Management of deep carious

MANAGEMENT OF
DEEP CARIOUS
LESIONS

WHAT ARE DEEP CARIOUS LESIONS?
Deep carious lesion is a clinical diagnosis that is given when the
caries process has penetrated deep into the dentin with possible
pulpal exposure. Deep carious lesions cause pulpal
inflammation( i.e. pulpitis); if not managed ,they may result in
pulp necrosis and involvement of the periradicular tissues, with
possible pain requiring endodontic treatment or extraction.

DENTINAL CARIES
When enamel caries reaches the dentinoenamel junction it spreads rapidly
laterally because it is least resistant to caries.
Caries advancement in dentin proceeds through three changes:
1. Weak organic acids demineralize the dentin
2. The organic material of dentin ,particularly collagen , degenerates and
dissolves
3. The loss of structural integrity followed by invasion of bacteria

FIVE DIFFERENT ZONES IN CARIOUS DENTIN
 ZONE 1: NORMAL DENTIN
o Deepest area
o Have tubules with odontoblastic processes
o Intertubular dentin with normal cross banded collagen
 ZONE 2 : SUBTRANSPARENT DENTIN
o Zone of demineralization of intertubular dentin
o Damage to odontoblastic process evident
o Dentin capable of remineralization
 ZONE 3 : TRANSPARENT DENTIN
o Zone of carious dentin softer than normal dentin
o Collagen cross linking remains intact

o Pulp remains vital
 ZONE 4 : TURBID DENTIN
o Zone of bacterial invasion
o widening and distortion of dentinal tubules
o Collagen irreversibly denatured
o Not self repair zone
 ZONE 5 : INFECTED DENTIN
o Outermost zone
o Consists of decomposed dentin
o No recognizable structure to dentin teeming with bacteria
o Great numbers of bacteria dispersed in granular material

Affected and infected dentin
In operative procedures , it is convenient to term dentin as either
infected or affected dentin
AFFECTED DENTIN- softened, demineralized dentin that is not
yet invaded by bacteria- inner carious dentin(does not require
removal)
INFECTED DENTIN- outer carious dentin and bacterial plaque –
both softened and contaminated with bacteria ( requires
bacteria)

PULPITIS
Pulpitis is inflammation of dental pulp tissue.

CAUSES OF PULPAL
INFLAMMATION Bacterial cause
 Can damage pulp through toxins secreted by bacteria from
caries
 Accidental exposure
 Mechanical cause
 Traumatic accident
 Attrition
 Abrasion
 Luxation or avulsion of tooth

 Thermal cause
 Uninsulated metallic restoration
 During cutting
 Bleaching
 Electrosurgical procedures
 Laser beam
 Periodontal curettage
 Periapical curettage
 Idiopathic cause
 Aging
 resorption: internal or external

GROSSMAN’S CLINICAL CLASSIFICATION
1. PULPITIS: Pulpitis
Reversible papulosis Irreversible pulpitis
Symptoma
tic (acute)
Asymptom
atic
(chronic)
acute chronic
Abnormally
responsive to
cold
Abnormally
responsive to
heat
Asymptomatic with
pulp exposure
Hyperplastic pulpitis
Internal resorption

2. PULP DEGENERATION:
a) calcific ( radiographic diagnosis)
b) Other ( histopathological diagnosis)
3. NECROSIS

REVERSIBLE PULPITIS
Reversible pulpitis is a mild to moderate inflammatory condition
of the pulp caused by noxious stimuli in which the pulp is
capable of returning to the normal state following removal of
stimuli.
SYMPTOMS
 Characterized by sharp pain lasting for a moment , commonly
caused by cold stimuli
 May result from incipient caries and is resolved on removal of
caries
 Pain does not occur simultaneously

 TREATMENT
 Best treatment is prevention
 No endodontic treatment is needed
 Periodic care to prevent caries , desensitization of hyperactive
teeth and use of cavity varnish or base before insertion of
restoration is recommended
 If pain persists despite of proper treatment then it should be
considered as reversible

IRREVERSIBLE PULPITIS
It is a persistent inflammatory condition of the pulp , symptomatic
or asymptomatic , caused by a noxious stimulus. It has both acute
and chronic stages in pulp
 CLINICAL FEATURES
 EARLY STAGE
 Paroxysm of pain caused by: sudden temperature changes like
cold , sweet, acid foodstuffs
 Pain often continues when cause has been removed
 May come and go spontaneously
 Pain: sharp, piercing, shooting, generally severe

 LATE STAGE
 Pain more severe and throbbing
 Increased by heat and sometimes relieved by cold , although
continued application of cold may intensify pain
DIAGNOSIS
 Visual examination and history : on inspection may see deep
cavity involving pulp or secondary caries under restorations
 Radiographic findings : may show depth and extent of caries
 Percussion: tender on percussion(due to increased intrapulpal
pressure)

 Vitality tests:
 Thermal test: hyperalgesic pulp responds more readily to cold
stimulation than for normal tooth , pain may persist even after
removal of irritant.
 Electric test: less current is required to initial stages . As tissue
becomes more necrotile more current is required to generate
the response

The results of diagnosis
No exposure Pulp exposure
Conventional
cavity
preparation
and
restoration
Indirect
pulp
capping
Vital
(traumatic)
exposure
Non-vital
(carious)
exposure
Direct pulp
capping
RCT

DENTIN THICKNESS
 We must remember that no material can provide better
protection for the pulp than dentin
 The remaining dentin thickness , from the depth of cavity
preparation to the pulp, is the most important factor in
protecting the pulp

REMAINING DENTIN THICKNESS
 Shallow cavity depth- preparation 0.5 mm into dentin (ideal
depth)
 Moderate cavity depth- remaining dentin over pulp of at least 1-
2mm
 Deep cavity depth- depth of preparation with less than 1.0mm of
remaining dentin over pulp

REACTIONARY DENTIN DEPOSITION
 Reactionary dentin deposition observed beneath cavities with
RDT above 0.5mm as well as beneath cavities with a RDT below
0.25mm
 Maximal reactionary dentin appeared to be beneath cavities with
an RDT between 0.5 to 0.25mm
 Area of reactionary repair influenced by the choice of
restoration material
(from greatest least calcium hydroxide ,composite ,resin
modified glassionomer [RMGI] cement, and zinc oxide- eugenol)
 Odontoblast numbers maintained beneath cavities with a RDT
above 0.25mm

INDIRECT PULP CAPPING
It is a procedure performed in a tooth with deep carious lesions
adjacent to pulp. In this procedure , all infected carious dentin is
removed leaving behind the softened carious dentin adjacent to
pulp. Caries near the pulp left in place to avoid pulp exposure
and preparation is covered with a biocompatible material

DECISION MAKING IN USE OF
SEALERS , LINERS AND/ OR BASES
 remaining dentin thickness in tooth preparation
 Thermal conductivity of restorative material
 Presence or absence of pulpal symptoms –pain to stimuli
• Thermal
• Osmotic changes
• Duration of symptom
• Spontaneous pain

INDICATIONS
 Deep carious lesions near the pulp tissue but not involving it
 No mobility of tooth
 no history of spontaneous toothache
 No tenderness on percussion
 No radiographic evidence in pulp pathology
 No root resorption or radicular disease
CONTRAINDICATIONS
 Presence of pulp exposure
 Radiographic evidence of pulp pathology
 History of spontaneous toothache
 Tooth sensitive to percussion

CLINICAL TECHNIQUE
 Band the tooth if tooth is grossly decayed
 Remove soft caries either with spoon excavator or round bur
 A thin layer of dentin and some amount of caries is left to
avoid pulp exposure
 Place calcium hydroxide paste on the exposed dentin
 Cover the calcium hydroxide with zinc oxide eugenol cement
 Teeth should be evaluated after 6 to 8 weeks
 After 2 to 3 months , remove the cement and evaluate the
tooth preparation

During this waiting period :
 The carious process is arrested
 Soft caries hardened
 A protective layer of reparative dentin is laid down
Success of indirect pulp capping depends upon
 Age of patient
 Size of exposure
 Restorative procedure
 Evidence of pulp vitality

DIRECT PULP CAPPING
Procedure that involves the placement of biocompatible material
over the site of pulp exposure to maintain vitality and promote
healing

INDICATIONS
 Small mechanical exposure of pulp during :
tooth preparation
traumatic injury
 No or minimal bleeding at exposure site
CONTRAINDICATIONS
 Wide pulp exposure
 Radiographic evidence of pulp pathology
 History of spontaneous pain
 Presence of bleeding at exposure site

CLINICAL PROCEDURE
 Administer local anesthesia
 Isolate the tooth with rubber
dam
 When vital and healthy pulp
exposed , check the fresh
bleeding at exposure site
 Clean the area with distilled
water or saline solution and
thin dry it
 Apply calcium hydroxide over
the exposed area

 Give interim restoration such as zinc oxide eugenol for 6 to 8
weeks
 After 2 to 3 months , remove the cement very gently to
exposure site .
 If secondary dentin formation takes place over the exposed site
, restore the tooth permanently with protective cement base
and restorative material.
 If favorable prognosis not there, pulpotomy or pulpectomy is
done

Direct pulp capping techniques
Calcium hydroxide technique Total etch technique
hemostasis
Disinfect cavity
CaOH
Resin modified glass ionomer
IRM restoration
hemostasis
Disinfect cavity
primers
adhesives
Resin modified glass
ionomer
restoration

FACTORS AFFECTING SUCCESS OF DIRECT PULP
CAPPING
 Age of the patient
 Type of exposure
 Size of exposure
 History of pain

MATERIALS USED FOR PULP
PROTECTION
These materials help to:
 Insulate the pulp
 Protect the pulp in case of deep carious lesion
 Act as barriers to micro leakage
 Prevent the bacteria and toxins from affecting the pulp

PULP PROTECTING AGENTS
 CAVITY SEALERS: protective coating on the cavity walls
creating a barrier to leakage, to seal dentinal tubules
ADVANTAGES:
 Used to reduce micro leakage
 Reduces postoperative sensitivity
 Prevents discoloration of tooth by checking migration of ions
into dentin
 In case of amalgam restoration , it improves the sealing ability
of amalgam

 RESIN BONDING AGENTS: an adhesive sealer is commonly
used under compound restorations for application, cotton tip
application is used to apply sealer on all areas of exposed
dentin
INDICATIONS:
 To seal dentinal tubules
 To treat dentin hypersensitivity
 LINERS: cement or resin coating of minimal thickness (less
than 0.5mm) placed as a barrier to bacteria or to provide a
therapeutic effect (pulpal sedative or antimicrobial
effect).applied to cavity walls adjacent to pulp (calcium
hydroxide, zinc oxide eugenol )
 it also stimulate formation of reparative dentin

 CAVITY BASES: placed to replace missing dentin , placed in
thicknesses of 0.5-1mm
 Provide thermal insulation
 Encourage recovery of injured pulp from thermal,
or chemical trauma, galvanic shock and micro leakage
 MATERIALS USED AS BASES:
 Zinc oxide eugenol
 Zinc phosphate cement
 Zinc polycarboxylate cement
 Glass ionomer cement

CALCIUM HYDROXIDE CEMENT
 calcium hydroxide has been used as a lining material since
the 1920s
 Because of the basic pH of about 11, calcium hydroxide is
both antibacterial and can neutralize the acidic bacterial
byproducts.
 The high pH creates an environment conducive to the
formation of reparative dentin
 In addition , calcium hydroxide has the capacity to mobilize
growth factors from the dentin matrix , causing the
of new dentin
 Biocompatible in nature

MERITS OF CALCIUM HYDROXIDE
CEMENT OVER ADHESIVE CEMENTS
 Adhesive resins can be acidic and
cause pulpal irritation
 Many dentin bonding agents and
resin reinforced glass ionomers are
actually detrimental to the pulpal
tissues
 In contrast, calcium hydroxide has
been shown to provide a
significantly improved potential for
pulpal repair compared to
adhesive resins

DEMERITS OF CALCIUM HYDROXIDE
 Unfortunately , the self-setting calcium hydroxide liners are
highly soluble and subject too dissolution over time
 Traditional calcium hydroxide liners are easily lost during acid
etching
 Dentin bonding agents that contain water, acetone, or alcohol
can also detrimentally affect the properties of calcium hydroxide
 Therefore, when a restoration of composite resin is planned,
glass ionomer cement should line the cavity preparation, sealing
over the calcium hydroxide material, if used

MINERAL TRIOXIDE
AGGREGATE(MTA)
 In recent years, mineral trioxide aggregate (MTA) preparations
have been introduced
 These silicate cements are antibacterial, biocompatible, have a
high pH, and are cable to aid in the release of bioactive dentin
matrix proteins
 MTA is a powder consisting of fine hydrophilic particles of
tricalcium silicate, tricalcium aluminate, tricalcium oxide, and
silicate oxide
 It also contains small amounts of other mineral oxides, which
modify its chemical and physical properties

 Hydration of the powder results in formation of colloidal gel
with a pH value equal to 12.5 (similar to calcium hydroxide) that
solidifies to form a strong impermeable hard solid barrier in
approximately 3 to 4 hours
 It is hypothesized that tricalcium oxide reacts with tissue fluids
to form calcium hydroxide

MERITS AND DEMERITS OF MTA
 The material has a low solubility and a radiopacity slightly greater than that
of dentin
 Because of its low compressive strength , it should not b placed in
functional areas
 Another significant disadvantage for the restoration is that the setting time
may take several hours. As a result , 2 step procedures are frequently
necessary , requiring interim restorations
 MTA is an excellent material for direct vital pulp exposures and numerous
endodontic applications
 The material has good long term sealing capabilities , and some studies
show greater success than conventional calcium hydroxide

Management of deep carious

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