Caries going sub-gingivally

[Inkdot]

Hi there,

I have a question from my clinic session. My demonstrator was examining my patient's 44, and advised me that since the caries is going subgingivally, the only treatment option for this tooth was extraction.

Can someone please explain the logic behind this?

Thanks

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[lemoncurry]

I'm a little rusty on my non-1-32 tooth numbering schemes. Is this a lower right 1st premolar?

Honestly I'd have to see an x-ray to give you the best answer. If the decay is sub-g and is close to the bone and is nearing the pulp, I would probably recommend extraction. Sure, you could do RCT, possible crown lengthening, post if needed, and crown. Most patients, in my experience (mostly in public health), aren't going to go for those "heroics."

Part of the rationale is that your instructor may understand the patient population demographics better than you and is jumping to the most logical conclusion based on his experience in what these patients usually choose. It's something that you will develop over years of practicing in the same area.

 

[Inkdot]

I'm a little rusty on my non-1-32 tooth numbering schemes. Is this a lower right 1st premolar?

Honestly I'd have to see an x-ray to give you the best answer. If the decay is sub-g and is close to the bone and is nearing the pulp, I would probably recommend extraction. Sure, you could do RCT, possible crown lengthening, post if needed, and crown. Most patients, in my experience (mostly in public health), aren't going to go for those "heroics."

Part of the rationale is that your instructor may understand the patient population demographics better than you and is jumping to the most logical conclusion based on his experience in what these patients usually choose. It's something that you will develop over years of practicing in the same area.

Thanks for your answer, it makes sense. Yes, I'm referring to the lower right first premolar.

Given the caries is subgingival and there is no pseudopocketing or recession on this tooth, would the diagnosis of the 44 be given as root caries?

Not all root caries is subgingival (i.e. root caries would not be subgingival if there was recession that went below the extent of the root caries, as per my understanding). If the root caries in this instance was not subgingival, would I be able to cut into it and restore it?

 

[lemoncurry]

If the school wants you to differentiate between caries and root caries, then I would say root caries. Also, I would see if the patient has a history of dry mouth, especially due to medications. If that is the case, then restoration has a worse prognosis.

Can you drill and fill caries that are sub-g? Absolutely. I would recommend restoring such caries (depending on what class of restoration it is) with glass ionomer or amalgam. If it is a class two, I would do an open sandwich technique (GI on the bottom, full thickness at the base of the box, regular composite on top). If it is class V, I would use straight RMGI such as Riva, Ionolux, or Fuji II.

 

[Inkdot]

If the school wants you to differentiate between caries and root caries, then I would say root caries. Also, I would see if the patient has a history of dry mouth, especially due to medications. If that is the case, then restoration has a worse prognosis.

Can you drill and fill caries that are sub-g? Absolutely. I would recommend restoring such caries (depending on what class of restoration it is) with glass ionomer or amalgam. If it is a class two, I would do an open sandwich technique (GI on the bottom, full thickness at the base of the box, regular composite on top). If it is class V, I would use straight RMGI such as Riva, Ionolux, or Fuji II.

So we can drill and fill sub-g caries assuming it does not have a hopeless/ poor prognosis? Then why, in this instance, did my demonstrator say to extract? Was it because he suspects it is close to bone and pulp, and therefore exo is seen as the easier treatment option than endo + fixed pros for this tooth based on pt demographics, as you suggested earlier? Sorry, I just want to confirm.

Why would you choose to use Fuji-II and not Fuji-IX for a class V restoration?

 

[lemoncurry]

Yes, I am guessing that his recommendations are based on those things. It's all dependent on the size and location of the sub-g caries. It's not an automatic extraction.

I don't like using fuji IX because I am impatient and I can't wait for it to set up. As a student, maybe a different story, but I like to be able to light cure my fillings so they stay put. I don't use fuji II anymore because I think that Riva or Ionolux are much better RMGI materials.

 

[Inkdot]

Yes, I am guessing that his recommendations are based on those things. It's all dependent on the size and location of the sub-g caries. It's not an automatic extraction.

I don't like using fuji IX because I am impatient and I can't wait for it to set up. As a student, maybe a different story, but I like to be able to light cure my fillings so they stay put. I don't use fuji II anymore because I think that Riva or Ionolux are much better RMGI materials.

No worries. The only reason I thought one may hesitate with the use of Fuji-II for a class V lesion is due to difficulty of access of the light curing unit subgingivally, hence I thought the light would not be able to penetrate the full extent of the Fuji-II and cure it in this instance.

 

[Faux]

Can we get a radiograph?

 

[yappy]

Without seeing the lesion it is hard to say. I think the real challenging cases are when the caries extend subcrestal. However, if the caries extend only below the level of the gingiva then I think restoring with fugi II, or some other RMGI, is the best option. Cord or full thickness flap may be necessary. If the lesion extended to the pulp, or at/below bone, necessitating CL/NSRCT/crown then all bets are off. At that point it's important to follow patient preference after they're briefed on pros/cons and the cost of alternatives.

 

[Inkdot]

Can we get a radiograph?

Next clinic session I'll ask my demonstrator if I can take a PA of the 44.

Without seeing the lesion it is hard to say. I think the real challenging cases are when the caries extend subcrestal. However, if the caries extend only below the level of the gingiva then I think restoring with fugi II, or some other RMGI, is the best option. Cord or full thickness flap may be necessary. If the lesion extended to the pulp, or at/below bone, necessitating CL/NSRCT/crown then all bets are off. At that point it's important to follow patient preference after they're briefed on pros/cons and the cost of alternatives.

Yes, I think you're right. I also read in an Operative Dentistry textbook by Harald et al. 2012 that subgingival restorations were difficult, in the sense that the cavity preparation would be challenging, but also placing the dental material in that area would also be tricky. It may also predispose the patient to future periodontal problems if not done adequately.

Only, I don't see why you said RMGI is the best option... why not a conventional GIC? I would think both RMGIs and conventional GICs have advantages and disadvantages in this instance, not sure what would make RMGIs the 'better' option. Perhaps since RMGIs contain resin, it would be aesthetically more pleasing when restoring the 44B. Also, I think I read that RMGIs are less acidic than the conventional (not sure how significant this reduction in acidity would be). Additionally, RMGIs do allow for faster finishing and polishing. On the other end of the spectrum, however, conventional GICs such as Fuji IX are more viscous (therefore easier to handle). They also do not need to be light cured, which is beneficial subgingivally, since it is difficult for the curing unit to access. Conventional GICs also have greater fluoride-releasing properties.

From a clinical standpoint, however, my knowledge is limited by experience, since I am still a student. I would therefore be very interested to hear your opinion.

 

[yappy]

Next clinic session I'll ask my demonstrator if I can take a PA of the 44.



Yes, I think you're right. I also read in an Operative Dentistry textbook by Harald et al. 2012 that subgingival restorations were difficult, in the sense that the cavity preparation would be challenging, but also placing the dental material in that area would also be tricky. It may also predispose the patient to future periodontal problems if not done adequately.

Only, I don't see why you said RMGI is the best option... why not a conventional GIC? I would think both RMGIs and conventional GICs have advantages and disadvantages in this instance, not sure what would make RMGIs the 'better' option. Perhaps since RMGIs contain resin, it would be aesthetically more pleasing when restoring the 44B. Also, I think I read that RMGIs are less acidic than the conventional (not sure how significant this reduction in acidity would be). Additionally, RMGIs do allow for faster finishing and polishing. On the other end of the spectrum, however, conventional GICs such as Fuji IX are more viscous (therefore easier to handle). They also do not need to be light cured, which is beneficial subgingivally, since it is difficult for the curing unit to access. Conventional GICs also have greater fluoride-releasing properties.

From a clinical standpoint, however, my knowledge is limited by experience, since I am still a student. I would therefore be very interested to hear your opinion.

Fugi IX would be fine. I like II because of the handling properties, duel cure, and more aesthetic finishing.