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Localization: Complaints:
Pits NO complaints (more
Fissures often)
Cervical area Bad esthetic (spots in
SMOOTH cervical area of frontal teeth
Approximal surfaces SURFACES and spots after braces)
(between teeth) Slight sensitivity to sour or
cold or sugar food (not very
often)
Caries
A Little Bit about Terminology
1. Caries of enamel:
- white spot (non-cavitated) = initial caries, incipient caries.
- cavitated caries of enamel = superficial caries.
Typical localization
(vestibular surfaces of all or
almost all teeth are affected)
Caries of Enamel
Differential Diagnostics
Caries of Enamel. Differential Diagnostics
Aim of treatment:
1. Makes weak demineralized enamel hard again, stop
progression of demineralization and prevent microbial
migration into dentin (aim is actual for vestibular/buccal and
approximal surfaces).
2. Return normal light reflection and refraction for better
esthetic (aim is actual for vestibular/buccal surfaces only).
Caries of Enamel on Smooth Surfaces.
Treatment
For better understanding of treatment methods
its necessary to remember enamel structure,
histopathology of carious spot and also some
biochemical processes in enamel apatite and
saliva.
Enamel Structure
Enamel Structure:
3 Solid enamel
structure
Caries of Enamel on Smooth Surfaces.
Histopathology
Area of
increased
microporosity
Healthy solid
White carious spot
enamel (increased subsurface
microporosity)
Enamel rod,
longitudinal section,
side view
Hydroxyapatite
crystal
Chemical Composition of Enamel
Longitudinal section
SEM
Hydroxyapatite of Enamel
Calcium hydroxyapatite Ca10(PO4)6(OH)2 has hexagonal lattice, in the middle of
hexagonal axis OH- group is located. In acidic conditions mineral ions come out
from crystal lattice, empty spaces after ions coming out are called vacant places.
Each crystal surrounded by firmly bound water so called hydration shell . Mineral
ions from external source could come into hydration scell and go deeper in
crystal to substitute another ions or to deposit in vacant places.
crystals
Ca
OH -
vacant place
pH = 5.5
Hydroxyapatite of Enamel
If pH is neutral HAP is stable, isomorphic substitution can occurs in the outer
layer of enamel. Ions dont come out and HAP will not be destructed.
If pH < 5.5 destruction of HAP starts, first PO43- come out from HAP, then
- , and after that - Ca2+. Destruction of HAP is not a fast process, after
some ions came out from HAP, vacant places occurs there. These places
could be filled by mineral ions from saliva (physiological process) and from
varnishes, gels etc. (remineralization therapy).
2+ Sr2+, Mg2+
PO43- 42-, 32-
- Cl-, F-
Hydroxyapatite of Enamel
Ions substitution this process is Ions deposition this
a base for all preventive measure process is a base for caries
when we want to enhance healthy spot treatment procedures.
enamel. Most widespread caries Micropores of caries spot
prevention is rinsing and
should be filled by mineral
application of fluorides. Fluorides
ions incorporated in vacant
replace OH- in outer layer of
enamel and form there places of partly dissolved
fluorapatites (FAP) and crystals. And also new
fluorhydroxyapatite (FHAP). It is crystals should be restored
known that fluorapatite and FHAP if some crystals were fully
is more acid-resistant (and caries- dissolve.
resistant) than pure HAP. Thus
caries resistance of teeth
increases.
Caries of Enamel on Smooth Surfaces.
Treatment
Natural Two approaches Artificial
Micropores are filled by micropores are filled
deposition of mineral ions NOT by natural mineral
from external source (gel, ions but by artificial
varnish) - process is substance polymeric
similar to natural income resin.
of minerals into enamel
from saliva.
Remineralization therapy: Infiltration therapy:
So, if imagine that a person ate some sweets, pH decreased a lot and dissolution of HAP
started. Time was running, saliva was secreting, pH started to normalize. During this
normalization formation of FAP and FHAP starts earlier than pure HAP formation.
HAP
FAP
pH
4.0 4.5 5.0 5.5
Acid Neutral
Remineralization Therapy by Fluoride
Fluorapatite formation
It is also known that OH- could be replace by F- totally (in that case fluorapatite
(FAP) will be formed) or partly (in that case fluorhydroxyapatite apatite
(FHAP) will be formed). Both apatites have increased acid-resistance (caries-
resistance), demineralization of these crystals starts about pH = 4.5
(compare with pure HAP dissolution about pH=5.5). Thus FAP and FHAP have
increased caries resistance to compare with HAP.
Remineralization Therapy by Fluoride
CaF2 globules formation
CaF2
HPO4
3. Drying.
ICON is indicated for caries of enamel without spreading into dentin (E1, E2) or with
minimal spreading into dentine (D1). It is considered that if involving of dentin is
small, after infiltration of demineralized enamel small number of bacteria in dentin
will be entombed and die in absence of nutrition not longer possible to have through
micropores of enamel. The only problem here is how to know is dentin involving is
big or small as far as radiological investigation not always gives ideally correct data.
Some clinicians use additional methods of diagnostics as fluorescence,
transillumination for clarification of clinical situation.
ICON Caries Infiltration Technique
Set:
1. 15% HCL acid for pre-treatment
of lesion (Icon-ETCH)
2. Ethanol for drying of lesion
before application of resin
(Icon-DRY)
3. Light-cured resin for infiltration
of caries lesion (Icon-
INFILTRANT)
4. Brushes
5. Syringe tips for vestibular
surfaces and for approximal
surfaces 3 2 1
ICON Caries Infiltration Technique
6. Brushes.
7. Syringe tips for
vestibular
surfaces and for
proximal surfaces.
Surface zone
15 % HCL
2 minutes micropores
micropores