Management of Moderate and Deep Carious
lesions
Salah Hasab Mahmoud
Professor & Chairman of Operative Dentistry Department
Faculty of Dentistry, Mansoura University
Member of Academy of Operative Dentistry at USA
*Change is the law of life.
And those who look only
to the past or the present
are certain to miss the
future *
• RDT is defined as the distance between the floor of
the cavity preparation and the roof of the pulp
chamber.
• RDT → the Key-feature in determining the depth
of the carious lesion
• RDT is at least 1.5- 2 mm in moderate carious lesions &
less than 1.0 mm in deep lesions
Factors Affecting the Response of Dental Pulp
to Carious Process
• Rate of Progress
• Depth of involvement
• Number and virulence of the organism
Changes of the Dental Pulp Due to Caries
When the lesion progresses causing cavitation, more
extensive dentin and pulp reactions occur including:
Saturation of the dentinal fluid
by minerals
Presence of enzyme activity on
carious dentin (alkaline-
phosphatase)
Presence of fewer and cuboidal odontoblasts (instead of tall
columnar shape)
Damaged odontoblasts which
are replaced by odontoblast-
like cells
Increased synthesis of collagen
type I and non-collagen proteins
Formation of reparative (from odontoblast-like cells)
and reactionary dentin (from the initial odontoblasts).
Assessment of the Remaining Dentin
• The key factor of success in the treatment of such cases is to differentiate between the CID and
CAD
• The clinical differentiation between CID & CAD is one of the most difficult challenges encountered
clinically
• Conventional means of detection are based on visual and the tactile sensation; however, these
methods are subjective and variable amongst practitioners.
Conventional Tactile and Visual Methods
Discolored, leathery dentin (identified with scraping spoon, not poking with the
explorer) can be left once the cavity floor is reasonably firm to avoid the risk of pulp
exposure.
Using of Caries-Disclosing ‘Detector’ Dyes
1% acid red 52 solution in propylene glycol
complexes specifically with denaturated
collagen fibers; however, the dyes could not
stain either sound dentin powder or
demineralized intact collagen.
• Intended to enhance complete removal of infected
carious dentin without over-reduction of sound dentin
• The dye was purported 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.
Using a Remaining Dentin Thickness Detector Device ‚Prepometer ”
• This is a good, unique product.
• It is a battery-powered instrument designed to determine dentin thickness by
measuring electronic resistance of the dentin above the pulp.
• The resistance is measured, evaluated, and displayed by LED lights on the
unit.
• As the resistance decreases, the light colors change, indicating the increasing risk of
pulpal exposure.
• Each measurement takes 10 seconds.
• No patient discomfort.
• The use of Prepometer practically minimizes the risk of damaging the pulp.
• Colored light diodes inform within seconds about the thickness of the dentine when
surfing over the prepared tooth.
GREEN indicates a thickness, which would allow further preparation.
YELLOW will indicate that preparation should stop here.
ORANGE will indicate the closer you get to the pulp.
Treatment of Deep Carious Lesions
Minimally Invasive Concept ‚Prevention of Extension‛
MID includes:
• Early detection of dental caries
• Assessment and management of caries-risk remineralization of early caries lesions
• Restoring cavitated lesions
• Restriction of the excavation to the caries-infected areas and using adhesive-based
technologies
• Conservative cavity designs; such as slot and
tunnel preparations, are one of the characteristic
features of MID
• Retentive features changed from macro-mechanical
to micro-mechanical
• MID converts Black’s concept from
“extension for prevention” to
“prevention of extension”.
Stepwise Caries Excavation
In this technique, the caries excavation is performed in two stages with a time lag period.
The rationale of using stepwise excavation is to
• Stop the acute phase of the lesion
• Reduce the irritation of pulp tissue
• Giving the pulp chance for the formation of reparative dentin
Clinical Steps for stepwise ‚indirect pulp capping’
In the First Appointment, the soft caries should be removed leaving the deepest ‚firm‛ layer
of caries-infected tissue, which will be covered with a cavity lining (Ca OH, MTA, or
Biodentine) and interim filling restorative material.
In the Second Appointment, After a certain period of time, ‚4-12 months‛,
the cavities are re-entered to excavate the residual carious tissue
Concept of Partial Caries Removal (PCR)
Any grossly softened caries-infected-dentin must be
excavated, nevertheless, in deep carious lesions where the
inner most layer of dentin, which directly covers the pulp,
contains a high concentration of bacteria‛ provided to create
well-sealed restorations.
“The Seal is the Deal”
Indirect Pulp Capping Video
Atraumatic restorative treatment (ART)
ART is an example of the 1-step partial caries excavation technique.
Steps
• Slightly widening of the access opening of small
cavities using specially designed pyramidal-shaped
hand instruments (to improve the accessibility to the
carious lesion
• Excavation of grossly softened caries-infected dentine
using a hand excavator
• Caries removal is verified by tactile sensation method
using a ball-end explorer
• Cavities are cleaned with
Chlorhexidine & restored with high
viscosity GI restorative materials.
Vital Pulp Thereby ‘Direct Pulp Capping’
Defined as a wound dressing of the exposed clinically normal pulp with the absence of signs and
symptoms of severe pulpal disease.
Exposure site characterized by
★ Pin point (small in size)
★ no perfuse bleeding and can
be controlled
★ The periphery of the
exposure site is surrounded
by sound dentin
Factors affect the success of direct pulp capping
• Size of the exposure
• Isolation of the operating site to reduce bacterial contamination
• Control of the bleeding site
• Pulp repair capacity
• General health of the patient
• Patient age
Direct Pulp Capping Procedures (Video)
Best wishes Dear Students
