Treatment of deep dental caries: basic methods

Deep caries does not appear suddenly, but is a consequence of ignoring the destruction of the tooth, which begins with slightly visible changes in the enamel, the formation of a "cavity", its deepening into the hard layers - dentin. Sometimes it occurs for a reason beyond a person's control, for example, poor-quality treatment of the middle stage of the pathology. Tooth decay occurs with certain symptoms (short-term pain from an irritant, their increased sensitivity), requiring an immediate response. Treatment of deep caries is a rather complex process that is resolved in the dentist's office by a highly qualified specialist.

The treatment of deep carious lesions presents a significant challenge to the practitioner. Conventional treatment of carious lesions of any kind requires the removal of all infected and diseased dentin to prevent further cariogenic activity and to provide a well-mineralized dentin matrix for restoration. However, when the procedure risks exposing or even damaging the pulp, the course of treatment becomes less predictable and may require measures such as indirect pulp capping (usually using a calcium hydroxide-based protective material), pulpotomy, or, in extreme cases, pulpectomy. Choosing among these options can be challenging for the dentist, as well as for the patient, who is advised of the risks and asked to participate in the decision. [ 1 ]

How is deep caries treated in adults?

The tactics of treating deep caries in adults depends on the severity of the destructive process. There are several forms of pathology:

• compensated (corresponds to a chronic course) - the intensity of the tooth disease is not high, and the bottom of the carious cavity is hard;
• decompensated (acute) with several points of damage, the depth of which reaches the peripulpar soft dentin.

In the first case, caries is treated in one visit, in the second case, two are required. Studies comparing either partial caries removal or stepwise, staged caries removal with subsequent complete removal of infected tissue from deep carious lesions were the subject of a 2006 Cochrane review. [ 2 ]

The therapy is performed under local anesthesia, so the patient does not experience any unpleasant sensations, except for the injection itself. A new method of pain treatment and reduction of local anesthesia use in deep caries has recently been introduced. The dentist's task is to save the tooth, put a quality filling, prevent relapses, remineralize the remaining dentin and ensure the formation of secondary.

Stages of treatment of deep caries

In case of chronic caries, the stages of treatment of deep caries consist of:

• opening the carious cavity, using spherical burs to remove damaged tissue, enamel fragments hanging over it, and leveling its bottom;
• antiseptic treatment with broad-spectrum antimicrobial drugs;
• application of a special lining to isolate dentin from pathogenic microorganisms;
• application of an insulating layer to secure the healing layer;
• installation of a permanent photopolymer filling;
• its fitting and polishing.

The acute form of the disease, due to the depth of the lesion, a very small distance from the pulp, and the possibility of complications, requires a temporary filling after all the previous points. After 10-12 days, if there are no patient complaints, it is replaced with a permanent one. Some studies show that partial removal of caries is preferable to complete removal of caries in order to reduce the risk of carious impact.

Materials for the treatment of deep caries

A 2% aqueous solution of chlorhexidine or a gel based on it, and 3% hydrogen peroxide are used as disinfectants in the treatment of deep caries.

The lining for the bottom of the carious cavity is made of calcium preparations with antibacterial action: calcemin, calcium hydroxide, calcipulp, calcimol, calcevit. Some of these products are made in the form of a syringe with a needle and a cap for ease of application, others are prepared on a glass plate by mixing several compositions. The task of this layer is to maximally protect healthy tissues from infections and saturate them with mineral components that improve the structure of the teeth. A study conducted in 2019 showed that linings with calcium hydroxide did not affect the clinical success of treating deep caries lesions of primary or permanent teeth. [ 3 ]

An insulating lining for deep caries overlaps the healing layer by 0.5-0.7 mm to create a seal and is made of glass ionomer cements: Ketak Molar, Glassin Rest, Cemion.

Filling material for deep caries

The filling material for deep caries must meet a number of requirements:

• be safe for health;
• have good adhesion to tooth tissue;
• be resistant to mechanical impact;
• give minimal shrinkage;
• preserve color;
• resist bacteria;
• serve for a long time.

Previously, copper and silver amalgams were used for fillings. The use of amalgam does not pose a health risk, except for allergic reactions in a few patients. [ 4 ], [ 5 ] Despite their strength, they are now practically not used due to their unaesthetic appearance. Glass ionomer cements are used in cases of multiple caries, the location of the affected area below the gum tissue.

Filling in modern dentistry is carried out using more modern materials, which include composites and compomers. [ 6 ], [ 7 ], [ 8 ] They can be light-reflecting or chemically reflective, with preference given to the former. [ 9 ]

A new trend is an alternative to fillings - ceramic inlays, which are made to the shape of the tooth, cover the holes and are firmly fixed. [ 10 ]

Deep fluoridation for deep caries

Usually, the procedure of fluoridation - strengthening teeth with fluoride-containing preparations is used to prevent the development of caries, but in case of deep damage, this method is also used. Deep fluoridation of dentin is carried out using a dentin-sealing liquid, which contains copper-calcium hydroxide. [ 11 ], [ 12 ]

Alkaline copper fluoride, when precipitated, has a permanent powerful bactericidal effect and prevents the occurrence of secondary caries.

Pastes for the treatment of deep caries

In the treatment of deep caries, multi-component pastes are used, which include preparations of different directions. They should have an antimicrobial effect, stimulate the formation of secondary dentin, and have an anti-inflammatory effect.

One of the options could be the following composition:

• calcium hydroxide and chloride - promote the appearance of substitution structures in deltin; [ 13 ]
• titanium oxide - radiopaque component; [ 14 ], [ 15 ]
• metronidazole - has an antimicrobial effect; [ 16 ]
• hydrocortisone - has an anti-inflammatory effect;
• collagen - binds dentinal fluid, is an odontotrope. [ 17 ]

Other medicinal pastes may contain fluorides, hydroxyapatites, NSAIDs, glucocorticoids, chlorhexidine, sodium hypochlorite, novocaine, various medicinal plant oils, vitamin solutions, etc. It is worth noting that all toothpastes have a remineralizing effect. [ 18 ]

In case of acute deep caries, a combination of fast-acting drugs is used. Their task is to relieve pain, inflammation, swelling, destroy pathogenic microflora, and normalize blood circulation in the pulp. Their effect should be short-term but effective. They are used as a therapeutic lining installed for several days under a temporary filling.

Treatment of deep caries in children

Although baby teeth are not permanent and will fall out, caries in children should not be ignored. Its deep stage can lead to troubles inherent in the disease. For the treatment of deep caries lesions in children, both selective or stepwise (one- and two-stage) incomplete removal and complete removal of caries are used. [ 19 ]

The treatment algorithm is practically the same, but with some peculiarities. And the doctor also needs to have the skills of a psychologist to persuade the child not to be afraid and to sit for 20-30 minutes.

At the beginning of the session, the injection site is treated with a special anesthetic ointment or spray so that the little patient does not even feel it, while a very thin needle is used, and the anesthetic itself is in a minimal dose.

The carious cavity is prepared using technologies that allow targeted action without affecting healthy tissues (using a powerful stream of air, water or a special abrasive).

Disinfection of affected areas is carried out with a solution of copper and calcium hydroxide, which is quite safe.

Other materials are used for fillings than for adults. Plastics with artificial resins and silicate cements are considered dangerous, while silicophosphate and glass ionomer are more suitable. There are fillings with fluoride, which gradually strengthen the tooth, and children are also interested in multi-colored, shiny ones, and there are some.

Toothache after treatment of deep caries

For most people, going to the dentist is not an easy step and each person expects that the treatment will relieve him from suffering. But sometimes the tooth continues to hurt. Why does this happen? In fact, such a reaction is normal and can be caused by several reasons:

• a consequence of the introduction of an anesthetic drug into the gum in close proximity to the tooth;
• by treating tooth enamel with a special agent, which is then dried. This causes the dentin to lose moisture, which leads to increased sensitivity and pain, and it goes away within 1-2 weeks;
• insufficient drying of the tooth - the adhesive used to securely fix the filling gets into the dentinal tubules.

Pulpitis after treatment of deep caries

There is also a more serious reason for the appearance of pain after treatment of deep caries. Paroxysmal or aching, not responding to painkillers, swelling of the gums indicates the development of complications, including pulpitis - inflammation of the dental nerve. [ 20 ] It does not go away on its own and you need to immediately contact the clinic to prevent tooth loss.

Probing the bottom of the cavity is very painful. Treatment may consist of removing the nerve, cleaning the canals, and filling them. Although the tooth is dead after this, pain is still felt for some time. In some cases, conservative treatment is used.