion

Chemo mechanical

Caridex Carisol, Enzymes

Photoablation

Lasers

Excavators, handpieces and burs

28

For caries removal a round bur is recommended with

diameter corresponding to size of carious lesion.
Larger burs recommended.
Water irrigation is optional because low speed (700800 Rpm) is employed.

29

Slow-speed bur or hand excavator can be used for

carious dentine excavation. As the hand excavator

will remove softened tissue with more sensitive
tactile feedback than a bur, this method is the more
self-limiting of the two.

Polymeric Burs
30

Consists of a polymer (PEKK- Polyether- ketoneKetone) with hardness of 50 KHN, which was higher
than hardness of carious dentin(0-30KHN) but
lower than sound dentin (70-90KHN).

Ceramic burs
31

The cera burs are all ceramic round burs made of

alumina-yttria stabilised zirconia and are available in
different sizes.

CHEMO-MECHANICAL METHOD
32

Caridex sodium hypochlorite solution buffered with an amino acid

containing mixture of aminobutyric acid, sodium chloride and
sodium hydroxide.

Carisolv -

consists of two carboxymethylcellulose based gels: a

red gel containing 0.1 M amino acids (glutamic acid, leucine and
lysine),

NaCl, NaOH, erythrosine (added in order to make the gel visible

during use); and a second containing sodium hypochlorite (NaOCl

0.5% w/v)

33

The two are thoroughly mixed in equal parts at room

temperature before use and then applied, using

the hand instrument, onto the exposed carious
dentine and left for 60 seconds prior to gently but
firmly abrading away the softened dentine to leave a
hard, caries-free cavity.

cutting tips of the hand

instruments

SONO ABRASION
34

Caries excavation by sono-abrasion is based on the use

of cutting tips coupled to high-frequency, sonic, airscaler handpieces under water cooling. A maximum 2-N
torque force should be applied.

Air abrasion
35

Air abrasion system uses 27um diameter alumina

particles to remove tooth stains and to prepare shallow
cavities.
Cutting efficiency depends on type and size of abrasive
particles as well as particle speed and angle of surface
approach

Fluorescence aided caries excavation (FACE)

36

A slow speed hand piece with a fiber optic violet light

source (370-420 nm) allows the operator to use a 530
nm yellow glass filter, areas exhibiting orange red
fluorescence can be identified and removed with a bur.

Lasers
37

- Erbium laser.
- wavelengths( 2.94um and 2.78um).

38

THANK YOU

39

TYPES OF PULP THERAPY

40

Indirect pulp
capping
Direct pulp
capping
Pulpotomy

FACTORS AFFECTING PULP THERAPY

41

Age

FACTORS

Extent
of
caries
(BDJ , Dec 2001,Vol191,No.11)

AGE
42

Increasing
age

Fibrous pulp
tissue

Secondary
dentin
formation

Capacity to
respond
DPC

Decreased
blood supply

Reduction in
pulp volume

(BDJ , Dec 2001,Vol 191,No.11)

FACTORS
(BDJ , Dec 2001,Vol 191,No.11)

43

EXTENT
OF CARIES
Should be
small- good
prognosis
Large carious
lesion- poor
prognosis

A more favourable prognosis for the pulp following

direct pulp capping may be expected if:
44

The tooth has been asymptomatic (no spontaneous

pain, normal response to thermal testing, and is

vital) before the operative procedure.
The exposure is small, less than 0.5 mm in diameter.
The hemorrhage from the exposure site is easily

controlled.

45

The exposure occurred in a clean, uncontaminated

field (such as provided by rubber dam isolation).

The exposure is relatively atraumatic and little

desiccation of the tooth occurred, with no evidence

of aspiration of blood into the dentin (dentin
blushing).

Calcium hydroxide Ca(OH)2:

46

Most common pulp-capping agent

Antibacterial and disinfects the superficial pulp
High pH (about 12.5)

How does Ca(OH)2 work??

47

Liquefaction necrosis of the superficial pulp

Neutralization of toxicity in deeper layers
Coagulative necrosisIrritation of adjacent pulp
Minor inflammation response Hard tissue barrier

48

Dentin bridges beneath calcium hydroxide pulp caps

contain tunnel defects, therefore an additional base

material is necessary to seal the exposed pulp from
the external environment.

Calcium hydroxide materials tend to soften,

disintegrate, and dissolve over time.

Direct Pulp Capping

49

Definitions
Tre a t m e n t o f a n e x p o s e d v i t a l p u l p b y

sealing the pulpal wound with a dental

material placed directly on a mechanical or
traumatic exposure to facilitate the
formation of reparative dentin and
maintenance of the vital pulp.
Ingle 2008

50

Calcium hydroxide promotes reparative dentin

bridges over any area of frank pulpal exposure.

Such repair usually occurs in 6 to 8 weeks and may

be evident radiographically in 10 to 12 weeks.

Success may be improved with a resin-modified,

glass-ionomer liner placed over the calcium

hydroxide.

Why?
51

Conservative treatment

Saves the tooth and Preserves

vitality

INDICATED
52

Exposure is less than 0.5 mm in diameter

Exposure is in clean, uncontaminated field
A pin point exposure having sound dentin at

t h e p e r i p h e r y, w i t h n o h e m o r r h a g e .
T h e b l e e d i n g c o a g u l a t e s i m m e d i a t e l y.
Exposure was not made during excavation of

infected dentin.

DIRECT PULP CAPPING

53

OBJECTIVES

Treat the damaged pulp tissue

Aid in formation of secondary dentin

54

History- No recurring or spontaneous pain. No swelling.

Preoperative assessment-Normal vitality tests.

Not tender to percussion.

No swelling. No radiographic evidence of
periradicular pathology.
Young patient.
Radiographically obvious pulp chamber and root
canal.
Clinical findings- Pink pulp
Bleed if touched but not excessively.

DIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock ,R walker )

55

ISOLATION

Rubber dam

Cavity

Caries free
Pulp wound exluding
blood or
serum

DIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock
56 ,R walker )

Washing of exposed pulp

Sterile water or saline

Achieve haemostasis
Profuse bleeding > 5 min

Severe pulp inflammation

57

sterile cotton pellet to control

bleeding

Mix capping agent

58

Apply to exposure site

Base/liner then restore

DIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock ,R walker )

59

Permanent ,well adapted

restorative material is
then placed.

If composite is used

Resin modified GIC as a

base is applied.

Healing with calcium hydroxide

60

pulpal tissue is disinfected and necrosed by the

calcium hydroxide.
Dentin bridge formation below the necrotic zone.

5/26/15

61

Other pulp capping agents

5/26/15

Mineral Trioxide Aggregate or MTA

62

Composition:
Tricalcium silicate
Tricalcium aluminate
Tricalcium oxide
Silicate oxide

Mineral Trioxide Aggregate or MTA

63

Composition:
Tricalcium silicate
Tricalcium aluminate
Tricalcium oxide
Silicate oxide

Properties:
64

Low or no solubility

PH value 10.2 after mixing and rises to

12.5 after 3 hours

Antibacterial effect

Induces pulpal cell proliferation

Stimulation of mineralized tissue formation

(Mineral Trioxide Aggregate: A Comprehensive LiteratureReviewPart I: Chemical, Physical, and Antibacteria lProperties) (Direct pulp capping with mineral trioxide aggregateJ Am

Dent Assoc 2008;139;305-315) (MTA AND CALCIUM HYDROXIDE FOR PULP CAPPINGJ Appl Oral Sci 2005; 13(2): 126-30) Properties:

INDIRECT PULP CAPPING

65

I t i s d e f i n e d a s a p r o c e d u r e i n w h i c h t h e

material is placed on a thin partition of

remaining carious dentin that, if removed
might expose the pulp.
Ingle 6th edition

T h e d e l i b e r a t e r e t e n t i o n o f s o f t e n e d d e n t i n

near the tooth pulp and medication of the

remaining dentin with calcium hydroxide.
Sturdevant 2007

66

67

In a tooth with a deep carious lesion, no history of

spontaneous pain, normal responses to thermal

stimuli, and a vital pulp (shown by electric testing), a
deliberate, incomplete caries excavation may be
indicated.
This procedure is termed indirect pulp capping and
is characterized by placement of a thin layer of
calcium hydroxide on the questionable dentin
remaining over the pulp.

INDIRECT PULP CAPPING

68

Application of an agent

to a thin layer of
dentin/remaining caries
to maintain the vitality of
the pulp.
Indicated when a deep

carious lesion is
encroaching on ,but not
actually into the pulp.

INDIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock ,R walker )

69

OBJECTIVES :

to prevent pulp exposure.

To aid pulpal recovery by medication.
To Maintain a normal & healthy pulp.

Indicated
70

No history of spontaneous pain.

Normal response to vitality tests.
The pain does not continue after the removal of a hot or cold

stimuli.
No periradicular changes should be evident.

INDIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock ,R walker )

71

Excavation of all carious

dentin might risk a

traumatic breach in the
pulp .

Some of carious dentin

over the pulp is LEFT

INDIRECT PULP CAPPING

(Endodontics , 3rd edi.,C Stock ,R walker)

72

Remaining carious

dentin is dressed with

Ca (OH)2

To kill residual bacteria

Encourage
remineralization

Followed by application

of Zinc Oxide Eugenol

Prevent bacterial leakage

INDIRECT PULP CAPPING

73

Pulpotomy
Definition
Pulpotomy is defined as the surgical removal of

infected coronal pulp and its objectives are

preservation of the radicular pulp vitality and relief of
pain.

Indications
In the treatment of pulpally involved permanent teeth

with open apices and vital pulp.

 Administer local anasthesia

78

FINAL RESTORATION
The quality of the final restoration is critical to the longterm maintenance of pulp vitality and sustained normal
function of the pulp-capped or pulpotomized tooth.
The more conservative the restorative treatment,
preserving the remaining healthy tooth structure, the
higher the probability of pulp survival.

79

REFERENCES
Keys to clinical success with pulp capping: A review of
the literature. Operative dentistry
2009,34-5,615-625
80
Analysis of Pulpal Reactions to Restorative Procedures,
Materials, Pulp Capping, and Future Therapies
American dental journal 2002,vol 13 no 6 509-520
Ingles endodntics 6th edi.

Mc Donalds,DENTISTRY FOR CHILDHOOD & ADOLSCENT 8TH

edi.

M.A. Marzouk: OPERATIVE DENTISTRY:

A clinical guide to dental traumatology, Louis Bermann,

1st edition.