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Dental Tribune U.S. Edition

f HT page 1D About the author in the room, was that rebalancing the oral pH and providing the miss- ing components of saliva, thus for- feiting the reasons for the amalgam in the first place, could treat many of these lesions. Following are some of the impor- tant glossary terms from Dental Clinics of North America. These definitions are quoted from the entry: Defining Dental Caries for 2010 and Beyond. References for the definitions can be found in the source for the following summary. Caries process The caries process is the dynamic sequence of biofilm-tooth interac- tion that can occur over time on and within a tooth surface. This process involves a shift in the balance between protective factors (that aid in remineraliza- tion) and destructive factors (that aid in demineralization) in favor of demineralization of the tooth struc- ture over time. The process can be arrested at any time. Demineralization Demineralization is the loss of cal- cified material from the structure of the tooth. This chemical process can be biofilm mediated (i.e., car- ies) or chemically mediated (i.e., erosion) from exogenous or endog- enous sources of acid (e.g., from the diet, environment or stomach). Caries lesion/carious lesion A caries/carious lesion is a detect- able change in the tooth structure that results from the biofilm-tooth interaction occurring due to the disease caries. It is the clinical manifestation (sign) of the caries process. “People have dental caries, teeth have caries lesions.” Although attempts have been made in the literature to separate the term “caries lesion” from “cari- ous lesion” (and in some cases to deprecate the term carious) — in some instances the latter is being used to refer to an “active” lesion — we find that applying those dis- tinctions to everyday practice can be confusing, and thus we suggest that both terms can continue to be used interchangeably. Caries lesion severity This is the stage of lesion pro- gression along the spectrum of net mineral loss, from the initial loss at a molecular level to total tissue destruction. This involves elements of both the extent of the lesion in a pulpal direction (i.e., proximity to the den- to-enamel junction and pulp) and the mineral loss in volume terms. Noncavitated and cavitated lesions are, for example, two specific stag- es of lesion severity. Noncavitated lesion (a.k.a. incipi- ent lesion, initial lesion, an early lesion or white-spot lesion) A noncavitated lesion is a car- ies/carious lesion whose surface appears macroscopically intact. In other words, it is a caries lesion without visual evidence of cavita- tion. This lesion is still potentially reversible by chemical means or arrestable by chemical or mechani- cal means. White-spot lesion This is a noncavitated caries/cari- ous lesion that has reached the stage where the net subsurface mineral loss has produced changes in the optical properties of enamel, such that these are visibly detect- able as a loss of translucency, resulting in a white appearance of the enamel surface. However, it must be noted that although initial lesions appear as a white, opaque change to the naked eye, not all white-spot lesions are either initial (beginning lesions) or incipient, as they may be present for many years and may involve enamel and/or dentin. Brown-spot lesion A brown-spot lesion is a noncavi- tated caries/carious lesion that has reached the stage where the net subsurface mineral loss — in conjunction with the acquisition of intrinsic or exogenous pigments — has produced changes in the opti- cal properties of enamel, such that these are visibly detectable as a loss of translucency and a brown discoloration, resulting in a brown appearance of the enamel surface. Microcavity/microcavitation This is a caries/carious lesion with a surface that has lost its original contour/integrity, without visually distinct cavity formation. This may take the form of localized “widen- ing” of the enamel fissure mor- phology beyond its original features within an initial enamel lesion, and/or a very small cavity with no detectable dentine at the base. Caries lesion activity (net progression toward demineralization) The summation of the dynamics of the caries process resulting in the net loss of mineral over time from a caries lesion (i.e., there is active lesion progression). Active caries lesion A caries lesion from which, over a specified period of time, there is net mineral loss, that is, the lesion is progressing. Criteria include visu- al appearance, tactile feeling and potential for plaque accumulation. Lesion is likely active when sur- face of enamel is whitish/yellowish opaque and chalky (with loss of luster); feels rough when the tip of the probe is moved gently across the surface. Lesion is in a plaque stagnation area, that is, pits and fissures, near the gingival and approximal sur- face below the contact point. In dentin, lesion is likely active when the dentin is soft or leath- ery on gently probing. The term active caries should be avoided and replaced by active caries lesion. Arrested or inactive caries lesion A lesion that is not undergoing net mineral loss, that is, the caries pro- cess in a specific lesion is no longer progressing. It is a scar of past dis- ease activity. Clinical observations to be taken into consideration for assessing caries lesion activity include visu- al appearance, tactile feeling and potential for plaque accumulation. Lesion is likely inactive when sur- face of enamel is whitish, evidence of lesion arrest but also one or more of other definite changes, includ- ing increased mineral concentra- tion (remineralization), increased radiodensity, decreased size of white-spot lesions, increased hard- ness of the surface and increased surface sheen compared with a pre- vious matte surface texture. For the day-to-day clinician some of this sounds like an academic exercise. Attention to the details in terminology for even a week can make very positive changes in the practice and healthier patients will emerge. HT HYGIENE TRIBUNE | January/February 2011 Clinical 3D Obsolete hygiene terms ‘Caries free’ This term has frequently been used when referring to assessments made (of either individuals or groups) even where the diagnostic threshold employed has been at the “dentine or worse” level, ignoring all grades of initial lesion that may also be present. The term should now be avoided and more precise terms used. ‘Active caries’ This term was used to mean any lesion that had penetrated into den- tine. The more modern definitions (e.g., active caries lesion) should now be used. ‘Radiation caries’ Caries lesions of the cervical regions of the teeth, incisal edges and cusp tips secondary to hyposalivation, induced by radiation therapy to the head and neck. ‘Watch’ This is a term sometimes used to indicate early, white-spot lesions in either smooth or occlusal surfaces. The term is used to either indicate uncertainty regarding the state of activity of the lesion or to indicate uncertainty as to whether it is actually a caries lesion to begin with. As it is not a diagnostic term, it cannot lead to any management deci- sion; the decision not to do anything or just “watch” should be elimi- nated from our choices of treatment. The term may have previously been used as a way to delay restor- ative intervention for sites that we were unsure about when we did not have many treatment options for these earlier stages of the disease. However, with the availability of better detection methods and non- invasive interventions, it is necessary to avoid using this term and make the best possible diagnostic call at any one point in time. Instead of watching over time, we should be monitoring the effect of our therapies and treatments on the lesions we are following. Shirley Gutkowski, RDH, BSDH, FACE, is an international speaker, and award-winning writer, with a focus on minimal intervention den- tal hygiene. She also publishes in nursing journals. Gutkowski is co-creator of Adopt A Nursing Home, a board member and fellow of ACE, and a member of the World Congress of Minimally Invasive Dentistry. Gutkowski is co-director of CareerFusion, a retreat for clini- cians interested in evolving their clinical career. You may reach her at crosslinkpresent@aol.com.