Deep dental caries in adults and children

The structure of the tooth is such that its lower part - the root is embedded in the gum, and with the help of the upper crown, food is crushed. Its hardness is ensured by tooth enamel, dentin, and dental cement. Inside the tooth, the cavity is a pulp chamber connected to the root canals. It is in the pulp a large number of nerve endings, blood vessels, lymph. Caries is a slow process of destruction of the hard layers, and deep - its last stage, in which the lesions reached great depth and they are separated from the pulp only a thin layer of bone tissue - dentin.[1]

Epidemiology

The prevalence of caries in the world is very large, over 90% of people have fillings in their teeth. Threatening picture in developing countries, because not everyone has the opportunity to properly care for them and to treat them in time.

The prevalence of caries in young children is estimated to range from 1 to 12% among children from developed countries. However, this figure rises to 56% in some Eastern European countries.[2]

Studies conducted in the Middle East showed that the prevalence of caries in 3-year-olds is from 22% to 61% [3]and in Africa it is from 38% to 45% [4]. Gender and age do not affect the prevalence of caries. In addition, caries is more common in younger age groups and their frequency decreases with age.[5] 

Causes of the deep caries

There are 2 reasons for the development of pathology:

• progression of untreated average caries (primary);
• education due to unsuccessful previous treatment or under filling (secondary). Secondary caries occurs mainly due to the formation of microcracks after tooth filling. When the microcrack width exceeds 50 microns, saliva will fall into the microcracks between the filling and the tooth tissue. Cariogenic bacteria in saliva will grow when the medium of microcracks is suitable, thereby causing secondary caries.[6]

Risk factors

Contribute to the complex primary pathology of the tooth the same factors as at the stage of its inception:

• poor oral hygiene;
• late treatment of the tooth and plaque removal;
• the presence of large amounts of sugar and other carbohydrates in the food; [7]
• poor nutrition and water; [8]
• hereditary disposition; [9]
• violation of metabolic processes in the body;
• imperfection of the structure of the hard layers of the tooth;
• nature of salivation (pH).

Pathogenesis

Deep caries begins at an early stage, when a white or pigmented stain appears on the enamel. This is due to the activity of bacteria contained in dental plaque, resulting from the nutrition of thermally processed foods that contain a lot of carbohydrates. Microorganisms. [10], [11]These acid-forming pathogens that live in the mouth cause damage by dissolving tooth structures in the presence of carbohydrate enzymes, such as sucrose, fructose, and glucose. During their fermentation, organic acids are formed in the oral cavity, washing out fluorine and calcium from enamel, which destroys it.

Penetrating deeper into the damaged solid structure, cariogenic bacteria expand this area. Before deep caries, a rather long process and passage of the superficial and middle caries stages takes place.

Dental caries is the process of enamel or dentin demineralization caused by acid caused by cariogenic oral bacteria. This process is opposed by the natural function of saliva - remineralize dental tissue, supplying calcium and phosphate ions, which are included in the crystal structure of tooth enamel. The progression of caries occurs as a result of an imbalance in the processes of demineralization and remineralization, which ultimately leads to cavitation.[12]

Symptoms of the deep caries

The first sign of deep caries is a sharp pain to a number of irritants. Complaints relate mainly to getting cold, hot, sour, sweet, biting solid food. [13]If it enters the carious cavity, the tooth can ache and ache for a long time until it is removed. Caries over a wide area often causes  bad breath.

Among children, caries is the most common of all chronic diseases. Milk teeth are distinguished by a thin enamel cover, a smaller volume of dentin, the presence of weakly mineralized areas in it, which contributes to the rapid spread of the pathological process.[14]

Not the least role in the development of caries is played by the low activity of the pulp, which is associated with the child’s still completely weak immune system.

Deep caries of a baby tooth is a relative concept, since with the same depth of a hole at different ages, the diagnosis can vary from superficial, for example, at 7 years, to deep at 3 years.

This can only be clarified with an x-ray, which clearly shows the distance of the hole from the pulp chamber.

Stages

The development of caries has several stages, determined by the depth of the process. It begins with a loss in a separate point of the natural luster of enamel. A white or brownish stain appears, mainly due to the loss of calcium salts. It is asymptomatic.

At the next stage of surface caries, when viewed at the spot, a defect is found that affects only the enamel. The deeper lesion in which dentin is involved is called average caries. These two stages are characterized by a reaction to temperature and chemical stimuli.

The presence of a deep carious cavity filled with dentine indicates deep caries. Usually the entrance to it is the body itself. Its sensing leads to painful sensations.[15]

Forms

There are various classifications of dental pathology, one of which is the acuteness of the process. From this point of view, there are 2 types of deep caries:

• acute or decompensated - the destruction of the tooth occurs quickly, the "hollow" is multiple, its extreme shape is the total damage to the teeth in the neck - the place where the crown goes to the root;
• chronic or compensated - develops slowly, and carious cavities are lined with solid dentin.

Other types include classification by localization (on contact surfaces, in the area of necks, cutting edges), occurrence (primary, secondary), process duration (fast and slow-flowing, stabilized).

Deep caries of the front teeth

Front teeth for us are important not only in terms of their main function, but also aesthetic. These incisors have a thin layer of dentin in comparison with others, are very painful when they are affected, they are easier to lose.

Often, caries develops on the inside, invisible on the outside, and not in the interdental spaces, and can only show up when symptoms appear. This is indicative of deep dentin caries and requires immediate action. Modern techniques allow you to restore the appearance of the tooth, if it is significantly affected by pathology.

Deep cervical caries

Radical or cervical caries affects the teeth in both children and adults. Located on the boundary with the gum line, characterized by rapid development, moving into a deep stage and affecting the root.[16]

Symptoms are characterized by hypersensitivity to cold, hot, sour, sweet, odor from the mouth. Multiple localization often indicates endocrine problems.

Deep caries under the seal

Treatment of caries and fillings do not guarantee the development of secondary deep caries. Sometimes a new carious cavity appears under the filling. This can happen both a few months after therapy, and after a longer time.

Such a relapse is possible for several reasons:

• poor-quality treatment (the antiseptic was not cleansing the carious tissue properly);
• shrinkage of the material for sealing, due to violation of the technology or the life of the seal (5 years or more);
• lack of tightness of the seal (it should fit snugly to the walls of the tooth, because bacteria easily penetrate into the gap);
• erasing the seal as a result of its improper "fit" or improper bite.

Sometimes the fault lies with the person himself: he chews on nuts, badly cares for the oral cavity, combines cold food with hot food. A problem is detected when the filling begins to “walk,” “enters” in the teeth during eating.

Deep caries under the crown

Putting on crowns, a nerve is removed from the tooth. This becomes a factor that complicates the identification of caries, because a person does not feel its manifestations. This often happens because of a crack in the crown, a badly cured tooth, gum disease, and disregard for oral hygiene.

This fact is revealed with the help of a snapshot or when caries covers adjacent teeth. We have to remove the prosthesis and begin treatment in a new way.[17]

Deep caries of the tooth root

Tooth root caries is the most insidious of all its existing varieties. Most patients with this diagnosis are in the older age group “who is over 60”.

The main reason for this lies in the atrophy or dystrophic phenomena of the gums associated with the deterioration of the blood supply, their descent and detachment from the root zone of the tooth. From this in the gum pocket accumulates a raid, which is a breeding ground for disease-causing bacteria.

Other factors provoking the development of root caries are periodontitis, unsuitable prostheses or become unusable, saliva reduction, poor-quality daily care or lack of it, complication of treatment of cervical caries. [18], [19]

Deep caries wisdom tooth

We associate wisdom teeth with young age, nevertheless they are most susceptible to carious damage. It occurs for the same reasons as other teeth, but their location in the area of the dental arch contributes to this. There is a difficulty in thorough cleaning them from plaque, changes in the surface of the enamel are not visible visually. Sometimes the wisdom tooth does not penetrate to the end, but only the tip is visible, covered by the gum, under which remains of food accumulate.

Deep lateral caries

The food we chew on is most of all stuck between the teeth, it is there that microorganisms are concentrated that emit organic acids that destroy enamel. Eliminating them is not very easy, for this you need to apply dental floss, which is used not all.

It is not always possible to recognize pathology at an early stage, but it progresses rapidly, going into a deep phase, penetrating into adjacent teeth and the root area.

Complications and consequences

Deep caries can be considered a consequence of caries, followed by more severe forms of the disease, such as pulpitis and periodontal inflammation, which can lead to tooth loss. Among the possible complications - cellulitis and abscess - purulent inflammation of tissues that pose a threat to life.[20]

Diagnostics of the deep caries

Diagnosing the condition of the pulp on the basis of clinical examination and the patient's symptoms is a difficult task in clinical practice, since it is a key factor in making therapeutic decisions in the treatment of deep caries. [21]Deep caries is easily diagnosed, for this is enough patient complaints and visual inspection. A dental mirror and a probe are used as instruments. It is more difficult to determine the destruction in contiguous cavities of the teeth or under the filling, a crown. In this case, it is detected with the help of a temperature test - cold with an unstressed nerve [22]or radiographs - the most reliable method.[23]

Differential diagnosis

Toothache with caries can imitate both trigeminal neuralgia and other chronic disorders of the trigeminal nerve. [24]Deep caries should be differentiated from the middle one, which has a less extensive carious cavity, and acute focal pulpitis. For the latter are characterized by prolonged aching pain (1-2 days), as well as paroxysmal, appearing both from the stimulus and without it. When probing sharply hurts at one point. 

Prevention

In the prevention of dental caries, there are several main rules: [25]

1. Oral hygiene.

Since dental caries does not progress without bacteria, daily removal of plaque with a toothbrush, flossing and rinsing is one of the best ways to prevent caries and periodontal disease. 

2. The use of fluoride.

Fluoride prevents tooth decay by suppressing the demineralization of the crystal structures inside the tooth and enhancing remineralization. Remineralized surface resistant to acid attacks. In addition, fluorine inhibits bacterial enzymes [26]. Fluoride can be obtained using water fluoridation, the use of fluoride toothpastes, fluoride mouthwashes, food fluoride additives and professionally applied fluoride compounds, such as gels and varnishes.

3. The use of sealants from pits and cracks in the teeth:

Most cases of caries in young children are found in holes and cracks. Pits and cracks are more susceptible to dental caries, as the anatomical structure contributes to the accumulation of plaque. Filling such irregularities with a flowable reducing material, the area becomes less morphologically susceptible [27]. This procedure is especially recommended for teething children and adults with a high rate of caries.

4. Xylitol:

Sucrose is a widely known cause of tooth decay, and an increased intake of sucrose increases the risk of tooth decay. However, it is impossible to completely eliminate sugar from the diet. Therefore, sugar substitutes have been developed to reduce the risk of caries. Xylitol is one of these sugar substitutes. Xylitol has a sweet taste, comparable to sugar, and it is not only non-karyogenic, but also anti-karyl. It keeps sucrose molecules from binding with Streptococcus Mutans (MS), thereby blocking their metabolism.[28]

Good carbohydrate minimizing food - in childhood it is important to consume foods rich in calcium (cottage cheese, milk), phosphorus (fish), vitamin D (liver of animals and fish, cereals, eggs), fluorine (walnuts, pumpkin, buckwheat, oatmeal spinach); give preference to solid foods, eat less sweets;

5. Vaccine:

Since dental caries is an infectious microbiological disease, there have been attempts to develop a vaccine. Some MS vaccines in the form of proteins, recombinant or synthetic peptides or protein-carbohydrate conjugates, as well as DNA-based vaccines, were experimentally successful. However, so far none of these vaccines have appeared on the market [29], [30]due to the difficulty of inducing and maintaining high levels of antibodies in oral fluids; research is still ongoing for clinical applications.

6. The role of the main educator in children:

Since dental caries is an infectious disease, the main source of infection for young children (most often the mother) can transmit microorganisms causing caries to the child, which leads to MS colonization in the infant's mouth. In fact, there is a direct relationship between the levels of MS in parents and their children [31]. Therefore, efforts to reduce the level of MS in parents, including maintaining oral hygiene and passing dental treatment, when necessary, are also important for the prevention of dental caries in young children.

7. A visit to the dentist for no reason every six months.

Forecast

The qualified treatment of deep caries gives a chance to preserve the chewing functions of the tooth, and by restoring or strengthening it with a crown, get a proper aesthetic appearance. Permanent teeth with deep caries of dentin, which are treated either by the method of partial removal of caries, or methods of gradual removal of caries have a high probability of survival after two years. [32]The forecast of the neglected state is not always favorable due to the risk of tooth loss.