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1、Chapter 3 Clinical Manifestations and Diagnosis of Dental Caries,Histophathology of Caries,Enamel Caries,The early enamel lesion consists of four zones of alternating levels of mineralisation.,It illustrates the dynamic nature of the caries process. The surface zone blocks the passage of calcium ion
2、s into the body of the lesion and may have to be removed to allow the lesion to become arrested (After Kidd & Joyston-Bechal, 1987).,Dentinal Caries,Dentine caries comprises two main layers.,In the outer layer, the dentine is heavily infected with bacteria. Both organic matrix and mineral have been
3、lost and the dentine is beyond repair. In the deeper layer, the dentine has been affected by plaque acids and demineralised. The number of colony forming units (CFU) of bacteria decreases (about 100 times) as cavity preparation proceeds into affected dentine. The damage in this layer is reversible i
4、f bacterial metabolism can be halted. A barrier of translucent (well mineralised) dentine may be formed ahead of the advancing lesion. Reactionary (secondary ) dentine forms to protect the pulp from acid irritation (After Kidd & Joyston-Bechal, 1987,Root caries lesions,Early : Appears as radiolucent
5、 zone in the root cementum,Steps in the formation of an arrested lesion in dentine,a) high concentration of dissolved mineral salts. b)If bcterial acidproduction is reduced, and the pH increases, the salts precipitate into large crystals of tricalcium phosphate which temporally block the tubule. c)
6、If further bacterial activity is suppressed, the odontoblast secretes collagen and calcium salts. Crystals of hydroxyapatite then form and block the tubule more effectively (After Daculsi et al, 1987),The Process of Demineralization and Remineralization,Caries is a dynamic process. Teeth are subject
7、ed to an ongoing cycle of demineralization and remineralization determined by the balance of factors.,Demineralization,Demineralization is the process of removing minerals, in the form of mineral ions, from dental enamel. A substantial number of mineral ions can be removed from hydroxyapatite lattic
8、ework without destroying its structural integrity,Remineralization,Remineralization is the process of restoring minerals - again, in the form of mineral ions - to the hydroxyapatites latticework structure.,促进再矿化阻止龋病发展,龋损的形成是脱矿与再矿化的连续性动力过程。,1、 除去致龋底物：木糖醇取代蔗糖， 减少碳水化合物摄入频率 Diet counseling : To identify
9、 the sources of sucrose and acidic foodstuffs in the diet To reduce the frequency of ingestion of both To use xylitol as sugar substitute.,2、 仔细刷牙，牙面不形成厚的牙菌斑 Oral hygiene : Plaque free tooth surface do not decay. Dental flossing Tooth brushing Rinsing,3、 在牙齿发育的再矿化期间，结合氟 离子，可形成更具抗龋能力的釉质 Use of fluori
10、de,Clinical classification of caries,Classification according to progression rate,Acute caries: progress fast, often in children and teenagers, light colored cavity.,Rampant caries, many tooth involved at same time acute caries feature often accompanied by systematic disorder. Such as sjogren syndro
11、me or saliva reduction after radiation.,Caries in a patient with impaired salivary function as result of radiation therapy(courtesy of Drs Jansma and Vissink, RUG, the Netherlands).,Chronic caries,progress slowly, black or brown colored cavity hard remaining dentine,Arrested caries,caries stop progr
12、essing because of,the local etiological change,Secondary caries (recurrent caries),caries recurred after treatment. Often at the margin the filling materials restoration or beneath The shadow located on the mesiolingual cusp adjacent to the larger occlusal amalgam restoration on the maxillary right
13、first molar indicates the presence of carious dentin,Classification according to the involving site,Occlusal caries Root caries Smooth surface caries,Classification according to the deepness,Superfacial caries(浅龋) white spot lesions, visibly frosted surface brown spot Dentin caries (中龋) cavitated le
14、sion involving the up part of dentin Deep caries (深龋) cavitated lesion involving the pupal third of dentin,Diagnosis,Visual change Probing: rough surface or trapping point pain upon probing Temperature test X-ray examination Transillumination,Visual change,Matte, white, active cervical lesions,Probi
15、ng: rough surface or trapping point pain upon probing,The explorer tip can easily damage white spot lesions,Temperature test,X-ray examination,Transillumination （FOTL,光纤透照法）：,Proximal caries lesion is detected in an anterior tooth with the use of transillumination,LAF（激光荧光法),Quantitative Light-induc
16、ed Fluorescence,QLF technical specifications,The QLF method is based on the auto-fluorescence荧光 of teeth. When teeth are illuminated with high intensity blue light they will start to emit light in the green part of the spectrum. The fluorescence of the dental material has a direct relation with the
17、mineral content of the enamel.,Quantitative Light-induced Fluorescence,DIAGNOdent pen (龋齿探测笔 ) DIAGNOdenthttp:/ pen,DIAGNOdent,Standard of diagnosis,Superfacial caries(浅龋),White spot or brown, dark lesion, rough upon probing No complaint, no hypersensitivity,Dentin caries (中龋),Cavity, hypersensitiv
18、ity upon probing, hot or cold stimulus.,Deep caries (深龋),Deep cavity, very sensitive and some pain upon stimulus, however the pain disappear as soon as the stimulus is taken away.,Treatment Strategy,Treatment Strategy,Preventive(casual,noninvasive) treatment Restorative (operative,invasive) treatmen
19、t,Preventive treatment,chemical therapy: use of fluoride with a regular daily administration or professional applied. pit and fissure sealing,一、 chemical therapy （化学疗法 ）,1药物治疗 适应证（1）恒牙早期釉质龋未形成龋洞者， 自洁作用较好的区域； （2）一年内将被替换的乳牙大面积浅龋； （3）静止龋。 药物 氟化物 硝酸银,药物治疗,氟化物 (fluorence) 75氟化钠甘油糊剂 8氟化亚锡溶液 酸性磷酸氟化钠（APF）溶液
20、 含氟凝胶（1.5APF凝胶） 含氟涂料 原理：氟与HA作用，形成氟磷灰石； 沉积氟化物，促进再矿化。 氟化物对软组织无腐蚀性，不使牙变色， 安全有效，前后牙均可使用。,药物治疗,硝酸银 10硝酸银 氨硝酸银 原理: 蛋白银沉淀 还原银或碘化银渗入牙釉质牙 本质，杀灭细菌，封闭病变区 对软组织有强的腐蚀性，不可用于牙颈部龋，并使牙变黑，只用于乳牙和后牙。,应用方法：,用石尖磨除牙表面浅龋，暴露病变部位 清洁牙面 隔湿吹干 涂布药物,2Remineralization (再矿化疗法 ) 再矿化液：主要为含有不同比例的钙、磷和氟。 适应症 平滑面早期釉质龋 龋易感者预防 应用方法： 漱口液每日含漱
21、 局部应用,pit and fissure sealing （窝沟封闭),适应证：窝沟可疑龋；与充填窝洞相邻的牙合面无龋深沟裂， 应用方法：清洁牙面、隔湿、酸蚀、涂布及固化封闭剂。,Definition of Operative Dentistry,Operative dentistry is the art and science of the diagnosis, treatment, and prognosis of defects of teeth which do not require full coverage restorations for correction.,Such
22、treatment should result in the restoration of proper tooth form, function, and esthetics while maintaining the physiological integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues; all of which enhance the general health and welfare of the patient.,Indication of Op
23、erative Dentistry,Caries Malformed, discolored, or fractured teeth Restoration replacement,Program of Operative Treatment,Patient assessment Examination and diagnosis Treatment planning,Cavity Preparation,The mechanical alteration of a defective , injured, or diseased tooth in order to best receive
24、a restorative material which will re-establish a healthy state for the tooth including esthetic corrections where indicated, along with normal form and function.,Classification of cavity,Class Class Class Class Class Class ,G.V.Black in 1908,Class I,All pit and fissure cavities are Class I. Cavities
25、 on occlusal surface; Cavities on occlusal two-thirds of the facial and lingual surfaces of molars; Cavities on lingual surface of maxillary incisor.,Class II,A cavity occurring on the proximal surface of posterior teeth are Class II. MO mesial and occlusal DO distal and occlusal MOD mesial, occlusa
26、l and dista,Class III,Cavities on the proximal surfaces of anterior teeth that do not involve the incisal angles are Class III.,Class IV,Cavities on the proximal surfaces of anterior teeth that do involve the incisal angles are Class IV.,Class V,Cavities on the gingival third of the facial or lingua
27、l surfaces of all teeth ( not pit and fissure cavities ) are Class V.,Class VI,Cavities on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth are Class VI.,洞型分类,一类洞：根据发生于所有牙齿的发育窝，沟内的 龋损所制备的洞型。 二类洞：后牙邻面的龋损所制备的洞型。 三类洞：前牙邻面未损及切角的龋损所制备的洞 型。 四类洞：前牙邻面损及切角的龋损所制备的洞型。 五类洞：所有牙齿
28、颊（唇），舌（腭）面龈1/3 牙面的龋损制备的洞型。 六类洞：所有牙齿牙尖，牙脊或冠轴交界的轴角 区的龋损所制备的洞型。,Cavity Structure,walls angles cavity,Walls,Internal walls: a prepared cavity surface that does not extend to the external tooth surface.,Axial walls: an internal wall parallel with the long axis of the tooth and occlusal of the tooth.,Pulp
29、al walls: an internal wall that is both perpendicular to the long axis of the tooth and occlusal of the pulp.,Walls,External walls: a prepared cavity surface that extend to the external tooth surface.,.,The external walls takes the name of the tooth surface that the wall is toward.,Angles,Line angle
30、: the junction of the two planal surfaces of different orientation along a line.,Angles,Point angle: the junction of three planal surfaces of different orientation.,Angles,Cavosurface angle: the angle of tooth structure formed by the junction of a prepared cavity wall and the external surface of the
31、 tooth.,Also referred to as the cavity margin or cavosurface margin.,3洞型结构 洞壁：窝洞的壁，分侧壁和髓壁(pulpal walls) 侧壁 与牙面垂直的壁(颊壁,龈壁) 髓壁 与洞侧壁垂直，位于洞底覆盖牙髓的洞壁。 轴壁 与牙长轴平行的髓壁 洞角 点角 三壁相交构成 颊轴龈点角 线角 两壁相交构成 颊髓线角 洞缘角 洞侧壁与牙面相交形成的线角 洞缘 窝洞侧壁与牙面相交构成洞的边缘,Cavity,Simple cavity: only one tooth surface is involved.,Compound cavity: two surfaces are involved.,Complex cavity: three or more surfaces are involved.,