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Treatment of Root-surface Caries Increases in the number of older patients in the patient population and tooth retention have contributed to this growing problem of root caries. Areas with root-surface caries usually should be restored when clinical and/or radiographic evidence of cavitation exists. Care must be exercised, however, to distinguish the active from the arrested (inactive) root-surface lesion. The arrested root-surface lesion may have sclerotic dentine that has darkened from extrinsic staining is firm to the touch of an explorer, may be rough but is cleanable. Successful caries arrest usually occurs in patients whose oral hygiene or diet has improved such that the balance between demineralization and remineralization has become favourable. Generally, these lesions should not be restored except when the patient expresses esthetic concerns. If it is determined that the lesion needs restoration, it may be restored with tooth-coloured materials or amalgam, depending on demands of the restorative material, preferences of the patient, and caries risk. Prevention is preferred over restoration. It is recommended that appropriate preventive steps, such as improvement in diet/oral hygiene and fluoride treatment (with or without cementoplasty/dentinoplasty to eliminate surface roughness), be taken so as to limit carious breakdown and the need for restoration. Root caries is common in older adults and in patients who have had periodontal therapy. Treatment of Root-surface Sensitivity It is not unusual for patients to complain of root-surface sensitivity, which is an annoying sharp pain usually associated with gingival recession and exposed root surfaces. The most widely accepted explanation of this phenomenon is the hydrodynamic theory. This theory postulates that rapid dentinal tubule fluid movement towards the external surface of the tooth elongates odontoblastic processes (which extend from the pulp through the pre-dentine and into dentine) and associated afferent nerve fibres. The elongation of the nerve fibres results in depolarization and the perception of pain (see Chapter 1). Causes of such fluid shifts include temperature changes, air-drying, and extreme osmotic gradients. Treatment methods that reduce rapid fluid shifts, by partially or totally occluding the ends of the exposed dentinal tubules, may help reduce the perceived sensitivity. Dentinal hypersensitivity may become a problem when periodontal surgery causes clinical exposure of root surfaces (such that dentinal tubules are exposed and open). Numerous forms of non-surgical treatment, such as fluoride varnishes, oxalate solutions, glutaraldehyde/HEMAbased desensitizers, resin-based adhesives, sealants, and desensitizing toothpastes that contain potassium nitrate, have been used to occlude the open tubules and, thereby, provide relief.

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Treatment with Amalgam Restorations Inaccurate information with regard to the safety of amalgam has resulted in controversy among healthcare providers, environmentalists, legislators, and the general population. Although the use of amalgam is considered safe by multiple independent agencies, the release of elemental mercury does contribute to environmental levels. Therefore, responsible handling is important. Chapter 13 presents the current indications for amalgam restorations and a more complete discussion of legitimate mercury concerns and the safe use of dental amalgam. Dental amalgam still is recognized as one of the most successful direct restorative materials and is especially indicated for patients deemed to be moderate or high caries risk.39

Treatment by Replacement of Existing Restorations Indications for replacing restorations include the following: I. marginal void(s), especially in the gingival one-third, that cannot be repaired and predispose to caries formation; II. poor proximal contour or a gingival overhang that contributes to periodontal breakdown; III. a marginal ridge discrepancy that contributes to food impaction; IV. overcontouring of a facial or lingual surface resulting in biofilm accumulation gingival to the height of contour and resultant inflammation of gingiva overprotected from the cleansing action of food bolus or toothbrush; V. poor proximal contact that is either open or improper in location or size, resulting in interproximal food impaction and inflammation of impacted gingival papilla; VI. recurrent caries that cannot be treated adequately by a repair restoration; and VII. superficial marginal gap formation (ditching) deeper than 0.5 mm that predisposes to caries.38 Indications for replacing tooth-coloured restorations include: I. improper contours that cannot be repaired, II. large voids, III. deep marginal staining, IV. recurrent caries, V. unacceptable esthetics.38