Management of deep carious lesions

There is no international consensus on the treatment of deep carious

lesions. This can be confirmed when textbooks on cariology and restorative
dentistry are compared with the endodontic literature. The cariology opinion
aims to prevent pulpal exposure, whereas the endodontic opinion pays little
attention to the possibility that a deep carious lesion might be process that can
be arrested.

The various methods used for management of deep carious lesions are
management of acute caries and chronic caries, indirect pulp capping, direct
pulp capping. The ultimate goals in managing deep carious lesions are
preservation of pulp vitality before arbitrarily instituting endodontic therapy
and reparative dentin formation.

Classification of techniques for the treatment of

carious dentin1

1 Excavation techniques -

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials
Manual Sharp hand excavator Mechanical Long-term High pressure Accepted
excavation removal of observations causes pain procedure
softened dentin especially in
Adequate tissue pedodontics
removal and anxious
patients
Over-excavation
is unlikely
Rotary Low-speed Mechanical Long-term Aversive for Widely accepted
excavation contraangled removal of Observations patients gold standard
handpieceswith softened dentin Efficient
electromotorsor Over Preparation
turbines. of tissues

Round carbon-steel Possible negative

burs effects on pulp
Controlled Torque controlled Selective caries Questionable Hardness of Experimental
selective rotary (step) motors, removal due to dentin varies
excavation (Endostepper, differences in
Brasseler), Carisolv hardness between
Drive healthy and
carious dentin

Polymer burs (Smart Selective caries Questionable Hardness of To time not

Prep, SS White) removal due to dentin varies convincing
differences in
hardness between Polymer burs are
healthy and ruined by hard
carious dentin dentin

Fluorescence-aided Exciting carious On-time feedback Excavation has to Interesting

caries excavation dentin with violet during excavation be visually technique with
(FACE, not blue light causes observed through clinical
commercialy available visible orange-red Quality control of a 530 nm potential,
yet) fluorescence, excavation highpass filter however limited
allowing clinical data
identification of
residual carious
dentin
Sono abrasion Airscaler handpiece Oscillating Less over- Unclear Experimental
(KaVo, Sirona) mechanical preparation than completeness of
removal with rotary excavation
Diamond-coated tips instruments
or brushes (KaVo) Limited scientific
Smaller access data
cavity possible

Air abrasion, Air pressure device Mechanical Selective caries Unclear Experimental
air polishing abrasion removal is completeness of
Abrasive powder principally excavation
(aluminium oxide, possible
resin, hydroxyapatite, Limited scientific
salts)
data

Chemo- Carisolv(MediTeam) Mechanical Adequate tissue Less effective than Limited clinical
mechanical sodium hypochlorite removal of removal rotary indications
excavation solution applied with chemically altered instrumentation
modified dull hand or or solved Carious Less pain (time consuming)
rotary excavators dentine
Safe
Enzymatic Exp. Enzyme Mix Proteolytic Enzymes are No clinical studies Experimental
 digestion Mix SFC-II (3M ESPE) enzymatic highly selective
digestion of collage
Promising in
vitro results

Photoablation(La Laser: CO 2, Selective ablation Self-controlled Expensive Experimental

ser) of carious dentin selective
Nd-YAG, excavation Time consuming Poor cost/
effectiveness
Er:YAG Thermal side ratio
effects
2 Disinfection techniques

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials
Ozone treatment Ozone generator O 3 gas disinfects Efficient method: Only limited data Clinically
(HealOzone, KaVo) effectively due to disinfection - for other defects effective for
oxidizing time less than 60 than primary root primary root
properties sec caries lesions caries lesions

Controlled Probably limited Depth of Promising

handpiece with need for enamel disinfection within results for
rubber cup preparation carious dentin not other
ensures safe yet determined indications, but
application more research
Silicon caps is still needed
limiting clinical
application

Photodynamic Photoactivated Disinfection with Effective non- Effect is limited by Promising

therapy disinfection (PAD, low energy laser in invasive dentin thickness technique, but
Denfotex): combination with disinfection limited clinical
studies
photosensitizers method

Antibacterial AgNO3, Impregnation Ease of use AgNO 3 : Adjunct, but no

therapy Biocompatibility, substitute of
Fluorides: SnF 2 , Disinfection of No special device Discoloration excavation
dentin and/or necessary
Silverdiamin-F smear layer Effectiveness with
-Amine-F respect to
prevention of
Chlorhexidine,Ca(OH) carious
2 progression is not
yet convincingly
proven
 Antibiotics: Step-wise Less probability Two appointments Promising
Tetracycline- excavation: of pulp damage obligatory technique, esp.
preparations antibacterial or opening in pedodontics,
(Ledermix,Riemser) therapy and Patients but limited
temporary followed Ease of use in compliance clinical studies
by re-entry and dental emergency necessary
final restoration situations

3 Sealing techniques

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials
Fluoride-releasing ART: Atraumatic Fluorides might Antibacterial Dentin sealing Proposed for
materials Restorative prevent caries restorative abilities are developing
Technique: progression or material is limited countries
hand excavators secondary caries thought to limit
and glass ionomer caries attack due Preventive effect of Limited political
cements to fluoride fluoride release is & professional
release still controversially acceptance
discussed

Limited data in
high risk
situations
Dentin adhesives Functional Sealing dentin Limited Adhesion to Accepted
hydrophilic and/or restoration excavation caries-affected procedure in
monomer systems margins hinders necessary dentin is less than primary teeth
developed for nutrition ideal
Promising, but
dentin adhesion transport to Efficient clinical
still
bacteria left after procedure Tolerable amount
experimental
excavation of residual technique in
bacteria has to be permanent
determined teeth
Recommendabl
e for root caries
lesions
Antibacterial resin Dentin adhesives Combination of Materials claim Antibacterial effect Promising in
materials containing sealing and to be forgiving of materials vitro results,
 antibacterial effect even under less without but limited
Chorhexidine than ideal antibacterial clinical studies
conditions release is unclear
Triclosan (Seal
&Protect, Dentsply)

MDBP:
antibacterial
monomer (Kuraray)

Management of acute decay2

Deep lesions i.e. deeper than 2mm from the DEJ confirmed as acute decay. It
can be treated in the following sequence.

The physiologic status of the P-D organ should be evaluated using

diagnostic tools.
All undermined or unwanted enamel in the preparation should be
removed.
All softened dentin should be removed if it is safe without creating an
exposure. This should be done by using a spoon excavator. The
reparability of the remaining dentin should be verified using basic fuchsin
or red dye solutions. Any infected dentin should be removed.
If There is more chances pulp exposure by removing all softened dentin the
deepest layer should be left intact, provided:
1. The P-D organ should be healthy.
2. The remaining dentin should be reparable.
3. The softened dentin that is to remain should be located in the deepest
part of the pulpal and/ or axial wall. The surrounding walls and at
least a portion of the pulpal and axial walls should be in hard sound
dentin.
If there is no pulp exposure appropriate intermediary base should be
given.

Management of chronic decay2

Chronic decay can be treated in following sequence:

The physiologic status of the P-D organ should be evaluated using

diagnostic tools.
All undermined or unwanted enamel in the preparation should be
removed.
All softened dentin should be removed, using either spoon excavators or
large round stainless steel burs in a slow speed hand piece. The
reparability of the remaining dentin should be verified using basic
fuchsin or red dye solutions. Any infected dentin /non reparable dentin
should be removed.
If removal of softened dentin leads an exposure of the pulpal tissues,
proceed with the appropriate pulp capping procedure or with endodontic
therapy.
If there is no pulp exposure appropriate intermediary base should be
given.

In slowly advancing lesions, it is expedient to remove softened dentin until

the readily identifiable zone of sclerotic dentin is reached. In rapidly advancing
lesions, there is little clinical evidence (as determined by texture or color
change) to indicate the extent of the infected dentin. For very deep lesions, this
lack of clinical evidence may result in an excavation that risks pulp exposure.
In a tooth with a deep carious lesion, no history of spontaneous pain, normal
responses to thermal stimuli, and a vital pulp (demonstrated 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. A direct pulp cap is the placement of calcium hydroxide directly on
exposed pulpal tissue (a pulpal exposure) and the surrounding deeply
excavated dentinal area. The techniques of indirect and direct pulp capping
may stimulate the formation of reparative dentin3.

Reference
1. Noack, Michael J., Wicht, Michael J., Haak, Rainer - Lesion Orientated Caries Treatment - a
Classification of Carious Dentin Treatment Procedures Oral Health Prev Dent 2 (2004), No.
3, Page 301-306
2. Operative dentistry modern theory & practice M.M. marzouk all india publisher 1997 -
Page 275 284
3. Sturdevants art & science of operative dentistry 5 th edition Theodore m Roberson 2008
Elsevier page 102-103