Cariology Part 7 Types of Caries

Summary

This dental lecture explores the dynamic caries process, emphasizing the balance between demineralization and remineralization. It categorizes caries based on location, structure involved, time relative to treatment, presence of cavitation, and activity level. The speaker discusses various types of caries, such as pit and fissure, smooth surface, interproximal, and root caries, highlighting their unique characteristics and challenges in diagnosis and treatment. The importance of distinguishing between arrested and active lesions is underscored, with a focus on evidence-based approaches to dental care.

Takeaways

• 🦷 The caries process is a dynamic balance between demineralization and remineralization, which can be either protective or pathologic in nature.
• 📍 Caries can be classified by location, such as pit and fissure, smooth surface, interproximal, and occlusal caries, each with distinct characteristics.
• 🏷 Caries can also be defined by the structure involved, such as enamel, dentin, coronal, or root caries, indicating the stage and severity of decay.
• ⏳ Time relevance to treatment is another way to classify caries, including primary, secondary, residual, and rampant caries, each with different implications for treatment.
• 🕳 Caries can be cavitated, where there is a physical hole in the tooth, or non-cavitated, where the tooth structure is still intact despite demineralization.
• 🔬 The activity of caries can be active, where the bacterial process is ongoing and can lead to cavitation, or arrested, where the process has stopped and the lesion is stable.
• 🌿 Pit and fissure caries often occur in teeth with less than ideal occlusal anatomy, making them prone to bacterial accumulation and decay.
• 🦷 Interproximal caries typically starts below the contact point between teeth and can be a precursor to facial and lingual caries, often requiring good oral hygiene practices like flossing.
• 👴 Root caries is a significant issue in older populations or those with gingival recession, as it progresses rapidly, can be large before detection, and is close to the pulp tissue, making it difficult to treat.
• 🦴 Enamel caries often starts as a white spot lesion and can remineralize if the demineralization process is halted, potentially preventing the need for a filling.
• 🔎 Diagnosis of caries, especially interproximal, can be challenging as up to 40% demineralization may be required before it's visible on radiographs, emphasizing the importance of regular check-ups.

Q & A

What is the caries process and why is it significant in dental health?

The caries process is the continuous cycle of demineralization and remineralization of the tooth structure. It is significant because it can lead to either protective or pathologic outcomes, depending on the balance of factors in the mouth that influence this process.

How can caries be classified based on its location in the mouth?

Caries can be classified by its location as pit and fissure caries, smooth surface caries, interproximal caries, and occlusal caries. These terms help to define the specific area of the tooth affected by the caries.

What does it mean to classify caries by the structure involved?

Classifying caries by the structure involved refers to identifying whether the caries affects enamel, dentin, the crown of the tooth, or the root surface. This helps in understanding the depth and severity of the caries.

What is the difference between primary and secondary caries?

Primary caries refer to the initial occurrence of caries in a tooth. Secondary caries develop around or near a previous filling or restoration, indicating a recurrence of the disease process in that area.

What is residual caries and why might it be left untreated during a dental procedure?

Residual caries are the portions of caries that remain in the tooth after a dental treatment, often intentionally left to avoid complications such as pulp exposure. The decision to leave residual caries is based on a clinical judgment to protect the tooth's vitality.

How can caries be described in terms of its physical presentation on the tooth?

Caries can be described as cavitating, where a physical hole has formed in the tooth, or non-cavitating, where the tooth structure is still intact despite the presence of demineralization.

What is the significance of classifying caries by its activity?

Classifying caries by its activity (active, non-active, or arrested) helps determine the current state of the disease process. An active lesion is progressing and requires treatment, while an arrested lesion has stopped progressing, potentially due to changes in oral hygiene or other factors.

What is meant by rampant caries and what does it indicate about a patient's oral health?

Rampant caries refers to the widespread occurrence of cavities on multiple teeth. It indicates a severe oral health issue, often resulting from poor oral hygiene, high sugar diet, or lack of fluoride exposure.

Why are pit and fissure caries considered the primary location for caries development?

Pit and fissure caries are considered the primary location because the anatomy of these areas, with grooves and fossa, can harbor bacteria more effectively, making them more susceptible to the caries process.

How does the progression of interproximal caries differ from other types of caries?

Interproximal caries often starts broad at the surface and narrows as it extends into the tooth, unlike pit and fissure caries which start narrow and broaden out. This v-shaped progression makes it a common area for caries to develop, especially in areas that are difficult to clean.

Why is root caries considered more alarming than caries on other parts of the tooth?

Root caries is more alarming due to its rapid progression, lack of initial symptoms, close proximity to the pulp tissue, and the difficulty in treating the affected area, especially in the presence of gingival recession.

How can the appearance of enamel caries be distinguished from hypocalcified lesions?

Enamel caries, or demineralized lesions, may appear less opaque and more glossy when the tooth is wet, becoming chalky white when dry. Hypocalcified lesions, often related to developmental conditions, appear opaque or chalky white regardless of the tooth's moisture level.

What is the significance of sclerotic dentin in the context of dentin caries?

Sclerotic dentin is a protective response of the tooth where the dentin becomes more mineralized and darker in color to slow down the demineralization process and protect the tooth from further caries progression.

How can the terms 'infected dentin' and 'affected dentin' be differentiated in the context of dental treatment?

Infected dentin contains bacteria and has irreversibly damaged collagen, requiring removal during restorative procedures. Affected dentin, while softened, does not contain bacteria and the damage is reversible, so it may not need to be removed.

What is the clinical significance of the study mentioned in the script regarding radiographic lesions?

The study provides a correlation between the radiographic appearance of caries and the likelihood of physical cavitation, offering a guide to determine whether a lesion is likely to be cavitated and thus in need of intervention.

How does the classification of radiographic caries into E1, E2, D1, and D23 groups affect clinical decision-making?

This classification helps clinicians assess the likelihood of cavitation and decide whether to proceed with restorative treatment or to monitor the lesion for changes over time, based on the extent of demineralization visible on radiographs.

Why is it important to consider a patient's caries risk level when interpreting radiographic findings?

A patient's caries risk level influences the likelihood of cavitation. High-risk patients are more likely to have cavitated lesions, even when radiographic signs are less indicative, thus affecting the decision to proceed with preventive or restorative measures.

Outlines

00:00

🦷 Understanding the Caries Process and Its Classification

The speaker begins by explaining the caries process, emphasizing its dynamic nature between demineralization and remineralization. They clarify that caries can be either protective or pathologic. The paragraph delves into various ways to classify caries, including by location (e.g., pit and fissure, smooth surface, interproximal, occlusal), by the structure involved (enamel, dentin, coronal, root), and by the timing relative to treatment (primary, secondary, residual). Additionally, caries can be cavitated or non-cavitated and active or arrested. The speaker introduces the concept of rampant caries, where extensive decay is present on multiple teeth, and provides examples to illustrate these classifications.

05:01

🦷 Anatomy and Occurrence of Pit and Fissure Caries

This paragraph focuses on the development of teeth and how imperfections in the occlusal surface, such as grooves and fossa, can lead to pit and fissure caries. The speaker explains that these imperfections can harbor bacteria, making them prone to caries. The caries process in pits and fissures often starts narrow and broadens out, forming an inverted V shape. The speaker also discusses the importance of recognizing variations in occlusal anatomy that may predispose teeth to pit and fissure caries and touches on the second most common area for caries development: interproximally, which is considered a smooth surface caries.

10:02

🦷 Characteristics and Challenges of Interproximal and Root Caries

The speaker discusses interproximal caries, which typically occurs in hard-to-clean areas, and how it often precedes facial and lingual caries. They describe the v-shaped cross-section of interproximal caries and the importance of regular flossing to prevent it. Root caries, especially in older populations or those with gingival recession, is highlighted as a significant issue due to its rapid progression, large size before detection, close proximity to pulp tissue, and difficulty in treatment. The speaker also explains the cross-sectional appearance of root caries as a u-shaped lesion, which can be helpful for diagnosis.

15:03

🦷 Enamel and Dentin Caries: Diagnosis and Treatment Considerations

The paragraph delves into enamel caries, which often begins as a white spot lesion and can be remineralized to prevent cavity formation. The speaker differentiates between demineralized and hypocalcified lesions, the former being reversible and the latter related to developmental conditions. They also discuss the possibility of arrested enamel caries, which may appear unsightly but do not require treatment for the caries process itself. Dentin caries is also covered, including the tooth's protective mechanisms such as sclerotic dentin and reparative dentin. The speaker explains the difference between infected and affected dentin and the implications for restorative procedures.

20:05

🦷 Radiographic Diagnosis and Management of Interproximal Caries

The speaker discusses the use of radiographs for diagnosing interproximal caries and the limitations of this method, as significant demineralization is required before it can be detected. They explain that interproximal caries can arrest but still appear as caries on radiographs, necessitating careful monitoring and assessment of activity. A study from 1992 is referenced, which correlated radiographic appearances with the physical presence of cavitation. The speaker provides a detailed analysis of different radiographic classifications (E1, E2, D1, D2) and their likelihood of cavitation, advising a cautious approach to treatment based on the patient's caries risk profile.

Keywords

💡Caries

Caries, commonly known as tooth decay or cavities, is a dental disease process involving the demineralization of tooth enamel and dentin due to acids produced by bacteria. In the script, caries are discussed in various contexts, such as pit and fissure caries, smooth surface caries, and root caries, highlighting the different types and locations where caries can occur in the mouth.

💡Democratization and Remineralisation

Democratization refers to the process where acids from bacteria in the mouth dissolve the minerals in tooth enamel and dentin, leading to tooth decay. Remineralisation is the opposite process where minerals are redeposited into the tooth, potentially reversing early stages of decay. The script emphasizes the dynamic balance between these two processes and their impact on the health of teeth.

💡Pit and Fissure Caries

Pit and fissure caries are types of dental caries that occur in the grooves and fissures of the occlusal (chewing) surfaces of teeth, often due to imperfect coalescence during tooth development. The script describes how these anatomical features can harbor bacteria, making them susceptible to caries, and their characteristic inverted V shape in the tooth structure.

💡Smooth Surface Caries

Smooth surface caries affect the surfaces of teeth that are not rough or grooved, such as the facial or lingual sides. The script mentions that these types of caries often occur after the development of interproximal caries, indicating that the presence of caries in one area can increase the risk of caries in other smooth surfaces.

💡Interproximal Caries

Interproximal caries develop between the teeth, typically in areas that are difficult to clean, such as below the contact point between two teeth. The script explains that these caries often require flossing to prevent and that they have a characteristic V-shaped appearance when viewed in cross-section.

💡Root Caries

Root caries affect the root surfaces of teeth, often in cases of gingival recession. The script discusses the rapid progression of root caries due to the lack of enamel protection, its proximity to the pulp tissue, and the difficulty in treating this type of caries due to the anatomical location and conditions.

💡Primary, Secondary, and Residual Caries

Primary caries refer to the initial occurrence of caries in a tooth. Secondary caries develop around existing dental restorations, while residual caries are remnants of caries left intentionally during treatment to avoid complications like pulp exposure. The script uses these terms to classify caries based on their timing and relationship to previous dental treatments.

💡Cavitating Caries

Cavitating caries are those that have progressed to the point where a physical hole or cavity has formed in the tooth structure. The script contrasts cavitating caries with non-cavitating caries, where the tooth structure is still intact despite demineralization, to illustrate the varying degrees of caries severity.

💡Active and Arrested Caries

Active caries are those where the disease process is ongoing and capable of causing further damage if untreated. Arrested caries, on the other hand, have stopped progressing, often due to changes in oral hygiene, fluoride exposure, or diet. The script explains how understanding the activity of caries can guide treatment decisions.

💡Rampant Caries

Rampant caries describe a severe condition where a patient has extensive tooth decay affecting multiple teeth. The script uses this term to illustrate an aggressive form of caries that requires comprehensive dental treatment and highlights the importance of preventive measures.

💡Demineralized and Hypo Calcified Lesions

Demineralized lesions are areas of the tooth where minerals have been lost due to caries, while hypo calcified lesions are related to developmental issues. The script differentiates these two types of lesions based on their appearance and implications for treatment, noting that demineralized lesions may be more responsive to remineralization efforts.

Highlights

The caries process involves a constant battle between demoralization and remineralisation of the tooth.

Caries can be classified by location, structure involved, time relevance to treatment, cavitation, and activity level.

Pit and fissure caries often occur due to less than ideal occlusal anatomy that harbors bacteria.

Interproximal caries is considered a smooth surface caries and typically occurs in hard-to-clean areas.

Root caries is a significant issue, especially in older populations, due to its rapid progression and close proximity to the pulp.

Enamel caries often presents as a white spot lesion and can be remineralized to prevent cavity formation.

Dentin caries can lead to the formation of sclerotic dentin, a protective mechanism of the tooth.

The difference between infected and affected dentin is crucial for determining the extent of restorative procedures.

Interproximal caries lesions can arrest but still appear as caries on radiographs, requiring careful monitoring.

A study in 1992 correlated radiographic appearances of caries to the presence of physical cavitation.

E1 caries lesions have a 0% chance of cavitation when halfway through the enamel.

E2 caries lesions have about a 10% chance of cavitation at the enamel-dentin junction.

D1 caries lesions have a 40% chance of cavitation when in the outer half of the dentin.

D23 caries lesions have a 100% chance of cavitation and require restorations.

High caries risk patients may require more aggressive treatment approaches despite radiographic findings.

Low caries risk patients may benefit from monitoring lesions rather than immediate intervention.

The importance of distinguishing between arrested and active caries lesions for appropriate treatment planning.

Transcripts

[Applause]

okay so next we're gonna talk about

different types of carries what do I

mean right different types of carries I

thought there was just like you got a

cabbie or you don't have a cavity right

well keep in mind the carries process

it's just that it's a process right it's

a constant battle between demoralization

and remineralisation so anytime that

carries process occurs it's either going

to be protective in nature or it's gonna

be pathologic in nature so that process

of the tooth of losing and gaining

minerals I mean that really is the

Carrey's process right it's it's those

four big things we discuss with all

those influencing factors contributing

to pathologic or protective factors in

the mouth so as a result of this dynamic

complex process there's different ways

that we can actually classify or define

caries in the mouth so one of those ways

is by looking at where it occurs the

location of the caries right so if you

think about you know just talking to

patients or even talking to your

colleagues about where caries is located

what kind of terms do you use well you

may say things like pit and fissure

caries smooth surface caries

interproximal caries occlusal caries

right those are all terms or definitions

that we use to define the location of

the caries another way we can classify

caries is by the structure involved this

could be a couple of different things

this could be like enamel caries dentin

caries or this could be like coronal

caries or root carries right different

structures involved with that carries

disease process so a third way we could

actually classify or define the caries

process is by the time relevant to the

treatment what I mean by that so like if

you have caries for the first time the

patient may have what we call primary

caries but then the patient

she's a feeling and then years later

they developed caries near that filling

site right or around the filling and we

call that secondary caries so we could

also classify caries as residual carries

meaning that when we go in to treat the

tooth we remove some of the caries but

we leave some of the caries present for

whatever reason maybe we're trying to

avoid a pulp exposure so we leave

residual caries present right so that's

another definition of the caries process

and the other thing you could think

about is is the caries cavitating

meaning that there's actually a physical

hole in the tooth or is it non capitated

meaning that the two structure is intact

but the caries hasn't actually caused

enough demineralization to occur where

there is now a physical hole in the

tooth and probably the last way we could

classify or define caries is by its

activity meaning like is the bacteria

that's present in the caries active or

is it non active or arrested right it's

a disease process and so that process

can be occurring or it could actually be

non occurring so if we say lesion is

active that means that it's actively

capable of producing that disease

process and if left untreated it could

eventually lead to a cavitation of the

tooth whereas an arrested carious lesion

means that that whole process was

actually stopped for whatever reason may

be the protective factors outweighed

those pathologic factors and now the

tooth was a be able to stabilize itself

and we were able to reduce those

bacteria accounts and the patient's

hygiene got better and they expose

themselves a more fluoride and their

diet changed so now that whole disease

process actually stopped and that

carious lesion is you know arrested and

you know this is one that kind of comes

up occasionally but we also classify

caries as rampant caries right what does

that mean that's like the patient who

comes in in

and they have cavity on every single

tooth every single tooth has a big

cavity on it and so we call that ramp it

carries meaning that it's just kind of

everywhere right it's it's a huge

process its extensive it's multiple

locations in the mouth that's what we

call rampant caries all right so let's

look at a few of these examples a little

bit closer so first let's talk about pit

and fissure caries all right so if a

tooth develops normal it doesn't have

any developmental issues everything's

perfect what happens is that occlusal

surface is actually a combination of

grooves and fossa that make up that

occlusal Anatomy now a lot of people

when their teeth develop those grooves

and those fossa do not completely

coalesce perfectly so what they're left

with is anatomy that's a little less

than ideal and it's also a little bit

more capable of kind of harboring that

bad bacteria it's more suitable for

caries to occur so it's not really ideal

so we call it pits and fissures right so

pits and fissures specifically means

that the tooth really did not develop

perfectly now because of this Anatomy

pits and fissures are actually the

primary location where people typically

get caries and again it's due to that

Anatomy it's able to harbor bacteria a

little bit easier due to that specific

occlusal morphology so if you look at

the caries process and pits and fissures

it's actually going to start very narrow

and it's going to kind of broaden out as

it kind of diffuses into that dentin so

it's gonna be an inverted V shape so I

actually include the slide in the

handout that actually shows some of the

variations that can occur with the

occlusal Anatomy some of the anatomy on

the teeth is very conducive of harboring

bacteria and just creating an

environment for that bacteria to cause

pit and fissure caries so the second

most common area to develop caries is in

approximately now interproximally is

actually considered a smooth surface

carries whereas also if somebody gets

carries on the facial or the lingual of

the tooth that's also considered smooth

surface caries now patients do not get

carries on the facial or the lingual of

the tooth if they don't already have

interproximal caries

so usually interproximal caries is a

prerequisite to developing that facial

and lingual caries now specifically for

interproximal caries again it typically

occurs in those hard to clean those

areas that's a little bit more difficult

to get into

so if patients aren't flossing on a

regular basis you know they're not

really cleaning in between the teeth and

so caries typically develops right below

that point of contact right right below

that interproximal contact point where

bacteria is able to kind of collect

right there and if you look at these

lesions under a cross-section they

actually look like a v-shaped meaning

that the area at the surface is actually

very broad and as the caries extends

into the tooth closer to the dej it

actually gets more narrow so it's a

v-shape and cross-section so root

surfaces are also an area that

especially in sometimes older

populations or in people who aren't high

caries risk and they have gingival

recession root caries is a big issue and

so in these patients there's a lot of

reasons why root caries is more alarming

than it could be if they get carries on

another part of the tooth so what are

some of the reasons why root caries is

such a big deal well number one it

rapidly progresses because there's no

enamel present on the root surface

there's no real good protection there's

no first-line defense for that carries

process so it basically starts out in a

very thin layer of cementum and then it

goes into the dentin and as you know

from dentin it just progresses very

quickly through that dentin so that's a

big issue another reason why root caries

is also a problem is it's oftentimes a

pneumatic you know you can have route

carries get very large before the

patient even realizes there's something

going on they don't have any true like

signs of sensitivity or pain until

oftentimes the carry solution is very

large now another thing about route

carries is it's very close to the pulp

tissue so again like these carious

lesions can get very big and they can

get very close to that pulp tissue

before you even know what's going on so

it's very quick for things to get pulp

involvement whereas if you had a cavity

like on the occlusal or an inner

proximal it can take months sometimes

years for that to kind of make its way

to the pulp tissue on a root surface it

doesn't take that long and one of the

last reasons why root carries is so

difficult is because they're very

difficult to treat think about the

location of these you get the gingiva

right there you got you know two

structure that's not really a whole lot

of enamel present so there's just a lot

of things that impact your ability to be

able to replace a really good sound

long-lasting restoration in those areas

very difficult conditions to work in

roof surfaces that are exposed in the

mouths of typically rough they're very

kind of plaque retentive they're very

difficult to keep clean so that's

another big issue with root surfaces and

if you look at a carious lesion that's

on a root surface in a cross-section you

know we talked about how the other areas

in the mouth are specific appearances to

that curious lesion in cross-section the

roof surface is no different for a root

surface the cross-sectional appearance

of caries is going to be a u-shaped

lesion so that can be very helpful

sometimes when you're trying to diagnose

these on a radiograph especially if the

caries is occurring in approximately

just look for that distinctive u-shape

lesion so enamel caries you know when

the caries process starts out the

majority time and a healthy person that

does not have ginger were session

they're going to have Kerry start out on

the enamel now typically the enamel will

have very distinctive appearances too

you may have a white spot lesion present

that's non capitated that's usually an

incipient or an early caries process

occurring now there is a difference

between you know a demineralized lesion

and a hypo calcified lesion now happy

calcified typically refers more to like

developmental related conditions whereas

demineralized lesions are the two

structure developed fine but due to all

these influencing factors the two

structures of losing minerals from the

tooth both of these lesions are going to

appear very white or opaque in

appearance and interestingly enough if

the tooth is a little moist it's a

little wet the demineralized lesion is

gonna be a little bit less opaque it's

gonna be a little bit more glossy but as

soon as the tooth is dried it's gonna

appear a very chalky white color now the

hypo calcified lesion is gonna look

opaque or bring chalky white regardless

of whether or not the tooth is wet or

dry so that's a good way to distinguish

those two lesions apart and if you're

dealing with a demineralized lesion

that's actually a good condition to

actually think about remineralisation of

that tooth doing things that help put

minerals back into the tooth you know

teaching the patient things they can do

to help remineralize that tooth so the

cavity never occurs and then the other

thing is enamel caries when it does have

remineralization when the disease

process stops you're actually gonna have

a resting of that caries and that can be

kind of alarming sometimes because

sometimes the enamel caries process gets

so far along and then it stops for

whatever reason you know maybe the

patient is brushing better more fluoride

exposure they're seen you know you on a

regular basis so they're doing all these

things right and the carries disease

process actually stops so what happens

is it stops and so it may leave a rough

and surface it may look like the tooth

is like a dark brown or like a black

color and a lot of practitioners

look at this and they'll say I'll look

there's a cavity there we need to treat

that when in reality it's actually an

arrested lesion

it doesn't need treatment for the sake

of the caries process because it's

actually been stopped it may need

treatment for aesthetic reasons because

it's kind of an eyesore but as far as

the caries process goes it should not

get any worse

so dentin carries dentin can have caries

once it's advanced past the enamel or in

certain situations where patients

actually lose her enamel for whatever

reason maybe they have a clue so we're

in combination with some erosion and now

they have exposed dentin on their teeth

so there's a lot of reasons why Denton

can be exposed but nonetheless when

caries process actually occurs on dentin

now you have dentin caries so oftentimes

the result of demineralization on to

structure it actually encourages the

tooth to try to fight this process so

sometimes what you can see is sclerotic

dentin or dentin that has a hyper

mineralized content a lot of minerals

present sclerotic dentin is actually

more shiny and it's darker in color

compared to normal dentin and this is

actually a protective mechanism of the

tooth to kind of slow down that

demineralization that carries

progression over time so another thing

that occurs whenever the caries process

is occurring in dentin you get hyper

mineralized you know didn't on the

surface but you also get dentin laid

down closer to the pulp reparative

dentin or tertiary dentin it's the to

stability to try to protect itself to

try to maintain its vitality and to

prevent that carries progress from

occurring more rapidly so sometimes

you'll hear the terms infected dentin

versus affected dentin essentially what

that means is infected dentin is dentin

that actually has bacteria infecting in

its present within the dentin and the

dentin collagen itself is actually

irreversibly damaged affected dentin is

actually Denton that does not contain

bacteria but it does contain collagen

that is reversibly damaged it's a little

bit softer but it's reversibly down

and it does not contain that bacteria so

when we're talking about removing dentin

during like a restorative procedure you

definitely want to remove the infected

dentin but you don't necessarily have to

remove the affected didn't so we talked

a little bit about interproximal lesions

now a common way to diagnose caries is

to look at radiographs right we usually

get bitewing radiographs and we look at

the interproximal contacts to determine

if there is caries occurring at those

interproximal contact areas

interestingly enough when the

demineralization process is occurring in

approximately for you to be able to

actually identify a change in the

radiograph to be able to identify

carries on that bitewing radiograph you

have to have up to 40% demineralization

of that tooth structure occur in that

specific area and again these lesions do

not happen overnight sometimes it can

take 3-4 years for these lesions to

occur because you have that process of

demoralization and remineralization so

you're not wrong when you see some of

these and you say you know what I don't

want to treat this right now but we're

gonna keep an eye on it we're gonna keep

watching this over time to see if that

carries gets worse so with these

interproximal caries lesions these can

also arrest

just like other curious lesions however

the only downside is is when they arrest

they still look like carries on the

radiograph so you have to be mindful if

you choose to watch these you have to

keep good notes for yourself and

understand you know is the lesion active

or is it non active you have to be able

to determine that if you're gonna choose

to watch these lesions so there was a

study done in 1992 that actually looked

at radiographic lesions and they looked

at various appearances of caries on the

radiograph and then what they did was is

they actually introduced an orthodontic

spacer or orthodontic separator between

the teeth and they allowed the teeth to

kind of slightly separate so they can do

a visual inspection of that proximal

surface

so they basically created a graph that

correlated radiographic appearance to

whether or not there was a physical

cavitation of that tooth present so for

this next part definitely refer to your

handout and look at this specific graph

that I'm talking about that correlates

lesion progression to a physical

cavitation on the tooth so let's look at

this

so it's classified or the curious lesion

is classified into four different groups

you have your E one group which is where

caries kind of extends into that outer

half of the enamel so in that specific

situation if you see a lesion extend

about halfway through the enamel

according to this article in the study

that they did when they looked at teeth

after they separated they had caries

extending halfway through the enamel

there was a 0% chance that tooth

actually being cavitate now if you look

at the e2 option which is where you have

caries extending to the inner half the

enamel so it basically goes through the

enamel and it kind of kisses that dental

enamel Junction when a lesion looks like

that according to the study it's

probably about a 10% chance that the

surface of that lesion is actually

cavitating so you know I'm thinking back

to dental school that e to presentation

was like the board lesion right when we

had to take your dental boards we were

always looking for lesions that look

like that that's like perfect right well

according to this article there's only a

10% chance that there's actually a

cavitation present which means that

there's a 90% chance that there's not

right so that means that you could

typically take the approach of

remineralizing these if you wanted to or

just watching them to see if they get

worse before you actually initiate a

irreversible procedure now let's look at

d1 so d1 means that the caries is it's

basically extended through the enamel to

the dej and now it's in that outer half

of the dentin so according to this

article

when you see that appearance

radiographically there's about a 40%

chance that the surface is cavitating so

that's even still pretty cool if you

think about it because you know most of

the time I would say especially when I

got out of dental school if I saw a

lesion that looked like that on a

radiograph it was getting a feeling 100%

of the time but if you look at

evidence-based dentistry you look at

this article there's only about a 40%

chance that the tooth even needs a

filling so pretty interesting definitely

something you want to put in your memory

bank the other thing is look at d23 okay

so that's where the carious lesion it

extends all the way through the enamel

it extends basically over halfway

through the dentin so it's really close

to that pulp tissue if you see that

appearance radiographically you have a

hundred percent chance of that tooth

being capitated according to this

article so definitely a hundred cent of

time these have to have restorations

they have to have interventions with a

burr with a filling all right so if you

think about that that typical appearance

for the radiograph you know you're

looking at the lesion it goes through

the enamel it just slightly past the dej

you can watch these lesions okay because

it's only a 40% chance it's actually

capitated

now the caveat is this if you have a

patient that is extremely high caries

risk you know as history would tell you

they've had multiple fillings currently

they have at least two or three other

fillings that need to be done and now

they have this lesion that looks like

this on one of the teeth I will tell you

that if it's a high risk patient that

basically fits that criteria I described

I will be more likely to do a filling on

that patient even though there's a 40%

chance it can be capitated because as

history has already proved this patient

has had a history of you know caries in

the past and they're at higher risk for

getting in in the future so I'm a little

bit more

aggressive in those of patients now if

you compare that to a patient who

they've never had you know a cavity and

their wife or maybe they'd only had like

one or two and they're 30 years old and

they have a lesion that looks like this

well I'm more likely to watch that

lesion in that specific person because

they're in a lower risk right their

caries risk is a lot lower compared to

the other person so that's how I

typically will use this information to

benefit me or to actually use this in

the clinic