Posterior_Direct_Restorations Salvatore_compressed

3

Diagnosis and Treatment of Early

Caries Lesions

Giovanni Sammarco

Treating caries does not mean cleaning and reconstructing a cavity but implementing procedures that create an environment unfavorable to the development and persistence of disease. Dental restoration is simply one stage of treatment. It deals with an outcome of the disease rather than the disease itself. This chapter covers basic concepts of cariology, diagnostic tools designed to identify caries lesions, and procedures for treating early caries lesions, namely remineralization and resin infiltration.

Dental Caries

The primary causes of tooth loss can be attributed to two main tooth and periodontal tissue problems, ie, caries and periodontitis, both caused by bacterial biofilm,1 followed by trauma and a dentist’s actions (iatrogenic causes). Caries is by far the most common disease in the world.

More than 40% of the world’s population has at least one untreated caries lesion in their mouth.2

More than 90% of human beings will experience caries at least once in their lives.3

Oddly enough, dentists are often unclear what is meant by the term caries. With periodontal disease, there is a clear distinction between outcomes (eg, pockets, recession, bleeding, mobility) and the causal disease. But it is often unclear whether the term caries refers to the disease, ie, a complicated pathologic process that involves initial triggers,

a causal chain of events, and final outcomes, or to one outcome, ie, the caries lesion.4

Continuing the parallel with periodontitis, it is very clear that once signs of disease are identified, the affected patient must undergo several meticulous clinical (Fig 3-1) and radiographic (Fig 3-2) investigations designed to identify and evaluate the situation through the calculation of numeric indices and very specific, staged checks. Based on the extent and severity of the situation, it will be possible to draw up a diagnosis, ie, to categorize the underlying disease (eg, periodontitis) using adjectives such as chronic, aggressive, localized, and generalized. These adjectives will be able to guide the subsequent causal therapy and reach an appropriate prognosis. The clear, well-established rules of nomenclature in periodontology should not be underestimated.5

FIG 3-1 Example of a periodontal chart. (Courtesy of University of Bern, Switzerland.)

FIG 3-2 Radiographic status of a patient with periodontal disease. (Courtesy of Dr F. Manfrini, Riva del Garda, Italy.)

In cariology, however, things are generally more vague; typically, only one finding is sought: a cavitated caries lesion. It is very difficult to objectively establish the severity of the condition under examination, given the widespread confusion over terminology4 and lack of importance attached to the topic of caries, which many consider to be basic knowledge that one automatically acquires by osmosis after enrolling in dentistry school.

Causal therapy is generally associated with treatment of periodontal disease but should be applied to nearly any abnormal processes, including caries.6 As the name suggests, causal therapy should address the causes giving rise to a disease; actions aimed at mere treatment of outcomes or symptoms are not worthy of the same medical standing.

Dental caries is a communicable disease of bacterial origin. Physically removing a lesion and replacing it with a restoration will not eliminate the bacteria or stop the caries spreading to the rest of the mouth and the margins of the recently performed restoration7 (Figs 3-3 and 3-4). Causal therapy is generally achieved by adopting an almost identical approach in all medical disciplines:

FIG 3-3 Secondary caries lesion near a composite restoration. The caries lesion did not develop because of the restoration but because nothing was done to reduce the risk of caries before or immediately after the restoration was performed.

FIG 3-4 Recurrent caries lesions that developed apical to two restorations, caused by failure to remove biofilm from the interproximal areas.

1.Diagnosis

2.Informing and educating the patient about the causes of disease (eg, making the patient understand the link between diet, cariogenic biofilm, acids, and disease)

3.Giving the patient instructions for controlling the causes of its prevalence (eg, lifestyle, smoking habits, diet, and hygiene)

4.Direct treatment of removable causes and outcomes of disease (eg, removing any excess filling material and calculus and/or restoring cavitated caries lesions)

5. Regular patient assessment

It is easy to understand how this type of approach comes close to the true concept of curing a disease; it is a set of etiopathogenic actions initiated with the aim of completely eradicating disease processes that are ongoing (causal therapy) or potential (primary prevention). These actions also take place at an individual level and can be described as disease management. The action of managing outcomes or symptoms (point 4 in the list above) cannot be called a cure, however useful and necessary it may be; this action can only be described as treatment. It is important to understand the macroscopic difference between a care plan, implicitly including all medical actions, even those of a preventive nature aimed at eliminating or reducing the influence of disease triggers (eg, referring patients for help in giving up smoking or advising them to drink plenty of water), and a treatment plan, which is simply a list of interventions (albeit important) to be performed at a dental clinic.

Outcomes and Definition of Caries

Cariologists agree that the concept of caries is not interchangeable with the concept of a caries lesion. In essence, caries cannot be removed but rather cured, while a caries lesion can be removed or treated by means of noninvasive, minimally invasive, or invasive procedures.4 A caries lesion is not the only outcome attributable to caries; in addition to broader oral outcomes (eg, chewing difficulties), systemic outcomes (eg, digestive difficulties), and psychologic outcomes (eg, social self-consciousness due to poor esthetics), the following tooth-related effects due to the direct or indirect action of caries can be identified (not necessarily in the order listed):

Surface demineralization, noncavitated caries lesion, white spot (WS) (Fig 3-5)

FIG 3-6 Brown spot affecting the mesial wall of a premolar. The initial WS has incorporated bacterial and food pigments and turned brown over time. This occurrence is often but not always due to a tendency to remineralize.

Pulp hyperemia

Cavitated caries lesion (Fig 3-7)