This document discusses conservative strategies for managing dental caries, including mechanical, chemico-mechanical, and physical approaches. Mechanical approaches include ART, indirect pulp capping, stepwise excavation, and selective removal to soft dentine. Chemico-mechanical caries removal uses chemical agents to soften infected dentin before excavation. Physical approaches include photodynamic antimicrobial chemotherapy, which uses photosensitizing agents activated by light to kill bacteria. The document compares the pros and cons of these different conservative caries management techniques.

1. CONSERVATIVE
CARIES
MANAGMENT
D R : A H M E D I S M A I L
T E A C H E R A S S I S T A N T A T D E N T A L B I O M A T E R I A L S D E P A R T M E N T ,
A I N S H A M S U N I V E R S I T Y , C A I R O , E G Y P T
D R . A M E D I S M A I L E @ G M A I L . C O M

2. • Prevention is much better than
treatment but once the cavitation
occurs our only resort will be to
conservatively treat the existing carious
lesion

3. Minimally invasive (MI)
treatment of dental caries is an
approach that considers handling of
carious lesions with conservative
techniques to preserve as much tooth
structure as possible

4. Conservative strategies for
managing cavitations in
Enamel orand Dentin
A) Mechanical
B) Chemico-mechanical
C) Physical

5. MECHANICAL:
stepwise removal, or selective
removal to soft dentine
1) ART
2) Indirect pulp caping
3) stepwise removal
4) selective removal to soft dentine

7. ART
partial removal of the involved tissues
with hand instruments and their
subsequent
restoration with high viscosity GI
Several studies with ART suggest that this
therapy has a comparable success rate than
traditional complete removal technique and
the subsequent restoration with composite
resin or
amalgam

8. ART
A meta-analysis on the survival of ART
restorations
found survival rates on one surface and
multiple
surfaces in primary teeth for more than 2 years
of 93% and 62%, respectively
In permanent teeth, ART restorations on one
surface exhibited survival at 3 and 5 years of
85%

9. ART
Similarly, another systematic review
showed a survival of ART
restorations on one surface of 95%
and 86% at 1 and 3 years,
respectively and of 72% at 6 years
after placement.

10. ART
The available evidence suggests that ART is a
scientifically-supported MI treatment. Since this
technique allows treatment in non-clinical
settings
at low cost, it may enhance access to care for
the community, especially in developing
countries

11. ART
Importantly, ART restorations on multiple
surfaces appear to be less successful and
would require more complex restorations
to ensure greater longevity.

12. IPC
 Involves leaving a thin layer of demineralized
tissue over the pulp which is covered by a
protective liner
 Final restoration is made in the same session
 The material used for pulp protection does
not appear to influence treatment success,
according to a Cochrane review.

13. IPC
Lesion arrest was reported in
primary teeth with a success rate of
78% at 4 years, with no difference
between an adhesive system and
calcium hydroxide used as liners

14. IPC
The main disadvantage of IPC is that
it involves procedures that are quite
close to the pulp, thereby increasing
the chances of pulp exposure

15. SW Excavation
 involves lesion removal in 2 stages.
 Stepwise removal technique consists
of a first step involving partial carious
tissue removal, leaving soft carious
tissue on the pulpal cavity floor of a
deep carious lesion, in a vital tooth.
Teeth are temporarily restored for a
period of up to 12 months

17. A re-entry is then necessary to remove the
carious tissue to firm dentine, followed by a
permanent final restoration. During the
temporary sealing, the soft carious dentine,
which was intentionally left remaining,
becomes harder and drier, both characteristics
of inactive lesions, exhibiting a low level of
bacterial infection.
SW Excavation

18. SW Excavation
The objective of this procedure is to
facilitate the physiological reaction of the
pulp-dentine complex, including dentinal
sclerosis and tertiary dentine formation.
Thus a 2-step process ensures pulp
protection by minimizing the risk of
exposure.

19. Several studies have indicated that SW
is a highly successful procedure. A
recent meta-analysis has revealed a 56%
reduction in the incidence of pulp
exposure in SW excavation compared to
complete caries removal or non-
selective to hard dentine, as it is the
most recently agreed term
SW Excavation (Pros)

20. 1- The risk of pulp exposure during re-entry
2- The failure of the temporary restoration
3- Increased costs resulting from the 2 sessions that are required to complete
treatment
4- some patients do not return for the final restoration due to the absence of
symptoms
SW Excavation (Cons)

21. Partial caries removal (Selective
removal to soft dentine)
In this strategy the final restoration
should be performed during the same
session, completing the procedure in a
single appointment. In fact, it has been
suggested that re-entering the cavity
after partial or selective removal in the
SW technique is unnecessary

22. Partial caries removal (Selective
removal to soft dentine)
In the selective removal of soft dentine
technique, selective removal to firm dentine
from the lateral walls of the lesion is
necessary, removing gently and without
pressure only the most outer layer of
softened dentine from the pulp wall with
manual or rotary instrumentation, and
placing the final restoration in the same
session.

23. A study that followed a cohort of patients
treated with selective removal to soft dentine
showed that 12 of 13 teeth with lesions
remained unchanged for 10 years.
The results showed a success rate of 91%
with selective removal to soft dentine
compared with 69% for the SW technique
Partial caries removal (Selective
removal to soft dentine)

24. Considering that selective removal to soft
dentine is even more MI and
conservative than IPC or SW, the risk of
pulp exposure was expected to be even
lower
Partial caries removal (Selective
removal to soft dentine)

25. B) Chemico-mech
chemomechanical caries removal is
generally considered as an effective
alternative to the traditional rotary
drilling method.

26. Chemico-mech
technique which removes infected dentin
through a chemical agent followed by
caries excavation with hand excavators
without pressure . It preserves healthy
structures, avoids pulp irritation, and
patient discomfort

27. Classification of products
1- GK-101 (1972)
2- Caridex (1984)
3- Caisolve (1998)
4- Pa-pacarie , Caricare (2003)

28. Chemico-mech
GK-101 in 1972 . It consisted of a non-specific
proteolytic agent, sodium hypo-chlorite in Sorensen’s
buffer
Caridex, uses three amino acids – lysine, leucine and
glutamic acid– to enhance the effect of sodium
hypochlorite on denatured collagen, and to decrease
the involvement of healthy hard dental tissue
Papacarie™, developed in 2003, has bactericidal,
bacteriostatic and anti-inflammatory characteristics
due to the presence of papain, chloramines and
toluidine blue salts in a thickening medium

29. Pros of chemico-mech
caries removal
Decreasing the level of patient’s fear and
anxiety caused by the use of rotary noise
and anesthesia

30. Cons of chemico-mech
caries removal
1- Taste of the liquid
2- Short shelf life
3- Requirement of special equipment
4- Heat evolution
5- Prolonged chair time

31. C) Physical (Photodynamic
antimicrobial
chemotherapy)
This therapy involves photosensitizing
agents, such as toluidine blue ortho (TBO),
which are activated by irradiation with light
of a specific wavelength to generate
cytotoxic species, including singlet oxygen
and free radicals capable of damaging
essential components of the cells or
modifying metabolic activities in an
irreversible way, resulting in a faster
bacterial killing effect

32. Pros
1) Rapid noninvasive topical
application of the photosensitizer in
the carious lesion
2) The bacterial killing after a short
exposure to light
3) No chance for resistance
development

33. Cons
1) Gap between what can be achieved
through a clinical intervention and
what is accomplished in pre-clinical
studies
2) Lack of outcomes for this therapy
under real situation factors (mixed
bacterial community enclosed within the
demineralized dentin structure)

34. Factors affecting success
of this TTT modlity
1) Structural proprieties of the
bacteria
2) The source of light used
3) The type of photosensitizers and
its concentration, solubility, and
polarity