Root surface caries

Don't ever forget that Root surface caries is a bitch to treat.

The individual chemical makeup of dentine makes it uniquely predisposed to catastrophic caries.

-The more apically you look, they thinner the dentine is before it reaches the pulp. It also means that any loss of tooth structure due to prep will result in a larger percentage loss of cross sectional area. Therefore the same amount of tooth structure lost on the root will result in a higher risk of catastrophic fracture
-This is a site patients often neglect to clean. the reason the recession appeared in the first place was likely influenced by poor oral hygiene, once the dentine is exposed the bacteria can get to work dislodging the mineral in the exposed root surfaces. root concavities suck as between molar and premolar roots are exquisitely hard for patients to clean without the proper instruction
-Dentine has a critical pH of 6.5 as opposed to 5.5 for enamel so any caries on dentine will be faster progressing and occur in milder conditions. In patients with caries free crowns, often check the root surfaces with a cautious eye. Often the enamel shell is untouched and the dentine is covered in caries. If the dentine surface is sound, the enamel surface is likely fine.
-These patients with significant recession are usually older and so due to pulp recession they do not feel pain from root surface caries until they present with apical periodontitis or acute abscess.
-It is a difficult site to access and treat usually due to the proximity to the gum and its apiacal position hinders visualisation. Root caries can often ringbark the tooth so you have to view it from multiple angles to make sure it is caries free.
-These patients often have a dry mouth predisposing them to caries. This can come from drug use, smoking or medications etc and may have contributed to their periodontal condition in the first place

My management of these patients involves the following:
1. Address the cause of caries: Oral hygiene instruction, hygiene products (below), removal of plaque and calculus, dietary advice (to restrict sugar and acids). Arresting the cause of the caries and managing the dentine hypersensitivity may reduce the need for anaesthetic and improve post op sensitivity
a. GC dry mouth gel in dry mouth patients for symptomatic relief but mainly as a carrier for remineralising agents
b. GC tooth mousse plus in dry mouth patients. This is essential as without available calcium and phosphate in saliva, Fluoride from products won't be bioavailable for remineralisation
c. High fluoride varnish: e.g MI Varnish or Duraphat for controlling dentine hypersensitivity patients who are younger or who have active acid erosion. (You would expect an elderly person with exposed dentine to not be sensitive. Some form of acid is likely opening up the sealed tubules)
d. High fluoride toothpastes and fluoride rinses: Rinses of any kind may help to clear food impaction in enlarged interdental spaces post meal. High fluoride toothpastes should be used in conjunction with CPP-ACP in dry mouth patients
e. Custom medication tray in the form of a bleaching tray will reduce clearance of any product from the mouth
f. A good idea is to use GIC as a varnish. Any high flow GIC e.g Fuji7 or even a CPP-ACP containing GIC e.g Fuji9 EP can be painted onto the root surface even over caries to arrest the lesion. This can be overlaid with high fluoride varnish ideally with CPP-ACP to quickly arrest the progression of root surface lesions.


2. Address the cause of recession: Toothbrush instruction in abrasion cases, medical management of reflux, address underlying OSA, address bruxism in abfraction patients, Periodontal treatment in perio patients.

3. Restorative work: Usually a Slow speed round bur is sufficient to clear root surface caries. Due to the proximity to the pulp you don't want to play around with a more aggressive diamond high speed bur. The speed of progression of root surface caries often gives them a yellow to light brown appearance so it is useful to have the tactile sense to discriminate between root surface caries and dentine. GIC is the ideal long term restorative material for dentine only restorations. Not only does the long term bond of composite degenerate but there is no protective element to composite resin. GIC will reduce plaque formation around it and can release fluoride and CPP-ACP for protection of the surrounding tooth structure. In active erosion cases it will sacrificially dissolve protecting the surrounding tooth structure yet again. This is more desirable to further loss of tooth structure

4. Ongiong management and review: These patients are high risk patients for further perio and decay. Review after 1 month to check oral hygiene and restorative status can be beneficial with 3 monthly reviews after that to catch problems early, repair and replace restorations as needed and to reinforce and improve oral hygiene strategies