Permanent posterior teeth - proximal caries
Permanent posterior teeth with proximal caries
Proximal caries is particularly difficult to diagnose visually, and radiographic examination is recommended at regular intervals based on an individual caries risk assessment. On visible surfaces (such as the mesial of a first permanent molar where an E has been extracted) there might be initial enamel changes, with a white spot lesion only detectable upon drying the enamel or more established with the white spot lesion visible even when the tooth surface is wet. Care should always be taken to avoid iatrogenic damage to the adjacent proximal surface (see Avoiding iatrogenic damage).
Images showing use of a separator to aid visualisation.
- If uncertain whether cavitated, a separator can be applied (left)
- Separator removed five days later, allowing visualisation (right)
Orthodontic separators may be used to allow visualisation, but this requires the child to re-attend after five days. Early diagnosis of lesions before they cavitate may allow them to be managed without operative intervention.
Initial caries (proximal)
Description: Visual diagnosis - teeth with white spot lesions or shadowing. Enamel is intact, though this may be difficult to detect visually.
Radiographic diagnosis - caries may be visible in the outer third of dentine.
Image shows a radiograph of a permanent tooth with an initial proximal carious lesion.
Aim: To use a preventive or minimally invasive approach to slow or arrest caries and reduce the risk of a permanent molar or premolar requiring a multi-surface restoration.
Identify and arrest initial enamel-only lesions paying particular attention to the mesial surface of first permanent molars.
Carry out site-specific prevention and monitor with bitewing radiographs (see Assessing carious lesions).
- Ensure that the parent/carer is fully aware of the potential impact on their child’s oral health.
Alternatively, seal the lesion (see Sealant/infiltration).
Moderate dentinal caries (proximal)
Description: Visual diagnosis - There may be enamel cavitation or cavitation with visible dentine, though this may be difficult to detect clinically. There may be dentine shadowing.
Radiographic diagnosis - on a bitewing radiograph these lesions are visible within dentine and may extend into the outer or middle third of dentine (see Assessing carious lesions).
Aim: To prevent caries progression by placing a sealant or a long-lasting restoration.
If there is enamel cavitation but no dentine caries visible clinically, place a proximal sealant using a resin fissure sealant material without removing caries, if feasible (see Sealant/infiltration).
Alternatively, carry out selective caries removal or, if necessary for a sound restoration, complete caries removal.
Seal the remaining fissures.
Factors that may influence whether to choose sealant or caries removal include:
- extent of cooperation
- the likelihood of re-attending for active surveillance
- accessibility
- extent of cavitation/lesion
Initial stages of enamel breakdown (cavitation) are very difficult to detect on the proximal surfaces of the teeth. Separation using orthodontic separators can be used but requires an extra appointment.
Extensive dentinal caries (proximal)
Description: Visual diagnosis - teeth with cavitation (this may be extensive) with visible dentine, or widespread dentinal shadow.
Radiographic diagnosis - on a bitewing radiograph, these lesions may extend into the inner third of dentine but do not reach the pulp.
Aim: To remove caries, avoiding pulpal exposure and provide a long-lasting restoration.
Carry out selective caries removal.
If the caries has extended to the pulp, pulp therapy (pulpotomy or pulpectomy/root canal therapy) may be required. The long-term prognosis of the tooth should be considered when treatment planning.