Medical History, Review of Systems, Social History, Extra/Intraoral Examination, Occlusion, and Radiographic Examination
The patient is healthy in all aspects, eats a normal diet, exercises, and utilizes occasional antihistamines for seasonal allergies. His past medical history and his review of systems are unremarkable. His social history is positive for daily beer or wine consumption and he denies use of recreational drugs or tobacco. He exercises regularly and periodically runs marathons. During marathon training he utilizes sports drinks for rehydration. The patient’s extra/intraoral examinations are within normal limits and the current clinical examination of teeth reveals no evidence of caries, except where noted, and excellent occlusion without evidence of excessive wear or physical damage (Figure 7.3.1). Radiographic examination is negative for approximal caries and occlusal radiographic findings are discussed later (Figure 7.3.2).
Though caries penetration to the dentoenamel junction is only obvious on the lower first molar radiographically and initial caries is noted on the occlusal surface of several molars clinically.
Initial and moderate dental caries on occlusal surface and high caries risk for “occlusal caries” ONLY. Low caries risk for smooth surface caries.
Nonsurgical Caries Management
No change in oral hygiene, as the patient has low smooth surface caries risk and no periodontal disease. He should continue brushing twice per day with fluoride toothpaste (1000 ppm) and performing current interproximal care regime as it has been successful in preventing all disease.
No change in diet except diet counseling as to the risk of sports drinks for erosion and as a sugar source for caries and dried fruits as “sticky” sugar source.
Sealant placement on molars with initial lesions, do not seal teeth that do not have evidence of disease activity.
Dental recall once per year with bitewing dental radiographs every 24 months unless risk changes.
Surgical Caries Management
The patient requires surgical management of the caries defect on the occlusal of tooth #30. The tenets of minimal intervention require that: the caries be removed to obtain clean margins at the enamel interface; the caries is excavated, without exposure of the pulp; and the tooth restored. No surgical extension of the preparation through the sound enamel, rather sealant is applied to any susceptible fissures, preventing future disease rather than destroying sound tooth structure (Ismail et al. 2015; Ripa and Wolff 1992; Wolff et al. 2007).
The diagnosis of the caries on the occlusal surface is no longer performed utilizing a sharpened explorer pressed into the fissure and looking for “tug back.” Caries detection starts prior to the physical examination of the patient with a comprehensive history. Like any of the healing arts, listening to what the patient tells the practitioner about the nature of the conditions afflicting them is important … in this case the patient is 26 years old and has never had evidence of occlusal caries, which indicates that the anatomy was not highly susceptible to caries because over 20 years these surfaces would have developed caries. The current clinical findings, active demineralization, and the deep lesion associated with fissures, indicates that the prior environment has obviously changed.
Visual and Visual/Tactile Detection
The physical detection of caries starts with a process of careful examination. The utilization of the sharp explorer to locate carious teeth was described by Taft in his text A Practical Treatise to Operative Dentistry in 1859 and later editions 1888, but there was no mention of the utilization of any pressure in the examination (Taft 1883). Radike (1968) enhanced Black’s original diagnostic criteria by describing areas as carious when the explorer catches with moderate to firm pressure in the pits and fissures, as well as, translucency around the fissures. Visual/tactile examination utilizing an explorer with moderate pressure, as recommended by Black and Radike, has fallen into significant disfavor. Ekstrand et al. (1987) demonstrated that use of a sharp explorer in a compressive fashion when examining the occlusal surface of teeth produced irreversible traumatic defects in the occlusal fissures that actually favored lesion progression (Ekstrand et al. 1987). Further, in a study of 34 dentists examining 61 teeth for occlusal caries revealed that there was no difference in diagnostic accuracy between those that utilized the traditional explorer and those that utilized visual only examinations. The explorer did not add to the accuracy of the examination. The percentage of “clinically” correct treatment decisions was about 73% for both techniques with examinations utilizing explorers having higher incidence of “over treatment” and examinations utilizing visual only having a higher incidence of “under treatment” (Lussi 1991). Teeth classified in the “under treatment” category utilizing the visual only examination technique probably should be recommended for sealant therapy, rendering this “under” diagnosis probably nonclinically significant (Beauchamp et al. 2008; Griffin et al. 2008). The finding of “over treatment” with the explorer were reported earlier by Bergman and Linden (1969). In addition, their experiments indicated that the explorer can convert a white‐spot lesion into actual cavitation. Ekstrand et al. (2007) demonstrated that the use of a periodontal probe lightly moved across the lesion to detect roughness improved a practitioner’s ability to determine lesion activity (Ekstrand et al. 2007). Roughness detected when lightly stroking the periodontal probe across the enamel in question is a sign of the current acid activity on the enamel surface and is classified as active disease. By 2001 the NIH Consensus Development Conference on Dental Caries Diagnosis and Management Throughout Life concluded that “the use of sharp explorers in the detection of primary occlusal caries appears to add little diagnostic information to other modalities and may be detrimental” (2001). The utilization of the explorer in a compressive force mode does not add diagnostic reliability if proper visual and radiographic examinations are conducted first. In fact, the use of the explorer AFTER visual and radiographic examination is minimally likely to locate undiagnosed lesions, rather more likely to inappropriately diagnose as carious lesions that at best should be sealed (see Figure 7.3.2). Avoiding damage created by explorers is important as Ismail (2004) emphasized that the “disease process may reverse or stop, resulting in complete healing of the demineralized dental tissue or in preservation of minutely damaged tissue” (Ismail 2004).
This patient presents with both initial dental caries with deep fissures on distal losing anatomy. In order to determine the proper therapeutic approach to treat these lesions, it is necessary to classify the lesions not only by depth and but also by activity (Ismail et al. 2013). The concept of caries activity recognizes that caries is a bidirectional disease with continued demineralization resulting in cavitation and continued remineralization resulting in lesion arrest or reversal (Pitts 2004). Cavitation is a continuum of a disease that starts with simple demineralization and if left untreated continues to deep cavitation and eventual loss of the tooth.
Caries examination of the occlusal fissure requires bright light, clean surfaces, compressed air, and a blunt ended explorer or periodontal probe. Quadrants should be isolated from saliva, surfaces cleaned so that fissures can be visualized, careful examination while the tooth is wet and then after thorough drying with compressed air. The periodontal probe/blunt probe is lightly scratched over the surface of the fissure to determine integrity AND to feel for surface roughness. The visualization is to determine whether the tooth appears glossy and smooth, white and frosted or whether there is a dark shadow beneath the fissure. Further visualization is performed to determine whether the fissure has lost integrity visually to or beyond the dentoenamel junction (DEJ). The fissure is evaluated for caries visually and tactilely as being: (i) Sound‐perfect dental anatomy with an intact fissure (Figure 7.3.3A and B); (ii) Initial caries‐loss of fissure anatomy (even if stained) that does not reach the DEJ (Figure 7.3.4A and 7.3.3B); (iii) Moderate caries, caries obviously penetrating beyond the DEJ (Figure 7.3.5A); and Extensive caries, caries penetrating deeply into the dentin approaching the pulp (Ismail et al. 2015) (Figure 7.3.6). The activity is assessed visually wet and dry with rough, chalky/white, nonreflective, and darkly colored sub‐surfaces all indicate that the decay is active (Ekstrand et al. 2007). Comprehensive examination of the occlusal surface requires diagnostic bitewing radiographs. The bitewing radiograph must be examined to confirm that no occult caries is present at or below the dentoenamel junction that indicates occult caries (Figure 7.3.5B). Teeth may have regions of many levels of caries with fissures ranging from sound to moderate or severe, in scoring the surface is always scored at the worst level.
Caries in the Pits and Fissures … It Is Different … Why?
After completion of a comprehensive examination it is necessary to decide on appropriate treatment. It is necessary to understand the unique environment of the fissure that makes treatment modalities different. Fissures are created during tooth formation by the coalescing of independent lobes of the tooth. The fissure formed may be totally coalesced (creating little likelihood of capturing food and developing caries), partially coalesced leaving periodic gaps or noncoalesced leaving a gap to the dentin (Figure 7.3.7) (Ripa and Wolff 1992). In the partially or noncoalesced, an ecologic environment is developed that retains bacteria, retains sugars, and restricts the ability of saliva or oral hygiene to reach the food/bacteria source. This allows the sugar‐fed bacteria resident in the fissure to produce acids for longer periods of time with little access to saliva to remove the acids or to buffer the acids (Wolff and Larson 2009). Changes in oral hygiene, diet, and systemic factors (particularly as they relate to salivary flow) are conditions most frequently associated with increased caries risk (Hara and Zero 2010). As there have been no changes in this patient’s medical history and there is no clinical evidence of xerostomia on examination, changes in diet and oral hygiene may be the likely cause. Hygiene on the occlusal surface is often made difficult by the anatomy of the fissure, which may be narrower than the diameter of the toothbrush bristle, thereby allowing food debris to remain in the fissure. In this case, the young dentally healthy male, leaving home where diet and homecare had permitted a healthy ecosystem to thrive, allowed a shift in the ecosystem toward acid production. Minor changes in the patient’s diet can result in significant acid production thereby creating an environment likely to produce caries (Newbrun 1979, 1982).
Management of Occlusal Caries
Management of occlusal initial caries lesions has shifted from surgical intervention to a medical management (Wolff and Larson 2009). Remineralization of initial lesions requires the reduction of plaque and reduction of the frequency of fermentable carbohydrate consumption (particularly sticky foods when speaking about occlusal surfaces). Unfortunately, due to the narrowness of the occlusal fissure, it is often difficult to remove the plaque better and equally difficult to prevent fermentable carbohydrate from penetrating deeply into the fissures (Figure 7.3.7).
Dental sealants protect the fissure from further demineralization by blocking the pits and fissures from caries causing bacteria and introduction of fermentable carbohydrate. This is done by blocking plaque accumulation. Sealants are highly successful in preventing caries (Beauchamp et al. 2008; Griffin et al. 2008; Oong et al. 2008) Sealing noncavitated active lesions had better outcomes than unsealed early lesions. Active initial lesions should be considered for immediate sealants and inactive initial lesions may be monitored for changes in activity (Ismail et al. 2013, 2015). The sealants resulted in caries reductions of 71% five years after placement (Griffin et al. 2008). It has even been demonstrated that sealing lesions with active caries results in the arresting of caries and prevents the lesions from advancing (Mertz‐Fairhurst et al. 1986; Mertz‐Fairhurst et al. 1998). The outcomes of all of this research indicate that the evidence‐based treatment decision for prevention and treatment of early lesions should be sealant placement whenever frank cavitation is not present (and in some cases even when it is present). When in doubt SEAL‐IT! Teeth #s 2, 14, 15, 19, 20, 28, and 29 will receive carefully applied resin‐based sealants. The lower‐right molar (tooth #30) will be treated with a lesion specific bonded composite restoration preserving the maximal amount of tooth structure, not the “old” extension for prevention. These guiding principles mean the preparation removes necessary caries, provides sound margins, and selects the restorative material utilizing the principle of the best evidence‐based material. Tooth destruction is kept to a minimum and form and function re‐established (Ismail et al. 2015; Ripa and Wolff 1992; Wolff et al. 2007).
- Dental occlusal caries requires a different diagnosis than present or not.
- Dental caries is diagnosed without a sharp explorer.
- Bitewing radiographs may demonstrate occult caries.
- When the extent and activity are questionable, the occlusal surface should be sealed rather than restored.