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Operative Dentistry - Best Practices

Caries Management:  Terminology

(last modified August 8,2014)

Caries Process: is the dynamic sequence of biofilm-tooth interactions that can occur over time on and within a tooth surface. This process involves a shift in the balance between protective factors (that aid in remineralization) and destructive factors (that aid in demineralization) in favor of demineralization of the tooth structure over time. The process can be arrested and/or reversed at any time.

Caries lesion: A caries/carious lesion is a detectable change in the tooth structure that results from the biofilm-tooth interactions occurring due to the disease caries. It is the clinical manifestation (sign) of the caries process. ‘‘People have dental caries, teeth have caries lesions.’’

Demineralization (decalcification): Is the loss of mineral or calcified material from the tooth structure resulting from a chemical process that can be the result of bacteria metabolic products (caries) or chemical acidic products (erosion) from exogenous (diet, environment) or endogenous sources (gastric).

Cavitated Carious lesions: A caries lesion with a distinct breakdown of the surface integrity that can be detected using optical or tactile methods. This cavitated lesion can be confined in enamel or extended through to dentin. Once the enamel is cavitated the bacteria start penetrating dentin causing superficial tubular invasion. In a slow progressing caries lesion, different layers (infected and affected) of carious dentin have been reported in the cavitated lesion.

Infected dentinal carious lesion: is the irreversible demineralized and denatured layer with bacterial invasion. Very soft, moist and easy to remove with a spoon excavator.

Affected dentinal carious lesion: dentin is partially demineralized (leathery\softer than normal), collagen is not denatured and contains minimal to no bacteria.

Caries along DEJ: The presence and treatment of discoloration and stain along the DEJ is a current controversy and a point of discussion. Traditionally during operative procedures the removal of all stain and softness of the DEJ has been taught. Some histological studies have shown that staining and demineralization along the DEJ is not always related to bacterial infection (Kidd et al 1996).

Deep caries lesions: When caries lesion encroaches the vital pulp we recommend a conservative approach to caries removal in asymptomatic deep caries lesions.  Although some morphological studies have shown a defined boundary between the highly infected and the caries affected dentin, clinically this presents a subjective and difficult decision regarding the amount of dentin that should be excavated. Some studies (Larger et al., 2003) have shown that is not possible to eliminate all the micro-organisms even during a conventional caries removal, as a few bacteria will remain even after all soft dentin is removed. On the other hand, some studies (Ricketts & Kidd, 2006 systematic review), that have evaluated activity and progression of sealed lesions with remaining infected dentin, have shown that the majority of the lesions appeared to be arrested both clinically and radiographically and showed a decrease or absence in micro-organisms with time.