龋临床特征和诊断

Chapter3

ClinicalManifestationsandDiagnosisofDentalCariesHistophathologyofCariesEnamelCariesTheearlyenamellesionconsistsoffourzonesofalternatinglevelsofmineralisation.Itillustratesthedynamicnatureofthecariesprocess.Thesurfacezoneblocksthepassageofcalciumionsintothebodyofthelesionandmayhavetoberemovedtoallowthelesiontobecomearrested(AfterKidd&Joyston-Bechal,1987).DentinalCariesDentinecariescomprisestwo

mainlayers.Intheouterlayer,thedentineisheavilyinfectedwithbacteria.Bothorganicmatrixandmineralhavebeenlostandthedentineisbeyondrepair.Inthedeeperlayer,thedentinehasbeenaffectedbyplaqueacidsanddemineralised.Thenumberofcolonyformingunits(CFU)ofbacteriadecreases(about100times)ascavitypreparationproceedsintoaffecteddentine.Thedamageinthislayerisreversibleifbacterialmetabolismcanbehalted.Abarrieroftranslucent(wellmineralised)dentinemaybeformedaheadoftheadvancinglesion.Reactionary(secondary)dentineformstoprotectthepulpfromacidirritation(AfterKidd&Joyston-Bechal,1987RootcarieslesionsEarly:AppearsasradiolucentzoneintherootcementumStepsintheformationofanarrestedlesionindentinea)highconcentrationofdissolvedmineralsalts.b)Ifbcterialacidproductionisreduced,andthepHincreases,thesaltsprecipitateintolargecrystalsoftricalciumphosphatewhichtemporallyblockthetubule.c)Iffurtherbacterialactivityissuppressed,theodontoblastsecretescollagenandcalciumsalts.Crystalsofhydroxyapatitethenformandblockthetubulemoreeffectively(AfterDaculsietal,1987)

TheProcessofDemineralizationandRemineralizationCariesisadynamicprocess.Teetharesubjectedtoanongoingcycleofdemineralizationandremineralizationdeterminedbythebalanceoffactors.DemineralizationDemineralizationistheprocessofremovingminerals,intheformofmineralions,fromdentalenamel.AsubstantialnumberofmineralionscanberemovedfromhydroxyapatitelatticeworkwithoutdestroyingitsstructuralintegrityRemineralizationRemineralizationistheprocessofrestoringminerals-again,intheformofmineralions-tothehydroxyapatite'slatticeworkstructure.促进再矿化阻止龋病发展龋损的形成是脱矿与再矿化的连续性动力过程。1、除去致龋底物：木糖醇取代蔗糖，减少碳水化合物摄入频率Dietcounseling:ToidentifythesourcesofsucroseandacidicfoodstuffsinthedietToreducethefrequencyofingestionofbothTousexylitolassugarsubstitute.2、仔细刷牙，牙面不形成厚的牙菌斑Oralhygiene:Plaquefreetoothsurfacedonotdecay.DentalflossingToothbrushingRinsing3、在牙齿发育的再矿化期间，结合氟离子，可形成更具抗龋能力的釉质UseoffluorideClinicalclassificationofcaries

ClassificationaccordingtoprogressionrateAcutecaries:progressfast,ofteninchildrenandteenagers,lightcoloredcavity.Rampantcaries,manytoothinvolvedatsametimeacutecariesfeatureoftenaccompaniedbysystematicdisorder.Suchassjogrensyndromeorsalivareductionafterradiation.

Cariesinapatientwithimpairedsalivaryfunctionasresultofradiationtherapy(courtesyofDrsJansmaandVissink,RUG,theNetherlands).

Chroniccaries

progressslowly,blackorbrowncoloredcavityhardremainingdentine

Arrestedcaries

cariesstopprogressingbecauseof

thelocaletiologicalchangeSecondarycaries(recurrentcaries)cariesrecurredaftertreatment.Oftenatthemarginthefillingmaterialsrestorationorbeneath

Theshadowlocatedonthemesiolingualcuspadjacenttothelargerocclusalamalgamrestorationonthemaxillaryrightfirstmolarindicatesthepresenceofcariousdentin

ClassificationaccordingtotheinvolvingsiteOcclusalcaries

RootcariesSmoothsurfacecariesClassificationaccordingtothedeepnessSuperfacialcaries(浅龋)whitespotlesions,visiblyfrostedsurfacebrownspotDentincaries(中龋)cavitatedlesioninvolvingtheuppartofdentinDeepcaries(深龋)cavitatedlesioninvolvingthepupalthirdofdentinDiagnosisVisualchangeProbing:roughsurfaceortrappingpointpainuponprobingTemperaturetestX-rayexaminationTransilluminationVisualchange

Matte,white,activecervicallesionsProbing:roughsurfaceortrappingpointpainuponprobing

TheexplorertipcaneasilydamagewhitespotlesionsTemperaturetest

X-rayexamination

Transillumination（FOTL,光纤透照法）：

ProximalcarieslesionisdetectedinananteriortoothwiththeuseoftransilluminationLAF（激光荧光法)

Thehardwareoftheintra-oralsystemincludesameasurementprobe,acontrolunit,andacomputerfittedwithaframegrabber.Thecontrolunitconsistsofanilluminationdeviceandimagingelectronics.Thelightsourceisaspecialarc-lampbasedonXenon氙technology.Thelightfromthislampisfilteredbyablue-transmittingfilter.Aliquidlightguidetransportsthebluelighttotheteethinthemouth.

QuantitativeLight-inducedFluorescenceQLF™technicalspecificationsQLF™theoryTheQLF™methodisbasedontheauto-fluorescence荧光ofteeth.Whenteethareilluminatedwithhighintensitybluelighttheywillstarttoemitlightinthegreenpartofthespectrum.Thefluorescenceofthedentalmaterialhasadirectrelationwiththemineralcontentoftheenamel.QuantitativeLight-inducedFluorescence

DIAGNOdentpen(龋齿探测笔)DIAGNOdenthttp:///products/handpieces_accessories/special_instruments/diagnodent/tutorial.asp?navid=500019&lan=Us&znavid=311000DIAGNOdentpenDIAGNOdentStandardofdiagnosisSuperfacialcaries(浅龋)Whitespotorbrown,darklesion,roughuponprobingNocomplaint,nohypersensitivityDentincaries(中龋)Cavity,hypersensitivityuponprobing,hotorcoldstimulus.Deepcaries(深龋)Deepcavity,verysensitiveandsomepainuponstimulus,howeverthepaindisappearassoonasthestimulusistakenaway.TreatmentStrategyTreatmentStrategyPreventive(casual,noninvasive)treatmentRestorative(operative,invasive)treatment

Preventivetreatmentchemicaltherapy:

useoffluoridewitharegulardailyadministrationorprofessionalapplied.

pitandfissuresealing一、chemicaltherapy

（化学疗法

）

1．药物治疗适应证（1）恒牙早期釉质龋未形成龋洞者，自洁作用较好的区域；（2）一年内将被替换的乳牙大面积浅龋；（3）静止龋。药物氟化物硝酸银药物治疗氟化物(fluorence)

75％氟化钠甘油糊剂8％氟化亚锡溶液酸性磷酸氟化钠（APF）溶液含氟凝胶（1.5％APF凝胶）含氟涂料原理：氟与HA作用，形成氟磷灰石；沉积氟化物，促进再矿化。氟化物对软组织无腐蚀性，不使牙变色，安全有效，前后牙均可使用。药物治疗硝酸银10％硝酸银氨硝酸银原理:蛋白银沉淀

还原银或碘化银渗入牙釉质牙本质，杀灭细菌，封闭病变区

对软组织有强的腐蚀性，不可用于牙颈部龋，并使牙变黑，只用于乳牙和后牙。应用方法：用石尖磨除牙表面浅龋，暴露病变部位清洁牙面隔湿吹干涂布药物2．Remineralization(再矿化疗法)

再矿化液：主要为含有不同比例的钙、磷和氟。适应症平滑面早期釉质龋龋易感者预防应用方法：漱口液每日含漱局部应用

pitandfissuresealing

（窝沟封闭)

适应证：窝沟可疑龋；与充填窝洞相邻的牙合面无龋深沟裂，应用方法：清洁牙面、隔湿、酸蚀、涂布及固化封闭剂。

DefinitionofOperativeDentistry

Operativedentistryistheartandscienceofthediagnosis,treatment,andprognosisofdefectsofteethwhichdonotrequirefullcoveragerestorationsforcorrection.

Suchtreatmentshouldresultintherestorationofpropertoothform,function,andestheticswhilemaintainingthephysiologicalintegrityoftheteethinharmoniousrelationshipwiththeadjacenthardandsofttissues;allofwhichenhancethegeneralhealthandwelfareofthepatient.

IndicationofOperativeDentistry

Caries

Malformed,discolored,orfracturedteethRestorationreplacement

ProgramofOperativeTreatment

PatientassessmentExaminationanddiagnosisTreatmentplanningCavityPreparation

Themechanicalalterationofadefective,injured,ordiseasedtoothinordertobestreceivearestorativematerialwhichwillre-establishahealthystateforthetoothincludingestheticcorrectionswhereindicated,alongwithnormalformandfunction.

Classificationofcavity

ClassⅠClassⅡClassⅢClassⅣClassⅤClassⅥ—G.V.Blackin1908

ClassI

AllpitandfissurecavitiesareClassI.

Cavitiesonocclusalsurface;Cavitiesonocclusaltwo-thirdsofthefacialandlingualsurfacesofmolars;Cavitiesonlingualsurfaceofmaxillaryincisor.ClassII

AcavityoccurringontheproximalsurfaceofposteriorteethareClassII.MOmesialandocclusal

DOdistalandocclusalMODmesial,occlusalanddista

ClassIIICavitiesontheproximalsurfacesofanteriorteeththatdo

notinvolvetheincisalanglesareClassIII.ClassIV

Cavitiesontheproximalsurfacesofanteriorteeththatdo

involvetheincisalanglesareClassIV.ClassVCavitiesonthegingivalthirdofthefacialorlingualsurfacesofallteeth(notpitandfissurecavities)areClassV.ClassVICavitiesontheincisaledgeofanteriorteethortheocclusalcuspheightsofposteriorteethareClassVI.洞型分类一类洞：根据发生于所有牙齿的发育窝，沟内的龋损所制备的洞型。二类洞：后牙邻面的龋损所制备的洞型。三类洞：前牙邻面未损及切角的龋损所制备的洞型。四类洞：前牙邻面损及切角的龋损所制备的洞型。五类洞：所有牙齿颊（唇），舌（腭）面龈1/3牙面的龋损制备的洞型。六类洞：所有牙齿牙尖，牙脊或冠轴交界的轴角区的龋损所制备的洞型。CavityStructure

wallsanglescavityWalls

Internalwalls:apreparedcavitysurfacethatdoesnotextendtotheexternaltoothsurface.

Axialwalls:aninternalwallparallelwiththelongaxisofthetoothandocclusalofthetooth.Pulpalwalls:aninternalwallthat