Posterior_Direct_Restorations Salvatore_compressed

FIG 3-41 Caries lesions identified using DiFOTI technique.

The benefits of FOTI and DiFOTI techniques include:

Absence of ionizing radiations

Frequent follow-ups are possible

Useful for children and pregnant women

Easier detection of cracks, caries infiltrations, and surface discoloration (anterior)

Images can be easily compared (DiFOTI)

Low cost (FOTI)

Information is provided regarding the size and buccopalatal location of the lesion

Examination of choice for anterior teeth, when combined with visual inspection (FOTI)

Limitations of the FOTI techniques are:

Low sensitivity in posterior sectors

Difficult to obtain photographic images and therefore compare different

examinations

Do not provide information on cavitation and lesion activity

Limitations of the DiFOTI technique are as follows:

Initial cost

Low sensitivity in detecting apical lesions in the contact area

Do not provide information on cavitation and lesion activity

Presence of a USB connecting cable

Handpiece sterilization is complex (the video camera lens can come into contact with oral fluids because the autoclavable terminal provided has an opening in that area)

Not applicable to anterior teeth

Other diagnostic methods

Dental companies are continually developing diagnostic methods that are alternative or supplementary to the ones mentioned previously. These cannot all be described here for obvious reasons, and this does not in any way imply that we are opposed to these methods.

However, additional useful methods aiding the diagnostic process include:

Plaque-revealing gels (Fig 3-42), particularly if able to highlight acidogenic plaque. The outcome of caries activity is more likely to be identified in areas where this specific biofilm builds up.

FIG 3-42 Tooth and periodontal surfaces stained with three-tone plaque-revealing gel: the plaque stained teal is acid producing and therefore potentially cariogenic.

Dental floss can help identify roughness and/or discontinuity if it frays when passed through interdental spaces.

Treatment of Early Caries Lesions

Remineralization

Remineralization is defined as the process whereby calcium and phosphate irons supplied by an external source are deposited inside spaces in the crystalline structure of the demineralized enamel to increase the crystalline lattice.32 This is mainly achieved by teaching patients how to prevent caries,33,34 consistently removing biofilm from tooth surfaces,34–36 and supplying remineralizing molecules (Box 3-1).37 Remineralization should be considered the best approach to noncavitated white spots originating from caries, ie, white spot lesions (WSLs).38 As already explained, the appearance of a WSL is strictly

related to whether or not it is active. Consequently, a positive outcome to the remineralization process is clinically revealed by a change from a rough, opaque surface (active white spot) to a shiny, smooth surface (inactive white spot), which may also incorporate brown pigments over time.14,39 Although white spots can disappear in an entirely natural manner40,41 or by mechanical removal of the demineralized surface,39,42 it is extremely rare for them to disappear altogether.39 Given that remineralization initially takes place primarily in the outer enamel layers, it becomes difficult for the minerals to reach the deepest subsurface layers, which is why such areas are likely to experience incomplete remineralization (Fig 3-43).

Fluoride is the most common remineralizing agent, and its beneficial effects have been widely demonstrated.46–48 When combined with calcium and phosphate, it creates a layer of fluorapatite on the surface of the remaining crystals. This replaces minerals lost through demineralization and makes the surface much more resistant to subsequent acid attacks.36,49 Casein phosphopeptide–amorphous calcium phosphate (CPP-ACP) pastes are another useful mineral supplement strategy. Casein phosphopeptide has the remarkable ability to stabilize calcium and phosphate ions present in solution, creating a CPP-ACP complex.50,51 This complex increases available calcium and phosphate levels, promoting the remineralization process.51 CPP-ACP is useful when treating WSLs and other types of hypomineralization, such as fluorosis and molar-incisor hypomineralization, as well as dental hypersensitivity. It is also used to prevent white spots of orthodontic origin.50 Remineralization is also often used to supplement minimally invasive techniques such as whitening52,53 and microabrasion.54 Dental floss can be used to convey remineralizing agents to the interproximal spaces.

Patients undergoing remineralization must be informed that this process requires time, dedication, and consistency.51 Furthermore, if the treatment is specifically carried out in esthetic zones, it is unlikely to remove areas of discoloration altogether. Table 3-2 provides an example of the cleaning/remineralizing approach based on the patient’s risk of caries. This approach should be recommended under all circumstances with cavitated and noncavitated lesions.

TABLE 3-2 Cleaning/remineralizing approach based on patient risk of caries

Resin infiltration

The technique of sealing grooves and pits in teeth with fluid resins is well established and has proved effective in preventing the formation of caries lesions in these particular areas of the tooth crown55–57 (see chapter 5). In the wake of these successes, dental science sought to apply the same preventive approach to the smooth surfaces of the crown.58,59 These are not subject to the same intracoronal development as grooves and pits and are thus exposed to greater friction and wear. They are not retentive and, in the case of interproximal surfaces, can be difficult to reach. These requirements prompted a need for a method that could prevent the progress of caries lesions by using fluid resins to infiltrate smooth enamel, particularly on interproximal surfaces, which are the areas of the tooth crown at greatest risk of caries.60,61 With a view to maintaining a minimally invasive approach while also considering the difficulty of working interproximally (where two teeth are in contact with one another) and the need to make the surfaces permeable through relatively invasive actions, an infiltration approach has been suggested for cases where caries-related demineralization (ie, white and/or brown spots) has already had an opportunity to become established but not caused cavitation and where the lesion is not expected to remineralize57 (Fig 3-44). Resin infiltration is therefore intended to stop (or slow down) the progression of an existing lesion rather than prevent one from becoming established (as in the case of sealing) through a minimally invasive method.