25 Minimal Interventional Treatment of Caries in the Permanent Dentition: Clinical Cases
Case 1: A 30-year-old Woman with Low-to-Medium Caries Risk
Age: 30 years
First visit: October 2010
Last visit: February 2011
Follow-up visit: October 2011
The patient was referred to the university clinic by a private practitioner, since a routine check-up had revealed several caries lesions as detected by radiographic examination. She had been informed that these caries lesions might be treated by caries infiltration (Chapter 17), but the dentist was not sure whether the technique would be adequate for the stages of caries present. No general health issues were reported by the patient.
Clinical Findings (Tooth Level)
Clinical examination revealed a permanent dentition with first bicuspids and third molars having been extracted for orthodontic reasons. Signs of gingivitis as well as tooth stain and calculus were observed; the oral mucosa was healthy. Modified BEWE index was assessed as score 2 for both anterior sextants (incisal abrasion), the sum was 5. No frank cavities, but some restorations could be detected at a first glance ( Fig. 25.1 ).
Caries detection was based on visual–tactile ( Fig. 25.1 ) and radiographic ( Figs. 25.2 and Fig. 25.3 ) examinations as well as DIAGNOdent measurements (see Fig. 25.4 ). In general, only four restorations (all first molars), for the upper first molars including the respective mesial approximal areas were detected clinically. The central fissure of the fourth first molar (tooth 46) had been sealed, but revealed some darkish area around the sealant. For the occlusal aspects of three second molars (teeth 17, 27, 37), caries lesions with ICDAS 2 were assessed, one of them being scored as active (tooth 17), the two others as being inactive (teeth 27, 37). Tooth 47 showed remnants of fissure sealant and an adjacent ICDAS 2 lesion ( Figs. 25.1 and 25.5 ). The D3MFT was counted as 5, including the fissure-sealed tooth 47 with adjacent active caries in need of restoration.
Radiographic caries assessment ( Fig. 25.2c, d ) revealed eight D1 lesions and four lesions being visible in enamel only. Thus, except for three approximal surfaces, all of these surfaces—being at a higher risk for caries development (mesial surface of second molar to distal surface of second premolar, first premolars are missing)—either showed a caries lesion or had already been restored.
Individualized bitewing holders are of great help to reduce overlapping of approximal surfaces in bitewings and to monitor caries progression/stabilization ( Fig. 25.3a–f ).
Diagnodent measurements were performed on all suspect occlusal surfaces of the posterior teeth as shown for the upper right posterior teeth. Fissure sealants as in the central fissure of tooth 16 might have given false-positively high values. Therefore, no measurement was performed in this case ( Fig. 25.4 ).
Detailed information about the findings for each tooth surface is available from the dental exam form ( Fig. 25.5 ). The treatment decisions will be discussed for each quadrant of an arch separately.
Caries Risk Assessment (Individual Level)
Caries risk was assessed as shown in Chapters 7 and 24. Caries experience (DMFT = 5) was in the lower range for the respective age group for a German population, where no water fluoridation is established. Medium, but regular consumption of sweetened food and beverages was reported. Oral hygiene was fair (API: 50%). The patient reported use of fluoride toothpaste (brushing twice daily) as well as fluoridated salt. She was aware of the benefits of flossing, but seemed not to have included this as a daily habit. Salivary flow rate was neither reported to be reduced by the patient nor considered by as of being below normality, thus no measurements were performed. As a result of integration of all these factors for caries, she was classified to have a low-to-medium caries risk (Risk: 31%). Nonetheless, it was assumed from the numerous approximal caries lesions that caries risk had been higher in previous years.
Salivary flow rate should be determined quantitatively if the patient either complains or if the dental professional detects any conspicuous signs and symptoms of xerostomia (dry mouth). In most patients qualitative assessment is sufficient.
Diagnoses and Treatment Plan
The patient was encouraged to proceed with brushing twice daily using regular fluoride toothpaste (1500 ppm F–). Advice for more regular use of flossing, including some practical tips on how to handle the floss, was given. As she used fluoride toothpaste and fluoridated salt, no other home-use fluoride products were recommended. The role of sugar consumption on the cariogenicity of the dental biofilm was explained, in particular with respect to sweetened beverages.
Diagnoses and treatment decisions regarding certain tooth surfaces are summarized in Table 25.1 . Inactive caries lesions received no current treatment, but were recorded for “particular surveillance.” Since the patient revealed a rather high number of approximal caries lesions, the deeper ones (mostly D1) were referred to the infiltration technique. Two fissures were sealed and four restorations placed. A more conservative approach might have favored noninvasive treatment of the caries lesions for a period of time (e.g., local application of fluoride varnish; Chapter 12). However, here the next intervention would have been already the placement of a restoration when the caries lesion exceeded radiographically the outer third of dentin or showed progression. The aim of the current treatment plan was to postpone or even avoid future restorations (see Chapters 17 and 20).
Right Upper Jaw (first Quadrant; Fig. 25.6)
Tooth 17. The noncavitated caries lesion in the central fissure was considered as being active, but radiographically no caries lesion extending into dentin could be detected. However, DIAGNOdent measurement revealed a medium (43) and lower (29) value for the central and the distal fissure, respectively. Thus, the decision was to seal all the fissure areas, without any prior excavation/preparation ( Fig. 25.7 ). The noncavitated caries lesion on the mesial surface extending radiographically into the outer third of dentin was infiltrated (positive papilla bleeding as single indicator for activity), since it was supposed to progress with noninvasive measures alone (see Fig. 25.10 ).
Teeth 16/15. Both restorations (mesio-occlusal and palatal-occlusal) of tooth 16 were judged as insufficient and renewed using composite ( Fig. 25.8 ). The noncavitated caries lesions at the distal surfaces of both 16 and 15 (positive papilla bleeding as single indicator for activity) extending radiographically into the outer third of dentin were infiltrated ( Figs. 25.9 and 25.10 ).
An unfilled transparent resin material enables further DIAGNOodent measurements of the sealed areas but is much harder to visualize clinically compared with colored sealants.
Left Upper Jaw (2nd Quadrant; Fig. 25.9)
Tooth 27. The noncavitated caries lesion of the occlusal aspect was considered as being inactive (visual–tactile examination). No radiolucency could be found and a medium DIAGNOdent value (25) was assessed. Since the status of the lesion was most likely to be stable (Caries non-progressiva), the decision was to monitor this surface. In comparison to the occlusal “active” caries lesion of tooth 17, where a fissure sealant was applied ( Fig. 25.7 ), for tooth 27 a less pronounced discoloration and a lower DIAGNOdent value were assessed. The noncavitated caries lesion on the mesial surface extending radiographically into the outer third of dentin was infiltrated (positive papilla bleeding as indicator for activity).
Tooth 26. The composite restoration was judged as being sufficient. However, the palatal fissure showed an active, noncavitated caries lesion and a DIAGNOdent value of 77 was measured. Nonetheless, this caries lesion was sealed and not filled, since the DIAGNOdent value was judged as being false-positively high (Caries progressiva superficialis). The noncavitated caries lesion on the distal surface extending radiographically into the inner half of enamel was infiltrated (positive papilla bleeding as indicator for activity).
Left Lower Jaw (3rd Quadrant; Fig. 25.10)
Tooth 37. The noncavitated caries lesion of the occlusal aspect was considered as being inactive by visual–tactile examination. No radiolucency could be found and a low DIAGNOdent value (14) was assessed. Thus, it was decided to monitor this surface (Caries non-progressiva). The noncavitated active (positive papilla bleeding as single indicator for activity) caries lesions on the mesial surface extending radiographically into the inner half of enamel were diagnosed as Caries progressiva superficialis. With regard to the relatively high number of approximal caries lesions it was decided to infiltrate and not only fluoridate this area.
Tooth 36. The occlusal composite restoration was judged as being sufficient. The noncavitated caries lesion on the distal surface extending radiographically into the outer third of dentin was infiltrated (activity assessment see above). The shallow, but active (no papilla bleeding, but opaque surface) caries lesion on the mesial surface (Caries progressiva superficialis) was referred to local fluoridation (Duraphat, Gaba, Lörrach, Germany).
Right Lower Jaw (4th Quadrant; Fig. 25.11)
Tooth 47. A noncavitated caries lesion (ICDAS 2) that was assessed as being active was visible adjacent to remnants of fissure sealant. No radiolucency could be found and a Diagnodent value of 27 (adjacent to the sealant) was assessed. It was decided to prepare the central fissure part (minimally invasive filling), since it was thought to be safer to remove the fissure sealant remnants, but leave the intact fissure sealant in the mesial fissure area. The noncavitated caries lesions on the mesial surface extending radiographically into the inner half of the enamel (E2) was infiltrated, since the lesion could be assessed as being active after drilling the distal surface of the adjacent tooth (Diagnosis: Caries progressiva superficialis).
Tooth 46. Although the occlusal composite restoration in the distal fissure area (hardly visible clinically, but detectable on the x-ray image) was judged as being sufficient, it was decided to remove the occlusal restoration to assess the adjacent approximal caries lesion extending radiographically slightly into the middle third of dentin. The fissure sealant showed a dark shadow around it. Therefore, it was also removed and the resulting cavity filled with composite ( Fig. 25.12 ). The noncavitated, active (opaque surface and papilla bleeding) caries lesion on the mesial surface (E1) was diagnosed as Caries progressiva superficialis. Since it was rather shallow it was decided to fluoridate (Duraphat).
Tooth 45. The noncavitated caries lesion on the distal surface extending radiographically into the outer third of dentin was infiltrated (papilla bleeding).
Clinical Aspect at the End of the Treatment
Several surfaces still showed signs of inactive caries lesions ( Fig. 25.13 ). The patient was told to inform any subsequent dentist about the minimal interventional concept of caries management to avoid unnecessary (invasive) treatments. For this purpose a booklet (see Chapter 17) was handed over, in which the radiological stages of the infiltrated approximal as well as the sealed occlusal caries lesions were listed. The standardizable bitewing holder was kept for the follow-up investigation.
According to the caries risk, the patient was supposed to be recalled twice annually. The last appointment of the treatment phase (4 months after initial treatment) was considered as a “first recall.” Advice and instruction with regard to flossing was repeated. Thereafter, first clinical, including radiographic, follow-up was performed 8 months after the end of the treatment. No clinical signs of new caries lesions were detected. Instructions for oral hygiene and noncariogenic diet were reinforced, a professional tooth cleaning was performed. Follow-up radiographs revealed no progression or onset of any caries lesion of posterior teeth ( Fig. 25.14a–d ).
Case 2: A 22-year-old Man with Medium Caries Risk
Age: 22 years
First visit: January 2011
Last visit: April 2011
Follow-up visit: October 2011
The patient visited the university clinic because he was concerned about gum bleeding. Regular antimicrobial mouth rinse had been recommended by a private practitioner one year before, but the patient did not notice any improvement. No cause-related noninvasive measures (e. g., professional cleaning or oral health instructions) had been performed. The patient was not aware of any caries lesions being present and was unsure whether bitewing radiographs had previously been taken. No general health issues were reported by the patient.