Treatment of deep caries of teeth: basic methods

Deep caries does not appear suddenly, but is the result of ignoring the destruction of the tooth, starting with slightly visible changes in the enamel, the formation of a hollow, and its deepening into hard layers - dentin. Sometimes it occurs for a reason that does not depend on the person, for example, poor-quality treatment of the middle stage of pathology. Tooth decay proceeds with certain symptoms (short-term pain from an irritant, their hypersensitivity) requiring immediate reaction. Treatment of deep caries is a rather complicated process, which is solved in the dentist’s office by a highly qualified specialist. 

Treatment of deep carious lesions is a serious problem for the practitioner. Traditional treatment of carious lesions of any kind requires the removal of all infected and affected dentin in order to prevent further cariogenic activity and to provide a well-mineralized dentin base for recovery. However, when the procedure risks exposing or even disrupting the pulp, the course of treatment becomes less predictable and may require such measures as indirect coating of the pulp (usually using a protective material based on calcium hydroxide), pulpotomy or in extreme cases - pulpectomy. Choosing among these options can be difficult for the dentist, as well as for the patient who is informed about the risks and asked to take part in the decision.[1]

How is deep caries treated in adults?

The tactics of treatment of 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, but the bottom of the carious cavity is solid;
• decompensated (acute) with several points of damage, the depth of which reaches the pulpary dentine.

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

Therapy is carried out under local anesthesia, so for the patient this process does not promise any unpleasant sensations, except for the injection itself. Recently, a new method of treating pain and reducing the use of local anesthesia for deep caries was introduced. The task of the dentist is to save the tooth, to deliver a high-quality filling, to prevent the development of relapses, to remineralize the remaining dentin and to ensure the formation of secondary.

Stages of treatment for deep caries

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

• disclosure of the carious cavity, use of spherical burs to remove damaged tissue hanging over it enamel fragments, leveling its bottom;
• antiseptic treatment with a broad spectrum of antimicrobial action;
• the imposition of special pads to isolate the dentin from the ingress of pathogens;
• the imposition of an insulating layer to fix the treatment;
• installation of permanent photopolymer fillings;
• its fitting and polishing.

The acute form of the disease due to the depth of the lesion, a very small distance from the pulp, the possibility of complications requires a temporary filling after all the preceding paragraphs. After 10-12 days, if there are no complaints from the patient, 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 caries. 

Materials for the treatment of deep caries

As disinfectants in the treatment of deep caries used 2% aqueous solution of chlorhexidine or gel based on it, 3% hydrogen peroxide.

The gasket on the bottom of the cavity is made of calcium preparations with antibacterial action: calcemin, calcium hydroxide, calcipulp, calcimol, calceum. Some of these tools 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 protect as much as possible healthy tissues from infections and to saturate them with mineral components that improve the structure of teeth. A study conducted in 2019 showed that calcium hydroxide pads did not affect the clinical success of treating deep caries lesions of dairy or permanent teeth.[3]

An insulating gasket with deep caries overlaps the layer of treatment by 0.5-0.7 mm to create a tightness and is made of glass ionomer cements: ketak molar, glass rest, cetion.

Sealing material for deep caries

Filling material for deep caries must meet several requirements:

• be safe for health;
• have good adhesion with tooth tissues;
• be resistant to mechanical stress;
• minimal shrinkage;
• keep color;
• resist bacteria;
• long serve

Previously, copper and silver amalgams were used for fillings. The use of amalgam does not pose a health hazard, with the exception of allergic reactions in a few patients. [4], [5]Despite the strength, now they are practically not used because of their lack of aesthetics. Stekloinomernye cements are used in the case of multiple caries, the location of the affected area below the gum tissue.

Filling in modern dentistry is carried out with the help of more modern materials, which include composites, compomers. [6], [7], [8]They are light and chemical reflections, preference is given first.[9]

A new trend - an alternative to fillings - ceramic inlays, made in the shape of a tooth, closing holes and tightly fixed. [10]

Deep fluoridation for deep caries

Typically, the procedure of fluoridation - strengthening teeth with fluoride-containing drugs is used in order to prevent the development of caries, but with deep lesions this method is also used. Deep fluoridation of dentin is produced by the dentin-sealing fluid, which contains copper-calcium hydroxide.[11], [12]

Alkaline copper fluoride, precipitating, has a constant powerful bactericidal effect, prevents the occurrence of secondary caries.

Pastes for the treatment of deep caries

In the treatment of deep caries used multicomponent pastes, including drugs of different directions. They must have an antimicrobial effect, stimulate the formation of secondary dentin, and have an anti-inflammatory effect.

One option may be the following composition:

• calcium hydroxide and chloride - contribute to the appearance of replacement structures in the deltina; [13]
• titanium oxide - radiopaque component; [14], [15]
• metronidozol - provides antimicrobial effects; [16]
• hydrocortisone - has anti-inflammatory action;
• Collagen - binds dentin fluid, is odontotropom. [17]

Fluorides, hydroxyapatites, NSAIDs, glucocorticoids, chlorhexidine, sodium hypochlorite, novocaine, various medicinal vegetable oils, solutions of vitamins, etc. Can be used as part of other medicinal pastes. It is worth noting that all toothpastes have a remineralizing effect. [18]

In acute deep caries, a combination of quick-acting drugs is used. Their task is to relieve pain, inflammation, swelling, destroy pathogenic microflora, and normalize blood circulation in the pulp. Their influence should be short-lived, but effective. They are used as a medical strip, installed for several days under a temporary seal.

Treatment of deep caries in children

Although baby teeth are inconstant and fall out, it’s not worth it to ignore caries in children. Its deep stage can lead to trouble associated with the disease. For the treatment of deep caries lesions in children, both selective or graduated (one- and two-step) incomplete removal, and complete removal of caries are used.[19]

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

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

The carious cavity is dissected using technologies that allow targeted action and not affect healthy tissue (through a powerful jet of air, water or a special abrasive).

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

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

Sore tooth after deep caries treatment

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

• the consequence of the introduction of an anesthetic drug in the gum in the immediate vicinity of the tooth;
• treating tooth enamel with a special agent, which is then dried. From this dentin loses moisture, which leads to hypersensitivity and pain, and within 1-2 weeks passes;
• the tooth lack of adhesion - an adhesive used for reliable fixation of the filling, gets into the dentinal tubules.

Pulpitis after deep caries treatment

There is a more serious reason for the appearance of pain after the treatment of deep caries. Paroxysmal or aching, not responding to painkillers, gum swelling indicates the development of complications, including pulpitis - inflammation of the dental nerve. [20]By itself, it does not pass and you must immediately contact the clinic to prevent tooth loss. 

The sensing of the bottom of the cavity is very painful. Treatment may consist in removing the nerve, cleaning the canals, and filling them. Although after that the tooth is dead, but pain is still felt for some time. In some cases, cost of conservative treatment.