Occlult caries

Caries that presents as Minor fissure caries but opens into extremely large dentine caries once preparation has started is known as occult caries. Do not be tricked by the narrow nature of the fissure caries, these often are quickly progressing and thus present as soft, light brown, flaky or almost liquidy dentine. You will likely discover these radiographically or due to the clinical presentation of the surrounding enamel being opaque white. Patients are typically teenages or younger because the caries is usually discovered before their 20s one way or another due to its fast progressing nature. Often, these will present in patients with fair oral hygiene. they will often report no symptoms until the pulp is exposed or the enamel cavitates.

Possible causes are:
-Fluoride bombs: Deep dentine caries occurs through the typical fissure route but due to fluoride exposure, the hydroxyapatite in enamel is replaced by stronger fluorapatite. This results in a strong shell suprastructure that doesn't cavitate later than is typical.
-Deep or undercut fissure patterns: Fissure caries can be predisposed by deep fissures or ones that widen at the base that hinders efficient cleaning. These can quickly become large dentine caries especially in a high cariogenic patient.
-Preeruptive intracoronal resorption: Occlusal tooth resorption may occur before or during tooth eruption and can have a similar presentation. Treat this the same as you would caries and restore with a well sealed restoration. Early intervention may be necessary as they can progress quite quickly towards the pulp and you can consider restoration before full eruption or a GIC fissure sealant to buy time for full eruption where more comprehensive treatment is possible.
-Hypomineralisation: This can often be seen and has a similar presentation where some teeth are affected and not others. Commonly affecting the 6s but also can affect the 7s. These usually present with quick enamel breakdown however, cavitated fissure occult caries can have a similar appearance to cavitated caries associated with enamel hypomineralisation

These are difficult cases to manage, early intervention and radiography can ensure long term prognosis of these teeth. However, due to their fast progression, the pulp or structural integrity of the tooth is often compromised. If the patient is young enough, management may include extraction and monitoring for space closure. In older patients, extraction and orthodontics may be a viable option. however, in the majority of older patients, restoration and long term maintenance with eventual loss of the tooth with or without replacement may be the most desirable option.