Deep tooth decay 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 part - the crown, food is crushed. Its hardness is provided by tooth enamel, dentin, dental cement. Inside the tooth there is a cavity - the pulp chamber, connected to the root canals. It is in the pulp that there is a large number of nerve endings, blood vessels, lymph. Caries is a slow process of destruction of hard layers, and deep caries is its last stage, in which the lesions have reached a great depth and are separated from the pulp only by a thin layer of bone tissue - dentin. [ 1 ]

Epidemiology

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

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

Studies conducted in the Middle East have shown that the prevalence of dental caries in 3-year-old children ranges from 22% to 61% [ 3 ] and in Africa it ranges from 38% to 45% [ 4 ]. Gender and age do not affect the prevalence of dental caries. In addition, dental caries are more common in younger age groups and their incidence decreases with age. [ 5 ]

Causes deep caries

There are 2 reasons for the development of pathology:

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

Risk factors

The same factors that contribute to complex primary tooth pathology are those that occur at the stage of its development:

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

Pathogenesis

Deep caries begins at an early stage when a white or pigmented spot appears on the enamel. This is due to the activity of bacteria contained in plaque, which occurs as a result of eating thermally processed food containing a lot of carbohydrates. microorganisms. [ 10 ], [ 11 ] These acid-forming pathogens that live in the mouth cause damage by dissolving the structure of the teeth in the presence of carbohydrate enzymes such as sucrose, fructose and glucose. When they ferment in the oral cavity, organic acids are formed, washing out fluoride and calcium from the enamel, which destroys it.

Penetrating deeper into the damaged hard structure, cariogenic bacteria expand this area. Deep caries is a fairly long process and passing through the stages of superficial and medium caries.

Dental caries is a process of demineralization of enamel or dentin caused by acid produced by cariogenic bacteria in the oral cavity. This process is counteracted by the natural function of saliva to remineralize dental tissue by supplying calcium and phosphate ions that are incorporated into the crystalline structure of dental 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 deep caries

The first sign of deep caries is a sharp pain to a number of irritants. Complaints mainly concern the ingestion of cold, hot, sour, sweet, biting hard food. [ 13 ] When it gets into the carious cavity, the tooth can hurt and ache for a long time until it is eliminated. Caries in a large area often causes an unpleasant odor from the mouth.

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

Low pulp activity, associated with the child’s still not fully developed immune system, plays an important role in the development of caries.

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

This can only be clarified with the help of 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 the loss of the natural shine of the enamel in a separate point. A white or brownish spot appears, which is mainly due to the loss of calcium salts. This occurs asymptomatically.

At the next stage of superficial caries, when examining the spot, a defect is found that affects only the enamel. A deeper lesion that involves dentin is called medial caries. These two stages are characterized by a reaction to temperature and chemical irritants.

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

Forms

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

• acute or decompensated - tooth destruction occurs quickly, there are multiple "cavities", its extreme form is total damage to teeth in the neck area - the place where the crown transitions to the root;
• chronic or compensated - develops slowly, and carious cavities are lined with hard dentin.

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

Deep caries of the front teeth

The front teeth are important to us not only for their main function, but also for their aesthetics. These incisors have a thin layer of dentin compared to others, are very painful when damaged, and are easier to lose.

Often, caries develops from the inside, invisible from the outside, and not in the interdental spaces and can be detected only when symptoms appear. This indicates deep dentin caries and requires immediate action. Modern techniques allow you to restore the appearance of a tooth if it has suffered significantly from pathology.

Deep cervical caries

Root or cervical caries affects teeth in both children and adults. It is located on the border with the gum line, is characterized by the rapidity of development, passing into a deep stage and affecting the root. [ 16 ]

Symptoms include increased sensitivity to cold, hot, sour, sweet, and bad breath. Multiple localization often indicates endocrine problems.

Deep caries under the filling

Caries treatment and filling do not guarantee the development of secondary deep caries. Sometimes a new carious cavity appears under the filling. This can happen both several months after the therapy and after a longer period of time.

Such a relapse is possible for a number of reasons:

• poor quality treatment (carious tissue was not properly cleaned with an antiseptic);
• shrinkage of the filling material due to a violation of the technology or the service life of the filling (5 years or more);
• lack of tightness of the filling (it must fit tightly to the walls of the tooth, since bacteria can easily penetrate into the gap);
• wear of the filling as a result of improper "fitting" or incorrect bite.

Sometimes the fault lies with the person himself: he gnaws nuts, takes poor care of his oral cavity, combines cold food with hot. The problem is discovered when the filling begins to "walk", "goes" into the teeth during eating.

Deep caries under the crown

When crowns are put on, the nerve is removed from the tooth. This becomes a factor that complicates the detection of caries, because a person does not feel its manifestations. This often happens due to a crack in the crown, a poorly treated tooth, gum disease, or ignoring oral hygiene.

This fact is detected with the help of a picture or when caries affects neighboring teeth. It is necessary to remove the prosthesis and start treatment anew. [ 17 ]

Deep root caries

Root caries is the most insidious of all its existing varieties. Most patients with this diagnosis belong to the older age group "over 60".

The main reason for this is atrophy or dystrophic phenomena of the gums, associated with deterioration of blood supply, lowering and separation of them from the root zone of the tooth. As a result, plaque accumulates in the gum pocket, which is a breeding ground for pathogenic bacteria.

Other factors that provoke the development of root caries include periodontitis, unsuitable or worn-out dentures, decreased saliva volume, poor daily care or lack thereof, and complications in the treatment of cervical caries. [ 18 ], [ 19 ]

Deep caries of wisdom tooth

Wisdom teeth are associated with young age, however, they are most susceptible to carious damage. It occurs for the same reasons as other teeth, but their location in the dental arch contributes to this. There is difficulty in thoroughly cleaning them from plaque, changes in the enamel surface are not visible visually. Sometimes a wisdom tooth does not erupt completely, and only the top is visible, covered by the gum, under which food debris accumulates.

Deep lateral caries

The food we chew gets stuck between our teeth the most, and that is where the microorganisms that release enamel-destroying organic acids are concentrated. It is not very easy to remove them, and for this you need to use dental floss, which not everyone uses.

It is not always possible to recognize the pathology at an early stage, and it quickly progresses, moving 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 are phlegmon and abscess - purulent inflammation of tissues that pose a threat to life. [ 20 ]

Diagnostics deep caries

Diagnosis of pulp condition based on clinical examination and patient symptoms is a challenging task in clinical practice, as it is a key factor in making therapeutic decisions in the treatment of deep caries. [ 21 ] Deep caries is easily diagnosed, patient complaints and visual inspection are often sufficient. A dental mirror and probe are used as instruments. It is more difficult to determine destruction in adjacent cavities of teeth or under a filling or crown. In this case, it is detected using a temperature test - cold with an unremoved nerve [ 22 ] or an X-ray - the most reliable method. [ 23 ]

Differential diagnosis

Toothache due to caries can imitate both trigeminal neuralgia and other chronic disorders of the trigeminal nerve. [ 24 ] Deep caries should be differentiated from medium caries, which has a less extensive carious cavity, and acute focal pulpitis. The latter is characterized by long-term aching pain (1-2 days), as well as paroxysmal pain, which appears both with and without an irritant. When probing, there is sharp pain in one point.

Prevention

There are several main rules for preventing caries: [ 25 ]

1. Oral hygiene.

Because dental caries does not progress without bacteria, daily plaque removal by brushing, flossing, and rinsing is one of the best ways to prevent tooth decay and periodontal disease.

2. Use of fluorine.

Fluoride prevents dental caries by inhibiting demineralization of the crystalline structures inside the tooth and enhancing remineralization. The remineralized surface is resistant to acid attacks. In addition, fluoride inhibits bacterial enzymes [ 26 ]. Fluoride can be obtained through water fluoridation, the use of fluoride toothpastes, fluoride mouth rinses, food fluoride supplements, and professionally applied fluoride compounds such as gels and varnishes.

3. Using sealants for pits and cracks in teeth:

Most cases of dental caries in young children occur in pits and fissures. Pits and fissures are more susceptible to dental caries because the anatomical structure promotes plaque accumulation. By filling such irregularities with a flowable restorative material, the area becomes less morphologically receptive [ 27 ]. This procedure is especially recommended for children with teething and adults with a high caries rate.

4. Xylitol:

Sucrose is a well-known cause of dental caries, and increased sucrose consumption increases the risk of dental caries. However, it is impossible to completely eliminate sugar from the diet. Therefore, sugar substitutes have been developed to reduce the risk of dental caries. Xylitol is one of these sugar substitutes. Xylitol has a sweet taste comparable to sugar, and it is not only non-cariogenic but also anticariogenic. It prevents sucrose molecules from binding to mutans streptococci (MS), thereby blocking their metabolism. [ 28 ]

A well-thought-out diet that minimizes carbohydrates - in childhood, it is important to consume foods rich in calcium (cottage cheese, milk), phosphorus (fish), vitamin D (animal and fish liver, cereals, eggs), fluorine (walnuts, pumpkin, buckwheat, oatmeal, spinach); give preference to solid food, eat less sweets;

5. Vaccine:

Since dental caries is an infectious microbiological disease, there have been attempts to develop a vaccine. Several MS vaccines in the form of proteins, recombinant or synthetic peptides or protein-carbohydrate conjugates, as well as DNA-based vaccines have been experimentally successful. However, none of these vaccines have been commercialized so far [ 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 primary educator in children:

Since dental caries is an infectious disease, the primary source of infection for young children (usually the mother) can transmit caries-causing microorganisms to the child, leading to MS colonization in the infant's oral cavity. In fact, there is a direct relationship between MS levels in parents and their children [ 31 ]. Therefore, efforts to reduce MS levels in parents, including maintaining oral hygiene and undergoing dental treatment when necessary, are also important for preventing dental caries in young children.

7. Visiting a dentist without a reason once every six months.

Forecast

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, to obtain the proper aesthetic appearance. Permanent teeth with deep dentin caries, which are treated either by partial caries removal or by staged caries removal methods, have a high probability of survival after two years. [ 32 ] The prognosis for an advanced condition is not always favorable due to the risk of tooth loss.