1、chapter 3 clinical manifestations and diagnosis of dental carieshistophathology of caries enamel cariesthe 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 ions

2、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 cariesdentine caries comprises two main layers.in the outer layer, the dentine is heavily infected with bacteria. both organic matrix and mineral have been lost

3、 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 if ba

4、cterial 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, 1987root caries lesions early : appears as radiolucent zone

5、 in the root cementum steps in the formation of an arrested lesion in dentinea) 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) if fur

6、ther 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 subjected to

7、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 latticework

8、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. 促進再礦化阻止齲病發展 齲損的形成是脫礦與再礦化的連續性動力過程。 1、 除去致齲底物：木糖醇取代蔗糖， 減少碳水化合物攝入頻率 diet counseling : to identify the s

9、ources of sucrose and acidic foodstuffs in the diet to reduce the frequency of ingestion of both to use xylitol as sugar substitute. 2、 仔細刷牙，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、 在牙齒發育的再礦化期間，結合氟 離子，可形成更具抗齲能力的釉質use of fluorideclini

10、cal 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 syndrome or sal

11、iva 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 progressing be

12、cause of the local etiological changesecondary 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 first mola

13、r 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(淺齲) white spot lesions, visibly frosted surface brown spot dentin caries (中齲) cavitated lesion invol

14、ving the up part of dentin deep caries (深齲) cavitated lesion involving the pupal third of dentindiagnosis visual change probing: rough surface or trapping point pain upon probing temperature test x-ray examination transilluminationvisual change matte, white, active cervical lesions probing: rough su

15、rface or trapping point pain upon probing the explorer tip can easily damage white spot lesions temperature test x-ray examination transillumination（fotl,fotl,光纖透照法）光纖透照法）： proximal caries lesion is detected in an anterior tooth with the use of transillumination laf（激光熒光法（激光熒光法)the hardware of the i

16、ntra-oral system includes a measurement probe, a control unit, and a computer fitted with a framegrabber. the control unit consists of an illumination device and imaging electronics. the light source is a special arc-lamp based on xenon氙氙 technology. the light from this lamp is filtered by a blue-tr

17、ansmitting filter. a liquid light guide transports the blue light to the teeth in the mouth. quantitative light-induced fluorescenceqlf technical specificationsqlf theorythe qlf method is based on the auto-fluorescence熒光熒光 of teeth. when teeth are illuminated with high intensity blue light they will

18、 start to emit light in the green part of the spectrum. the fluorescence of the dental material has a direct relation with the mineral content of the enamel. quantitative light-induced fluorescence diagnodent pen (齲齒探測筆 ) diagnodenthttp:/ pendiagnodentstandard of diagnosissuperfacial caries(淺齲) whit

19、e spot or brown, dark lesion, rough upon probing no complaint, no hypersensitivitydentin caries (中齲) cavity, hypersensitivity upon probing, hot or cold stimulus. deep caries (深齲) deep cavity, very sensitive and some pain upon stimulus, however the pain disappear as soon as the stimulus is taken away

20、. treatment strategytreatment strategy preventive(casual,noninvasive) treatment restorative (operative,invasive) treatment preventive treatment chemical therapy: use of fluoride with a regular daily administration or professional applied. pit and fissure sealing 一、一、 chemical therapy（化學療法化學療法 ） 1藥物治

21、療藥物治療 適應證適應證（1）恒牙早期釉質齲未形成齲洞者， 自潔作用較好的區域； （2）一年內將被替換的乳牙大面積淺齲； （3）靜止齲。 藥物藥物 氟化物 硝酸銀藥物治療 氟化物氟化物 (fluorence) 75氟化鈉甘油糊劑 8氟化亞錫溶液 酸性磷酸氟化鈉（apf）溶液 含氟凝膠（1.5apf凝膠） 含氟涂料 原理：氟與ha作用，形成氟磷灰石； 沉積氟化物，促進再礦化。 氟化物對軟組織無腐蝕性，不使牙變色， 安全有效，前后牙均可使用。藥物治療 硝酸銀硝酸銀 10硝酸銀 氨硝酸銀 原理: 蛋白銀沉淀 還原銀或碘化銀滲入牙釉質牙 本質，殺滅細菌，封閉病變區 對軟組織有強的腐蝕性，不可用于牙頸部

22、齲，并使牙變黑，只用于乳牙和后牙。應用方法應用方法： 用石尖磨除牙表面淺齲，暴露病變部位 清潔牙面 隔濕吹干 涂布藥物 2remineralization (再礦化療法 ) 再礦化液：主要為含有不同比例的鈣、磷和氟。 適應癥 平滑面早期釉質齲 齲易感者預防 應用方法應用方法： 漱口液每日含漱 局部應用 pit and fissure sealing（窩溝封閉) 適應證適應證：窩溝可疑齲；與充填窩洞相鄰的牙合面無齲深溝裂，應用方法應用方法：清潔牙面、隔濕、酸蝕、涂布及固化封閉劑。 operative dentistry is the art and science of the diagnosi

23、s, treatment, and prognosis of defects of teeth which do not require full coverage restorations for correction. such treatment should result in the restoration of proper tooth form, function, and esthetics while maintaining the physiological integrity of the teeth in harmonious relationship withthe

24、adjacent hard and soft tissues; all of which enhance the general health and welfare of the patient. caries malformed, discolored, or fractured teeth restoration replacement patient assessment examination and diagnosis treatment planning the mechanical alteration of a defective , injured, or diseased

25、 tooth in order to best receive a restorative material which will re-establish a healthy state for the tooth including esthetic corrections where indicated, along with normal form and function. class class class class class class g.v.black in 1908 all pit and fissure cavities are class i. cavities o

26、n occlusal surface; cavities on occlusal two-thirds of the facial and lingual surfaces of molars; cavities on lingual surface of maxillary incisor. a cavity occurring on the proximal surface of posterior teeth are class ii. mo mesial and occlusal do distal and occlusal mod mesial, occlusal and dista

27、 cavities on the proximal surfaces of anterior teeth that do not involve the incisal angles are class iii. cavities on the proximal surfaces of anterior teeth that do involve the incisal angles are class iv. cavities on the gingival third of the facial or lingual surfaces of all teeth ( not pit and

28、fissure cavities ) are class v. cavities on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth are class vi.洞型分類 一類洞：根據發生于所有牙齒的發育窩，溝內的一類洞：根據發生于所有牙齒的發育窩，溝內的 齲損所制備的洞型。齲損所制備的洞型。 二類洞：后牙鄰面的齲損所制備的洞型。二類洞：后牙鄰面的齲損所制備的洞型。 三類洞：前牙鄰面未損及切角的齲損所制備的洞三類洞：前牙鄰面未損及切角的齲損所制備的洞 型。型。 四類洞：前牙鄰面

29、損及切角的齲損所制備的洞型。四類洞：前牙鄰面損及切角的齲損所制備的洞型。 五類洞：所有牙齒頰（唇），舌（腭）面齦五類洞：所有牙齒頰（唇），舌（腭）面齦1/3 牙面的齲損制備的洞型。牙面的齲損制備的洞型。 六類洞：所有牙齒牙尖，牙脊或冠軸交界的軸角六類洞：所有牙齒牙尖，牙脊或冠軸交界的軸角 區的齲損所制備的洞型。區的齲損所制備的洞型。 walls angles cavity 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 too