Dental Caries

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Dental caries (Fig. 32-8) is the most common cause of failure of a cast restoration. Detection can be very difficult,12 particularly where complete coverage is used. At each appointment, the teeth should be thoroughly dried and visually inspected (Fig. 32-9). The explorer must be used very carefully

Radiopacity

Luting Agents

Dental Radiographic Structures

Fig. 32-5. Radiopacity of luting agents. These three in vitro studies compared the radiographic appearance of various luting agents to aluminum. The data were normalized to account for different specimen thicknesses used by the investigators. Excess luting agent will be more difficult to detect if materials with lower values are chosen. In addition, margin gaps and recurrent caries will be more difficult to diagnose.

Fig. 32-5. Radiopacity of luting agents. These three in vitro studies compared the radiographic appearance of various luting agents to aluminum. The data were normalized to account for different specimen thicknesses used by the investigators. Excess luting agent will be more difficult to detect if materials with lower values are chosen. In addition, margin gaps and recurrent caries will be more difficult to diagnose.

Patients who have received extensive treatment of this nature will require more frequent follow-up care.

Patients who have received extensive treatment of this nature will require more frequent follow-up care.

Plaque control record

Plaque control record

Name James Dunn HH1 n^

Plaque control record

Previous index 21% Present index

Plaque control record

Previous index 21% Present index

Plaque Control Record

Name J »mes Dunn _3lMl Date

Fig. 32-7. A, Plaque control record filled out at the first appointment for teaching proper oral hygiene measures. B, Plaque control record after four sessions of instruction. This patient's plaque level is such that definitive treatment can begin. This level of plaque control needs to be maintained during the follow-up phase of treatment.

(From Goldman HM, Cohen DW. Periodontal therapy, ed 5 St. Louis, 1973, Mosby.)

Name J »mes Dunn _3lMl Date

Fig. 32-7. A, Plaque control record filled out at the first appointment for teaching proper oral hygiene measures. B, Plaque control record after four sessions of instruction. This patient's plaque level is such that definitive treatment can begin. This level of plaque control needs to be maintained during the follow-up phase of treatment.

(From Goldman HM, Cohen DW. Periodontal therapy, ed 5 St. Louis, 1973, Mosby.)

Oral Periodontitis Fluoride Treatments
Fig. 32-8. Undetected caries beneath this FPD resulted in serious complications.

when assessing early enamel lesions because a "heavy-handed" examination may damage the fragile demineralized enamel matrix. An intact enamel matrix is essential for procedures that induce remineralization 13 (e.g., improved plaque control, dietary changes, topical fluoride applications).

Fig. 32-9. Drying the teeth facilitates assessment of the margin integrity of a cemented prosthesis.
Fig. 32-10. Occasionally, cervical amalgam restorations (arrows) can extend the useful life of a previously placed cast restoration and will prevent unnecessary and complicated replacement of the prosthesis.

Conservative treatment of caries at the cavosur-face margin is especially problematic. The lesion can spread rapidly, particularly if the restoration has a less than optimal marginal fit. Correcting the problem with a small amalgam, composite resin, or gold foil restoration is sometimes possible (Fig. 32-10). If the cast restoration is supported by an amalgam or composite resin core, the extent of the caries may be difficult to determine. When there is doubt that all carious dentin has been removed, replacing the entire restoration is recommended.

Root Caries. Caries of exposed root surfaces (Fig. 32-11) can be a severe problem in the age group commonly seeking fixed prosthodontic care. In the classic Vipeholm study," root caries accounted for more than 50%, of new lesions in patients in the 50-year-old age group. Root caries incidence increased considerably with age.' In the caries examination from Phase 1 of the Third National Health and Nutrition Examination Survey, root caries affected

Vipeholm Study

Fig. 32-11. Extensive root caries beneath a cemented FPD.

Fig. 32-11. Extensive root caries beneath a cemented FPD.

22.5%, of the dentate population. Root surface caries seems to be associated with individual dental plaque scores and high counts of salivary mutans streptococci 2° Age-related xerostomia or that caused by medication or radiation treatment has been implicated in the etiology of rampant caries 21-23 Other factors include the patient's economic status, diet, oral hygiene, and ethnic background. Only a most vigorous effort on the part of the dentist and patient will lead to resolution of the problem. Prevention is focused on diet counseling and fluoride treatment. Treatment often requires the placement of large cervical amalgam or glass ionomer restorations that wrap around the periphery of previously placed cast restorations. Such restorations are difficult to place. However, in view of the constraints, they are a preferred alternative to comprehensive retreat-ment with elaborate fixed prostheses.

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