OHP Lec 4: Dental Caries II

*ICDAS: 0* -what defects can be seen?

defects: --opacity (alteration in the translucency of the enamel but normal thickness); --hypoplasia (reduced localized thickness of enamel without dentin exposure); --hyperplasia (white spots looks same wet/dry) --stains --fluorosis (alteration in enamel translucency of varying degrees) --DI ==*sound* but may require restorative intervention

*ICDAS* International Caries Detection and Assessment System

image

*ICDAS* what is an advanced lesion?

lesions 5-6

*fissure caries* what is the shape of the lesion?

@ enamel: cone-shaped w/ apex toward occlusal & base toward DEJ @ dentin: lesion spreads laterally @ the DEJ --> cone shape w/ apex @ pulp & base toward DEJ

*anatomy of the occlusal surface: pits & fissures* what are non-coalesced fissures?

*incomplete fusion* of the lobes --> grooves/fissures are deeper than normal

*visual examination* can you see the white spot when it's wet or only after you dry it?

*visible when wet*: demineralization is *halfway through the enamel*, possibly into dentin *visible AFTER drying*: demineralization is *less than halfway* through

*anatomy of the occlusal surface: pits & fissures* -teeth develop from what? how many? -what is a groove/fissure? -what is a pit?

- 4 - 5 lobes -groove/fissure: *coalescence of 2 lobes* -pit: *2 grooves cross*

*caries process* what is an *active* lesion? what is an *inactive/arrested* lesion?

*active* lesion: exhibits *evidence of progression* for a specific period of time *inactive/arrested* lesion: exhibits *no evidence of progression* for a specific period of time

*ICDAS: 2* -what is it? -appearance when wet/dry? -histologically? -radiographically?

-*demineralization form inner 50% of enamel to outer 1/3 of dentin* -*wet*: *carious opacity* (white spot) &/or brown carious discoloration that is *wider than natural fissure/fossa* -*dry*: more pronounced -histologically: demin @ inner 50% of enamel & 1/3 of dentin --hyperplasia: -radiographically:

*ICDAS: 1* -what is it? -appearance when wet/dry? -don't confuse it w/ what? -histologically? --what is hyperplasia? -radiographically?

-*demineralization in outer 50% of enamel* -*wet*: *no* evidence of color change -*dry*: *carious opacity or discoloration* (white/brown) @ pit & fissure -histologically: demin. limited to outer layer --hyperplasia: -radiographically: *no radiolucency*

*ICDAS: 5* -what is it? -appearance when wet/dry? -histologically? -radiographically?

-*distinct cavity w/ visible dentin* -*wet*: *darkening of dentin visible through enamel* -*dry*: *visual evidence of loss of tooth structure @ entrance to or within pit/fissure* (frank cavitation* -histologically: inner 1/3 of dentin +/- into the pulp, clinically cavitated to <1/2 the surface -radiographically: radiolucency extends into middle 1/3 of dentin

*ICDAS: 6* -what is it? -appearance when wet/dry? -histologically? -radiographically?

-*extensive distinct cavity w/ visible dentin* --obvious loss of tooth structure --cavity is deep & wide --dentin is visible on the walls & at base --involves *at least 1/2 of a tooth surface* & possibly the pulp --always consider *status of pulp before starting Tx* -histologically :inner 1/3 of dentin +/- into the pulp, clinically cavitated to *>1/2 the surface* -radiographically: radiolucency extends into pulpal 1/3 of dentin

*ICDAS: 3* -what is it? -appearance when wet/dry? -histologically? -radiographically?

-*localized enamel breakdown involving the middle 1/3 of dentin* -*wet*: localized enamel breakdown -*dry*: carious loss of tooth structure within pit/fissure, but no dentin is visible in the walls/base; no discontinuity in the pit/fissure -histologically: *microcavitated* -radiographically:

*ICDAS* what is it? what are the categories?

-*logical* technique for evaluating lesions & categorizing them; gives *common language* -from best (0-no lesion) to worst (6) & give system of possible treatment & prognosis to give more confidence

*ICDAS: 4* -what is it? -appearance when wet/dry? -histologically? -radiographically?

-*underlying dark shadow from dentin w/ or w/o localized enamel breakdown* -*wet*: shadow of discolored dentin through apparently intact enamel --may seem grey, blue, brown --BETTER SEEN WET -*dry*: not as clear -histologically: demin @ middle 1/3 of dentin -radiographically: *more reliable at this stage*; radiolucency extends to mid 1/3 of dentin

*fissure caries* how does this shape compare to smooth surface caries? why?

-@ smooth surface: lesion is wider on surface & narrower @ base -demineralization follows inclination of enamel prisms & dentin tubules

*ICDAS: 0* -what is it? -don't confuse it w/ what? -histologically? --what is hyperplasia? -radiographically?

-NO evidence of caries/ *sound tooth* -don't confuse it w/ *enamel hyperplasia, fluorosis, surface discolorations/stains, dentinogenesis imperfecta* -histologically: no enamel mineralization or narrow zone of opacity --hyperplasia: *looks same wet & dry* & white opacity is in vicinity of groove/cusp but NOT in the groove -radiographically: *no radiolucency*

*anatomy of the occlusal surface: pits & fissures* why does fluoridation complicate this?

-can make enamel very strong -but, bacteria in the biofilm can get their carbs even through these defects if you don't see them -so, lesion can be progressing at the DEJ & it is difficult to detect

*ICDAS* what is an initial caries lesion?

-codes 1 & 2

*caries process* what is *remineralization*?

-gain of minerals (Ca, P, etc) in tooth

*ICDAS* is it an initial lesion or moderate lesion?

-if there is a break in the enamel, it is ICDAS 3 = moderate lesion

*anatomy of the occlusal surface: pits & fissures* why do caries lesions happen @ non-coalesced fissures?

-more susceptible than smooth surfaces -there is a *small, undetectable defect in the enamel* --can be too small for explorer tip to feel/can rap it -favors biofilm retention & maturation

*summary* -what is the most reliable way to identify early caries lesions @ occlusal surfaces? -what is ICDAS? -what are the best exam conditions? -what does a detailed exam help w/?

-most reliable way to identify early caries lesions @ occlusal surfaces: *visual criteria* -ICDAS: *is a visual criteria that provides a detailed assessment of the tooth surfaces and correlates to the severity of progression into the tooth enamel and dentin* -best exam conditions: good light, clean surface, examine wet then dry -detailed exam helps w/: risk assessment, prognosis, Tx planning

*fissure caries* why are they hard to spot?

-there is *no completely reliable way* to detect an early lesion -*seemingly intact* fissure can have caries activity in the dentin

*fissure caries* why don't radiographs help much?

-thickness of the enamel on the cusps means that the rays must go through a lot of dense tooth structure & that lowers the chance of seeing the demineralization --unless there is significant destruction --so pit & fissure caries are hard to see reliably until it is large/deep

*visual exam* -why did an explorer used to be used? -why is it no longer used?

-to feel for hardness/determine sticiness of the probe on fissures -ineffective & destructive --stick happens because of fissure anatomy, not because it finds decay --forcibly poking into the enamel surface destroys structure/breaks surface zone --use it to feel margins/grooves & remove plaque --you *CAN scratch root surfaces* to evaluate consistency ----soft = root caries

*visual examination* how do you get the teeth clean?

1. brush thoroughly or 2. prophy w/ pumice

*visual examination* what does it take?

1. skill, practice, patience 2. good lighting 3. clean teeth (no plaque) 4. air/water syringe to dry teeth

*fissure caries* how do you evaluate these?

1. tactile --ineffective & destructive 2. radiograph --helpful in late stages but not early 3. visual --MOST reliable

*ICDAS* what are the basic assumptions prior to exam?

The tooth is clean and free of plaque --This can be accomplished by flossing and brushing • This is a visual exam, tactile sensation is not part of the exam • --No tug back, or stick of the explorer to determine if there is a lesion on an occlusal fissure --WHO explorer used to confirm cavitation • The teeth are examined wet then dried with the air syringe