Dental caries

Dental caries is an acute or chronic pathological process, manifested by color changes, demineralization and destruction of hard tissues of the teeth and occurring with the active participation of microorganisms.

Throughout the centuries of history of the development of the specialty, more than 414 theories, views and concepts of the disease have been proposed. In 1898, Miller presented the chemistry-parasitic theory of caries development, universally recognized and confirmed by many scientists. The essence of the theory is that microorganisms of the oral cavity, which cause caries of teeth, in the presence of special low-molecular carbohydrates, produce organic acids. With their long-term effect on the enamel of the tooth, it is demineralized and the formation of a carious cavity. However, there are also secondary factors that cause tooth decay. These include the rate of secretion and oral fluid composition, pH, buffer saliva, frequency and duration of action of carbohydrates, violation of occlusion and pathology of tooth formation.

[1], [2], [3], [4], [5], [6], [7]

What causes dental caries?

One of the leading factors that causes dental caries is the tooth-bud. Dental plaque is a structured viscous plaque on the tooth, consisting of components of saliva, bacteria, bacterial metabolic products and food residues.

The process begins with the formation of a supragingival plaque on hard-to-clean areas of the teeth (fissures, approximal surfaces, cervical areas of the crown). Plaque is formed in several stages. First, an unstructured film 0.1-1 μm in thickness is formed on the surface of the tooth, consisting of saliva proteins. It includes acid, proline-rich proteins, glycoproteins, whey proteins, enzymes, immunoglobulins. These inclusions are interconnected electrostatically. The cell-free film plays the role of a semi-impermeable membrane that controls the metabolic processes between the oral cavity, the plaque and the tooth.

In the second stage, Gram-positive cocci (Streptococcus sanguis), actinomycetes, veylonelli and filaments are attached to the resulting film. The plaque increases in volume by dividing and further accumulating bacteria. Mature plaque on 60-70% of the volume consists of a dense layer of bacteria. It is not washed off by saliva and is resistant to mouth rinsing. The composition of the plaque matrix depends on the composition of saliva, the nature of nutrition and the products of the vital activity of bacteria. The microbial plaque formed is the key factor that causes tooth decay. The leading role in the process of caries formation is played by the one in the microbial plaque Str. Mutans, which has a significant productivity in the metabolism. In the presence of sugar Str. Mutans with the help of glucosyltransferases ensures a tight fit of microorganisms to the surface of the tooth. Thanks to anaerobic glycolysis, streptococci form organic acids (lactate, pyruvate), which, upon contact with the tooth enamel, demineralize solid tissues. Str. Mutans, along with the formation of organic acids, is resistant to an acidic environment. It is able to exist at an acidity below 5.5. Under these conditions, other microorganisms die. Other microorganisms of the oral cavity, which play a role in the pathogenesis of caries, are lactobacilli and actinomycetes. Lactobacilli in an acidic medium exhibit metabolic activity. Actinomycetes slightly increase the acidity of the dental plaque, but they contribute to the development of dental caries. In particular, Orlander and Blayner in 1954, in animal experiments, it has been proved that, if they are kept and sterile and cariesogenic dieted, tooth decay does not occur. As soon as the animals were injected into the oral cavity Str. Mutans, caries developed in animals. Also, there can be a transfer of cariogenic infection from one animal to another. Thus, the possibility of infection with caries in people, in particular from the mother to the infant through the nipple, has been shown.

The quality of nutrition and the frequency of eating carbohydrates (sucrose, glucose, fructose, lactose and starch), which form a nutrient medium for microorganisms - the main factor that causes tooth decay. Great importance in the system of protection of the oral cavity has oral fluid. It contains 0.58% of mineral components (calcium, phosphorus, fluorine, etc.). The pH is 6.8 fi.4, Within a day, up to 1.5-2 liters is released. Functions of oral fluid are numerous. These include: rinsing the oral cavity, neutralizing acids (bicarbonates, phosphates, proteins), remineralization of enamel (fluorides, phosphates, calcium), creating a protective coating on the tooth surface (glycoprotein, mucin), antibacterial action (antibodies, lysozyme, lactoferrin, lactoperoxidase), participation in digestion (amylases, proteases). The change in the volume of oral secretion (hyposalization) and its biochemical properties contributes to the development of caries.

Dental caries in the spot stage (initial caries)

There are no complaints of pain. Cosmetic defect: white or pigmented spot. Perhaps the feeling is nauseous.

Anamnesis: the spot appeared recently (days, weeks, pigmented - months). Dimensions, intensity of color stains increase. A white spot can pigment.

Inspection reveals an area of enamel whitish color or pigmentation of enamel. For children's teeth more characteristic white, for adults - a pigmented spot. Localization: cervical areas of the tooth, pits, fissures, proximal surfaces. Strict symmetry of lesions is not characteristic, multiple tooth caries are possible. Drying increases the opacity and whiteness of the stain.

Objective data. Probing: the surface of the enamel is not clinically changed, the probe does not stay, glides over the surface; there is no roughness. Soreness is not noted. Thermometry: physiological sensitivity is not changed (the tooth does not react to cold). Percussion - the reaction is negative. The affected area of the enamel is stained with methylene blue. Transillumination reveals the area where the luminescence is extinguished. Electroexcitability of the tooth within normal limits (2-5 μA). On the roentgenogram, there is no change in hard tissues and periodontium. Differential diagnosis is performed with non-carious lesions of the enamel.

[8], [9], [10]

What kinds of tooth decay?

To register the status of teeth in clinical documents, more than 20 systems have been proposed. In our country, the system of digital designation of teeth of the upper and lower jaws, proposed by Sigmonoidei in 1876

In 1970 in Budapest, the International Federation of Dentists (FDI). The International Organization of Standards (ISO) and the World Health Organization (WHO) approved an international system for marking teeth, where each half of the upper and lower jaws is designated by a number.

The tooth number is designated from the measuring tool to the third molar in numbers from 1 to 8, respectively.

In the United States adopted the universal digital system of the American Dental Association.

Permanent bite:

• 1-8 9-16
• 32-25 24-17

Temporary bite:

• ABCDE FYHI
• TSRQP ONMLK

ISO suggests the name of the surface of teeth adopted in the clinic, the letters:

• occlusive - O (O),
• Mesial - M (M),
• distal - D (D),
• vestibular (labial or buccal) - B (V),
• lingual - A (L),
• radicular (root) - P (G).

Classification of the carious process can be represented by the following features.

Topographical:

• tooth decay in the stain;
• superficial caries of teeth;
• average dental caries;
• deep tooth decay.

Anatomical:

• caries of enamel;
• caries of dentin;
• caries of cement.

By localization:

• fissure caries of teeth;
• Approximate dental caries;
• cervical caries of teeth.

At the suggestion of Black (1914), taking into account the localization of carious lesions, five classes are distinguished.

• Class 1 - cavities located in pits and fissures of molars and premolars, lingual surface of upper incisors and vestibular and lingual grooves of molars.
• Class 2 - cavities on approximate (contact) surfaces of molars and premolars.
• Class 3 - cavities on the approximate surfaces of the incisors and canines without affecting the cutting edges.
• Class 4 - cavities on the approximate surfaces of incisors and canines with lesion of the cutting edge.
• Class 5 - cavities in the cervical region on the vestibular and lingual surfaces.

American dentists also provide 6th grade.

Class 6 - cavities on the cutting edge of the incisors and on the tops of the hillocks.

By the duration of the current:

• fast tooth caries;
• slow tooth caries of teeth;
• stabilized dental caries.

By the intensity of caries development:

• compensated dental caries;
• subcompensated dental caries;
• decompensated caries of teeth (for children).

A number of authors proposed classifications that take into account the above properties of the carious process. Thus, E.V. Borovsky and P.A. Lace (1979) proposed the following classification.

Clinical form:

• a) stain stage (carious demineralization);
• b) progressive (white and light spots);
• c) intermittent (brown spots);
• d) suspended (dark brown spots).

Carious defect (disintegration):

• enamel (superficial caries of teeth);
• dentine;
• average dental caries;
• deep tooth caries;
• cement.

By localization:

• fissure caries of teeth caries;
• caries of the cervical region.

With the flow:

• rapid tooth decay; caries of teeth;
• slow caries caries of teeth;
• stabilized process.

By the intensity of the lesion:

• single lesions;
• Multiple lesions;
• systemic lesions.

Dental caries

Dental caries is characterized by pain in the tooth, which are strictly causal, disappear immediately after eliminating the irritating factor. The presence of a defect in hard tooth tissues.

Anamnesis. The dynamics of sensations: in the early stages - a sense of nausea, then - pain from sweet, then - pain from thermal and mechanical stimuli. Defect of the tooth appears after the eruption (the tooth erupts intact).

Inspection. Localization outside the immune zones (prigesnevaya, proximal surfaces, areas of pits and fissures). Strict symmetry of lesions is not present. Possible single defects of individual teeth or multiple caries of teeth. When examining a spot or a cavity is determined.

Objective data. Roughness when probing the bottom and walls of the cavity. Percussion is painless. Electroexcitability of pulp within physiological sensitivity (2-10 μA). On the roentgenogram in the periodontal gap there is no change.

[11], [12],

Superficial caries of teeth

Complaints: pain from chemical irritants (from sweet). Defined cosmetic defect in the form of a shallow cavity, color disturbance. The roughness of the enamel is detected.

Anamnesis: sensations have appeared recently (weeks). Previously, there was a change in the color of the enamel in a separate area of the tooth. When a pigmentation appears on the altered area, the pain from the sweet can disappear.

Inspection: defect within the enamel - walls whitish or pigmented. Localization - sites of low enamel resistance (cervical, proximal areas, pits, fissures).

Objective data. Probing reveals surface roughness. There is no soreness. Thermometry and percussion are painless. The enamel around the defect is stained with methylene blue. Transillumination reveals suppression of luminescence. Electroexcitability of the pulp within the limits of normal (2-5 μA). On the roentgenogram, there is no change in the periodontal cleft.

Additional information is provided by sounding. With caries and acid necrosis the surface is rough, the tip of the probe is retained in microdefects. With hypoplasia, fluorosis, erosion, wedge-shaped defect, the tip of the probe slides over the surface, there is no roughness, the surface of the defect is smooth, shiny.

Medium acute dental caries

Complaints of pain from chemical, thermal and mechanical effects, which disappears immediately after elimination of the stimulus. Presence of a cavity, jamming write.

Anamnesis: The cavity can exist for several weeks, months. Previously, there was a change in the color of the enamel in a separate area of the tooth, the roughness of the enamel, the pain from the sweet tooth.

Inspection reveals a cavity within the cloak dentin (middle depth), dentin light, without pigmentation. Localization - favored for caries (cervical region, proximal, occlusal surfaces, fissures, fossae). There are both single and multiple lesions.

Objective data. Probing reveals the roughness of the bottom and walls of the cavity, soreness in the area of the enamel-dentinal junction. The preparation of boron in this area causes pain. Thermometry is painful: a directed stream of coolant provokes a short-term pain reaction. Percussion is painless. The enamel around the defect is stained with methylene blue. Electroexcitability of pulp is not changed (2-5 μA). On the X-ray in the periodontal gap there is no change, in the region of the carious cavity the area of enlightenment is determined.

Average chronic dental caries

Complaints about cavity (food jam). The bottom and walls of the cavity are pigmented. Pains are absent or strictly causal (from cold), weak intensity.

Anamnesis: the cavity can exist for several weeks, months. Previously there was a change in the color of the enamel on a separate area of the tooth, the roughness of the enamel. When the pigmentation appeared on the altered area, the pain could disappear.

Inspection: the cavity is located within the cloak dentin (medium depth and size), the bottom and the walls are pigmented. Localization - favored for caries (cervical area, proximal, occlusal surfaces). Symmetrical, but more often single lesions are possible.

Objective data. Probing reveals the roughness of the surface of the defect, probing can be painless or weakly sensitive in the region of the enamel-dentine bond. The preparation of boron by EMF is painful. Thermometry: A directed stream of coolant can cause a painful short-term reaction of low intensity. Percussion is painless. The enamel around the defect is not stained with methylene blue. Electroexcitability of the pulp is preserved. On the radiograph in periodontium there is no change, a patch of enlightenment is detected in the area of the carious cavity.

[13], [14], [15], [16],

Deep sharp tooth decay

Complaints: acute pain from chemical, thermal and mechanical stimuli, disappears immediately after the elimination of the causative factor. It is possible to change the tooth in color, a crown defect, a cavity of considerable size, hit (stuck) write.

In the anamnesis - pain from chemical irritants (sweet), the presence of a cavity of small dimensions, which gradually increased.

Inspection reveals a deep carious cavity (of considerable size). The inlet is smaller than the width of the cavity, which is easily determined by probing. Enamel / dentin on the walls of the cavity can be light or melodic altered.

Objective data. Sounding the bottom of the carious cavity painfully, the softened dentin is pliable and removable in layers. Thermal stimuli cause an intense but short-term pain response. Percussion of the tooth is painless. Electroexcitability of the pulp is within normal limits or slightly reduced (up to 10-12 μA). On the roentgenogram, the area of enlightenment in the area of the carious cavity is determined. Messages with the pulp chamber are not present. There are no changes in the periodontium on the radiograph.

Deep chronic caries of teeth

Complaints of causal pain are mild or absent. Disturbs the presence of the cavity, where the food gets, the discoloration of the tooth.

In the anamnesis - pains from chemical, thermal, mechanical stimuli - strictly causal, short-term. In chronic course - the symptoms are mild, periodic.

Upon examination, a carious cavity of considerable depth is determined, distributed into the near-pulpary dentin. A wide inlet is characteristic. The bottom and walls of the cavity are covered with pigmented dentin.

Objective data. When probing, soreness is absent or weakly expressed in the region of the bottom of the cavity. The dentin is dense. Messages with pulp are not present. Thermometry is painless or weakly sensitive. Electroexcitability of pulp is slightly reduced (10-12 μA). On the roentgenogram, you can determine the dimensions of the carious cavity over the area of enlightenment. Changes in periodontitis are not found.

[17], [18], [19], [20]

Proximal caries of teeth

Complaints: it is typical to get stuck between the teeth. Changing the color on the proximal portion of the tooth. Possible pain from the cold.

Anamnesis gives me scant information.

Inspection, the cavity is not determined. Modified in color areas of the enamel may be identified: petiolate or pigmented

Objective data. Normal probing of the accessible tooth surfaces does not reveal cavities. With careful probing with a sharp instrument of the proximal area, a roughness is detected - the tip of the probe lingers in the dentin. Rinse mouth with cold water may not cause pain. Directed jet of coolant provokes a short-term attack of pain. Percussion of the tooth is painless. With transillumination, a portion of the glow suppression in the proximal part is detected. Electroexcitability of the tooth within normal limits or somewhat reduced (2-12 μA). X-ray diagnostics is given great importance: on the x-ray, the area of enlightenment in the region of the carious cavity is determined.

Caries of cement

The initial stage of caries differs by the softening of the cement. A defect is not detected, but the surface is characterized by a change in color: it brightens or, on the contrary, is pigmented, acquiring a light brown, rusty hue. The yielding is determined when probing. The appearance of a carious cavity is accompanied by the destruction of dentin. As a result, the probe tip is easily immersed in the root tissue. Thermometry, sounding become painful, which corresponds to the clinic of dentin caries (medium or deep).

Caries of cement can spread along the circumference of the tooth, circularly, towards the top of the root or, conversely, to the enamel-dentinal junction. The development of a defect on the proximal surface can be asymptomatic until the appearance of pulpitis.

The removal of dental deposits contributes to the visual detection of latent lesions of cement. Using an acute probe allows you to determine the softening of the dentin and the level of tactile sensitivity.

Radiographic examination - diagnose proximal caries of teeth.

The development of the carious process is possible under an artificial crown. Defeat limited to enamel, is rare, with a short period of the tooth under an artificial crown. With a longer period of 2 times more often carious damage to the dentin. The development of caries of cement also depends on the period of use of the artificial crown. Combined damage to the crown and root of the tooth is directly related to the duration of wearing the structure. The number of carious cavities in the prisidesal area is significantly increased, circular tooth caries is found in patients of older age groups.

The destruction of the crown of the tooth horizontally, without a pronounced carious cavity, is recorded with a prolonged stay of the tooth under an artificial crown. The defect of the slit-shaped form in the prigosneve region occurs in every fourth case. When the term of wearing the crown increases, the frequency of occurrence of prideparticular caries increases. Violation of the marginal fit of the filling, the development of secondary caries occurs regardless of the duration of the tooth under the artificial crown.

[21], [22], [23]

How to recognize tooth decay?

Diagnosis of tooth caries covered with an artificial crown requires careful probing of the tooth's neck. The reaction to thermometry is carried out using a coolant with a directional jet (Coolan). Diagnosis is greatly facilitated after removal of the artificial crown.

A thorough examination reveals a loss of natural gloss of the affected area of the enamel. It becomes opaque, and subsequently, upon transition to the chronic stage, when the pigment melanin and other dyes are deposited, acquires a brown or even black color. The patient does not react to the effect of temperature stimuli. The percussion of this tooth is painless. Electrodontometric diagnostics indicates the presence of indicators equal to 3-6 μA, which corresponds to the norm.

On the roentgenogram, especially on the approximal surfaces of the teeth, it is possible to identify foci of demineralization, to determine the lesion zone, the further course and the results of remineralizing therapy.

In clinical practice the basic and additional methods of caries diagnosis to the main methods are applied:

1. Stomatoscopy. Irradiation of teeth with ultraviolet lamp. In the absence of caries, tooth enamel will fluoresce yellowish light, and if the structure of the tooth (demineralization) is broken, the fluorescence will decrease.
2. Transillumination method. The technique consists in radiating tooth tissues with a halogen lamp to cure composite materials or a special lamp with fiber optics. The violation of the structure of the tooth will be noted in the form of the participants in the blackout. The technique is used for detecting secondary caries around the filling material, tooth enamel cracks and controlling the completeness of removal of the altered dentin when carious cavity is treated.
3. Vital staining. The method is based on the fact that the permeability of the enamel barrier is increased by dyes and the zone of demineralization or etching of enamel with acid. The cleared plaque and dried tooth is stained for 3 min with tampons with a 2% aqueous solution of methylene blue. The dye is then rinsed off with water and a stained enamel patch remains. The color intensity has a range from pale blue to bright blue with a color intensity of 0 to 100%, and in relative figures from 0 to 10 or 12, depending on the difference in scales. The control is carried out after 24 hours, the normal enamel is restored by this time and does not stain or if there is a change in the acid resistance a few days later is stained. By the duration of color preservation, one can judge the state of demineralization of enamel.
4. Colorimetric test. The procedure consists in successively rinsing the oral cavity with 0.1% glucose and 0.15% solution of methylene red. In areas of enamel, where there is a change in pH to the acid side at the rates of 4.4-6.0 and below, the color varies from red to yellow. The level of caries detection is 74.8% (Hardwick).
5. Reflection. Identification of the carious process in the cervical area of the tooth by reflected light of the illuminating lamp of the dental unit.
6. The device KAVO Diagnodent, the laser diode of the device creates pulsed light waves that fall on the surface of the tooth. Once the altered dental tissue is excited by this light, it begins to fluoresce with light waves of a different length. The length of the reflected waves is analyzed by the instrument. The level of tissue changes is reflected on the display of the device in the form of digital indicators or an audible signal. The device allows you to identify hard-to-reach areas of demineralization, fissure dental caries of approximated surfaces, or altered tissues when carious cavity is treated. The device does not cause any unpleasant sensations in the patient.

Examination of dental patients allows us to evaluate the patient's predisposition to a cariogenic process. The tendency of teeth to carious destruction is characterized by the following features: dental caries of the frontal row, rapid loss of fillings and the appearance of new carious cavities for one year after the sanation, the presence of several carious cavities on one tooth, the presence of depulled teeth and a large amount of plaque on the teeth.