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The objective of this article is to present evidence-based protocols for the diagnosis and
treatment of deep caries lesions in vital teeth. These protocols combine caries-detecting dye
andDIAGNOdentlaserfluorescencetechnologieswithanatomicalandhistologicknowledge
to arrive at ideal caries removal end points for adhesive restorations. These ideal caries
removal end points generate a peripheral seal zone that can support long-term biomimetic
restorations.Areviewofpublishedliteraturesince1980oncaries,cariesdiagnosis,and
cariestreatmentsandtheirrelationshipstoadhesivebondingtechniqueswascarriedout.
Combininganatomical,pathologic,andhistologicknowledgewithcaries-detectingdyeand
DIAGNOdentlaserfluorescencetechnologiescanproduceidealcariesremovalendpoints
foradhesivedentistrywithoutexposingvitalpulp.(Quintessence Int 2012;43:xxxxxx)
tomical structures.1114However,forlesions
endpointswouldpreservepulpvitalitywith-
oftoomuchvsnotenoughwhenitcomesto
approachisbasedondetailedknowledgeof
Thisknowledgeisthenintegratedwithvisual
dye staining and laser fluorescence technologies to guide the clinician in deep caries
diagnosis and removal. This combination
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
theocclusalsurface.Clinicianscanprevent
bondedrestorationwithexcellentlong-term
normalsuperficialdentin,DEJ,andenamel
MPawillbegenerated.17,18
areas will stain red from caries-detecting dye and have DIAGNOdent readings
asCariesDetector(Kuraray),CariesFinder
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
HISTOLOGY OF CARIES
LESIONS
MedicalandDentalUniversityontheanaly-
wereabletodistinguishtwolayersincaries
byfindingtwopropylene-glycolbasedcol-
layerwasnotsensitivetocontactandcould
formula).Theinterphasebetweentheouter
andinnercariousdentinwasreferredtoas
ofparallelgroupsoftubules,someofwhich
areoutercariousdentinandsomeofwhich
(PO4)6 (OH)2].Instead,theenlargedlumens
[Ca3 (PO4)2]calledWhitlockite.29Whitlockite
wardflowofpulpalfluid,whichisreferredto
astransudation.Italsoreducesthemove-
subtransparentzone(Fig4).
(Fig 5).
nized.31Theproblemwasthateachopera-
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
Fig 4 The deep caries lesion has two parts: outer and inner carious dentin. The inner carious dentin has three parts: the turbid
layer, the transparent zone, and normal dentin.
of bacteria present.41,42
DIAGNOdent proved its efficiency for
sure caries.43,44
DIAGNOdentshowedthatitcouldbeusedto
relatedwithtraditionalexcavationtechniques.
DIAGNOdentreadingsforthesuperficialden-
tinendpointwere8.262.69=(<12).The
were18.7517.10=(<36).Thesefindings
areneartheDEJ.14,46Dependingontheper-
meabilityoftheinnercaries(whichisrelated
technologythatwouldassesstheamountof
wasintroducedasawaytodiagnoseinitial
torsinGermanyandSwitzerlandfoundthat
rinswouldfluorescewhenirradiatedwitha
outercariousdentinwillincreasethevolume
Q U I N T E S S E N C E I N T E R N AT I O N A L
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diffusiontoincrease,whichwillcausehigher
dentinanddeepinnercariousdentin.Boston
peripheralsealzone.However,Americanand
Japaneseresearchersdidnottestthedeeper
the Japanese research using caries-detecting dye. Boston and Liao also investigated
eneglycolbasedcaries-checkdye(Nishika)
thishighermolecularweightcaries-detecting
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
Thisprotocolwilleliminatemostpulpexpo-
endodontic treatment.51,52Conservingmore
ible pulpitis.53Byeliminatingorreducingthe
functionalloadswillalsoimprove.54
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
dentinalbondingsystemsbondequallywell
todeepdentin,butsimplifiedtwo-steptotal-
Duringplacementoftherestorativemate-
shallowrestorationsbutisnotidealinlarger
load-bearing situations.15,61
samedecreaseinbondstrengthwilloccurif
negative effect.
also
endogenous
0.5mm)shouldbeavoidedwhilethebondto
64
activates
collagenase
a25%to30%reductioninbondstrengthwill
2.0%chlorhexidinesolutionwilldeactivatethe
attacks.SEProtect(Kuraray)withtheunique
proprietary methacryloyloxydodecylpyridini-
Inshallowpreparationsinsuperficialdentin,
c-factorpreparationshavealsobeenshown
dine(Consepsis,Ultradent)or benzalkonium
Bisco).68,69,84
topredictpotentialbondstrength.Cervical
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
Fig 10 Ideal caries removal end points and peripheral seal zone developed in an intermediate depth lesion using combined technologies.
STEP-BYSTEP
TECHNIQUE
1. C
reateaperipheralsealzoneofenamel,
DEJ,andnormalsuperficialdentinnear
sol
refrigerant
Endo-Ice
(Coltne-
proceedwithcariesdiagnosisandtreat-
3. R
emove highly infected outer carious
dentin inside of the peripheral seal zone
withoutexposingthepulp.Smallareasof
failed
restorations.
Stain
the
caries
Wait10secondsandrinse(seeFig12).
4. StartingneartheDEJ,usea1-mmround
1-to2-mmwidedependingonwhether
it is on the buccal and/or the occlusal
areas of a molar (1.5 to 2 mm) or on the
mesial and/or distal root dentin (1 mm).
Premolars are smaller, and the superficial dentin is narrower in all areas (see
Figs 10 and 11).
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
sealzoneisconfirmedbyDIAGNOdent
(Readingswillbearound48atlessthan
occlusalsurface(>3mmfromtheDEJ),
step:
Treat
the
peripheral
0.1% to
Carefullyremovered-stainedoutercari-
primer.85
Q U I N T E S S E N C E I N T E R N AT I O N A L
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temcanbeallowedtomatureforacertain
maximizethemTBS.86
total-etchoramildtwo-stepself-etching
CONCLUSION
dentinwillallowbiomimeticbondstrengths
bondableperipheralsealthatwillmimicthe
adhesive techniques.
10
Q U I N T E S S E N C E I N T E R N AT I O N A L
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Adhesive
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Bronkhorst
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Loomans
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Quintessence Int
2001;32:561570.
31. Massler M. Changing concepts in the treatment of
carious lesions. Br Dent J 1967;123:547548.
32. Fusayama T. Clinical guide for removing caries
using a caries-detecting solution. Quintessence Int
1988;19:397401.
11
Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
dentin stained with a caries detector dye and bacterial infection. Oper Dent 2005;30:8389.
DW,
Graver
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Alleman/Magne
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