Posterior_Direct_Restorations Salvatore_compressed
.pdf
process, but this should not detract from positive aspects of the event: an inactive lesion is an active lesion that has been halted through the intervention of optimal protective conditions.
Cavitated lesions may sometimes be present. These are usually brown but meet the typical description of inactive lesions (hard consistency revealed by light probing and located in properly cleaned areas of the dentition). These lesions are generally improperly referred to as dry, ie, early enamel cavitations that have stopped progressing due to an intervening favorable change in the environment (Fig 3-16). Even if such lesions are susceptible to plaque buildup, if located in easily inspected areas, they may simply require regular observation by a dentist if the risk of medium-term reactivation is considered low (3 to 6 months). This is particularly true for low-risk adult and elderly patients.
FIG 3-16 Inactive cavitated lesion on the occlusal surface of a maxillary molar, regularly cleaned by the patient and periodically checked by a dentist.
Diagnosis in Conservative Dentistry
Proper diagnosis of caries-related disease involves a two-level process:
1.A higher level, ie, causal or cariologic diagnosis. This involves analyzing factors promoting the disease and staging them based on their impact on the individual patient (or site).15,16
2.A lower level, ie, outcomes or lesion diagnosis. This involves identifying and recording all the outcomes of the caries activity (starting from stage ICDAS 1) and their effects.14
This chapter does not cover the cariologic diagnosis process. Table 3- 1 summarizes the main factors involved in the initiation of caries-related disease and the conditions that promote disease or health. An appropriate treatment plan is the consequence of both diagnostic processes. It will involve treatment of caries-related outcomes as well as strategies that will reduce or eliminate the influence of individual risk factors in the patient. These mainly medical actions must also involve the clinician’s awareness of risk assessment methods and techniques for constructively altering risk factors.15,17,18
TABLE 3-1 Etiologic factors in caries-related disease
Factor |
Subcategory |
Disease promoting |
Health promoting |
|
|
|
|
Bacterial |
Type |
Cariogenic |
Noncariogenic |
|
|
|
|
|
Quantity |
High, organized into |
Scarce |
|
|
biofilm |
|
|
|
|
|
|
Predisposing factors |
Present and |
Absent or scarce |
|
for buildup (eg, |
numerous |
|
|
crowded teeth, |
|
|
|
orthodontic |
|
|
|
appliances) |
|
|
|
|
|
|
Dietary |
Fermentable |
Large amount and |
Small amount and |
|
carbohydrates |
intake frequency |
intake frequency |
|
|
|
|
|
Acids |
Large amount and |
Small amount and |
|
|
intake frequency |
intake frequency |
|
|
|
|
|
|
|
|
|
Diet: Macroand |
Imbalanced |
Healthy and |
|
micronutrient intake |
|
balanced |
|
|
|
|
Salivary |
Quantity |
Scant saliva |
High saliva |
|
|
production |
production |
|
|
|
|
|
Quality |
Acidic saliva and/or |
Neutral or basic |
|
|
poor buffering |
saliva |
|
|
capacity |
and/or high buffering |
|
|
|
capacity |
|
|
|
|
Remineralization |
Availability of fluoride, |
Scarce |
High |
|
calcium, and |
|
|
|
phosphate |
|
|
|
|
|
|
Other |
Dental history |
High caries incidence |
No or low caries |
|
|
|
incidence |
|
|
|
|
|
Diseases/conditions |
Presence of |
Absent |
|
|
diseases/conditions |
|
|
|
with systemic or oral |
|
|
|
effects |
|
|
|
|
|
|
Drugs |
Use of drugs with |
No use |
|
|
systemic or oral |
|
|
|
effects |
|
|
|
|
|
|
Smoking/alcohol/drugs |
Use |
No use |
|
|
|
|
|
Socioeconomic status |
Low |
Medium, high |
|
and educational level |
|
|
|
|
|
|
|
Antibacterial |
No use |
Deliberate, regular |
|
substances (eg, xylitol, |
|
use |
|
stannous fluoride, |
|
|
|
chlorhexidine, dietary) |
|
|
|
|
|
|
Lesion diagnosis
The purpose of the dental diagnostic process is to assess hard tissue conditions, including the presence of anomalies, discoloration, and caries lesions and their activity. These and other caries-related assessments enable the clinician to place the patient in a risk class.
In academic terms, methods of dental diagnosis can be subdivided into two categories:
1. Standard examinations
Medical history and interview
Clinical examination 
Radiographic examination
2.Supporting examinations
Laser fluorescence
Transillumination
Other diagnostic methods
Medical history
The clinician takes the patient’s medical history to gather data that may have a bearing on the treatment plan. It is essential to create a written document detailing the patient’s current health conditions, allergies and intolerances, voluntary habits (smoking), and dental history and ask the patient to sign it. After finishing this documentation, which will have to be regularly updated, the dentist must spend some time interviewing the patient about their medical history. The aim is to obtain as much information as possible regarding:
Patient expectations and requirements
Dietary habits
Drug treatments
Hobbies, sports, habits
Smoking/alcohol/drugs
Type of toothbrush/toothpaste/dental floss used and method/frequency of use
Fluoride prophylaxis and use of mineralizing compounds 
Willingness to accept treatment and guidance
Clinical examination
A clinical examination is a visual and tactile procedure carried out with
the aim of identifying, evaluating, and classifying discolorations, lesions, and anatomical changes affecting inspectable tooth structures and the conditions of preexisting restorations. This procedure must be carried out in accordance with ICDAS II criteria with the teeth thoroughly cleaned, rinsed, and completely dried. It benefits greatly from the use of magnifying systems as well as proper lighting.19–21 In addition to the air/water syringe and cleaning devices used for preliminary tooth scaling and cleaning, other instruments useful for clinical examination are:
Dental explorer: Instrument with a fine, rounded tip, used to remove any plaque residue and probe grooves and suspect areas. This instrument must never be forced into grooves (maximum force, 25 g), because it can cause irreparable damage to surfaces (Fig 3-17).
FIG 3-17 Dental explorer with fine, rounded tip. The ends are specifically designed to easily reach all accessible surfaces.
Mechanical separator: Useful for slightly separating interproximal surfaces to visually evaluate the status of these areas and identify any cavitation (Fig 3-18).
FIG 3-18 (a) Ivory separator. (b) Elliott separator. (c) Cavitated interproximal lesion, surrounded by brown discoloration, rendered visible after separation.
Air-water-glycine (or erythritol) spray: Useful for quickly and gently removing plaque residues from grooves and separated interproximal surfaces (Fig 3-19).
FIG 3-19 Detail of an air-water-glycine jet able to quickly and easily remove biofilm from tooth surfaces.
Radiographic examination
When diagnosing lesions in lateral and posterior sectors, a radiographic examination plays a fundamental role, particularly in interproximal sectors, provided basic protective principles are observed: justification, optimization, and limitation.21–23
Despite the relatively low values of sensitivity (50%) and specificity (87%),21 the main radiographic examination for identifying interproximal lesions is the bitewing. This radiographic projection captures the maxillary and mandibular lateral and posterior teeth on one side, from the distal surface of the maxillary canine to the distal surface of the last tooth present in the arch. In some cases, particularly in adult patients with full dentition (up to third molars), two exposures may be required on each side to display all the required surfaces. This kind of projection is aimed at evaluating interproximal areas, and there should be no radiographic superimpositions in these areas. The use of dedicated centering devices and parallelism aids such as fine wedges (Fig 3-20) or periodontal probes
are particularly important for this purpose.