Article
On caries and its management
As dental professionals, it is essential to stay abreast of the latest evidence-based knowledge and information on diagnosing and managing dental caries. Despite the significant advancements in technology and dental materials, the management of dental caries still falls short of being optimal in some situations. Therefore, it important to correct these shortcomings and continuously update our practices. I would like to highlight some key points that I believe are vital when considering the diagnosis and management of dental caries. These points have been well investigated but have yet to be considered by many.
Using an explorer to diagnose dental caries is inappropriate as it has low specificity and sensitivity and is associated with high false positives, especially in fissure caries.
The word ‘catch’ we use to prove the presence of caries should not be used because sticking the explorer in the fissures does not necessarily indicate the presence of caries. Hence, the probe/explorer is used to check the surface texture of the tooth surface and cavitated caries lesion. Therefore, a blunt probe/explorer (i.e. WHO probe) can be used in such circumstances.
In order to reach the correct diagnosis and avoid false negative or false positive results, it is essential to isolate, clean, and dry the tooth. This allows us to identify demineralized enamel (white spot lesions) or carious lesions. The management of white spot lesions should be conservative. This includes polishing the lesions, applying a high concentrate fluoride (i.e. fluoride varnish), and most importantly, providing the patient with detailed oral hygiene instructions. This responsibility for patient care is a key part of our role as dental professionals.
Management of dental caries and caries removal must be based on the concept of ‘selective caries removal) not ‘complete caries removal’. Affected dentine (i.e. now known as firm dentine) should be maintained and not removed, especially in deep carious lesions. Soft dentine (previously known as infected dentine) should also be left in very deep lesions, and a step-wise technique may be considered. However, complete caries removal must be considered in the periphery of the prepared cavity to achieve a very effective sealing, as bonding between composite and hard (sound) dentine is more durable and stronger than between the composite and the firm and soft dentine.
A cavity liner is not always required, and MTA or Biodentine may be used in certain situations.
In certain clinical situations, vital pulp therapy (VPT) [such as pulpotomy] can be a valuable technique to avoid root canal treatment (RCT). Numerous published studies have shown medium to long-term success with VPT.
Our target in managing dental caries in our patients should be avoiding putting the patient in the ‘Restorativere-restorative cycle.’ Instead, we should consider what is known as non-restorative management (whenever possible).
Our goal should always be refurbishment and repair, not replacing the fillings (whenever possible, practical, and in the patient's best interest). Repairing and refurbishing a restoration can achieve several advantages, such as increased longevity and slowing the ‘restorative death spiral,’ process.