Treatment of tooth decay

Treatment of dental caries depends on the severity of destructive processes in the hard tissues of the tooth and the general condition of the body. Conventionally, two main approaches to treatment can be distinguished - these are invasive and surgical methods.

Treatment of dental caries using non-invasive methods

The non-invasive method is used to treat caries in the spot stage. With this form of caries, patients do not complain of enamel defects or pain when exposed to temperature and chemical irritants.

Treatment of dental caries at the stage of enamel demineralization consists of electrophoresis with solutions of calcium preparations (calcium gluconate (3-5%) or a solution of acidified calcium phosphate introduced from the anode, and fluoride preparations (0.2% sodium fluoride solution)) from the cathode. When performing electrophoresis, it is necessary to carefully isolate the tooth surface from contact with saliva and the oral mucosa. Electrophoresis is carried out for 10-20 days with mandatory monitoring of the results of treatment by the method of vital staining of tooth tissues after 5 sessions.

Treatment of dental caries by surgical methods

Along with non-invasive methods of treating caries, surgical methods are currently the main ones. Surgical treatment of dental caries consists of a number of stages:

1. Hygienic treatment of teeth.
2. Determining the color of the tooth and choosing the color of the filling material.
3. Preparation of hard dental tissues.
4. Isolation of the tooth from saliva.
5. Medicinal treatment of the formed cavity.
6. Applying the gasket.
7. Installation of matrices and wedges.
8. Drying of the tooth surface and acid etching of the enamel.
9. Rinsing the etched surface of the tooth and drying the surface.
10. Application of adhesive.
11. Introduction of filling material.
12. Polymerization of the material.
13. Finishing and polishing of fillings.
14. Post-bonding or application of fluoride protector.

Hygienic treatment of teeth

The first stage involves cleaning the surface of the restored tooth from plaque. Abrasive pastes and brushes are used for this purpose. The abrasiveness of the plaque is marked with RDA (KEA) indices. Abrasive pastes contain silicon oxide and various aromatic additives. It is advisable to use pastes that do not contain fluorine (Klint, Voco). Hygienic treatment of the tooth helps to correctly select the color of the filling material.

Determining the color of the tooth and choosing the color of the filling material

The correct choice of color requires compliance with the following conditions:

• It is better to select colors in natural light during the daytime (12 hours).
• The tooth surface must be moist.
• It is not recommended to select a color for more than 15 seconds.
• If in doubt about the color choice, a darker material should be used, since reflective composite materials become lighter during the polymerization process.

Currently, 2 types of shades are used: VITA and IVOCLAR.

Some materials come with their own signature color scheme.

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Treatment of dental caries: preparation of hard dental tissues

The most widely known and widespread method was the preventive expansion proposed by Blak (1914). During this period, a metal filling material, amalgam, was used in clinical practice, which had significant mechanical strength. Metal fillings, if properly prepared and filled, last 10 years or more. In order for the tooth tissues surrounding the filling to be preserved for this period, it was necessary to widely excise caries-susceptible areas of the tooth while preserving resistant zones, such as skeets of tubercles, when forming class I cavities.

Preparation involves radical excision of the altered tooth tissues. This treatment of dental caries is based on the most important principle - "expansion for the sake of prevention".

The method of preventive expansion has not lost its practical significance even today when filling teeth with amalgam. However, the use of amalgam has many negative aspects: coloring of the tooth tissues surrounding the filling, lack of adhesion to enamel and dentin, difference in the coefficients of thermal expansion of the material and tooth tissues, etc.

In the 40-70s of the 20th century, cements were widely used. The duration of preservation of a filling made of mineral cement was insignificant, which led to frequent replacement of the filling. Moreover, each time during subsequent treatment of cavities, it was inevitable to remove hard tissues of the tooth.

The emergence of polymer filling materials has led to the need to develop a new principle for the formation of carious cavities - a method of preventive filling. It involves minimal excision of healthy tooth tissues to immune zones with rounding of the corners of the formed cavity. This method involves surgical treatment of dental caries and non-invasive or invasive preventive sealing of fissures, as well as local fluoridation of enamel. In these cases, the state of the patient's individual caries resistance and the features of the filling materials should be taken into account.

In 1994, the Dutch doctor Taco Pilot proposed a method of removing carious tissue with an excavator and then filling the formed cavity with glass ionomer cement. It was called the ART method, which is based on the properties of glass ionomer cements to release fluoride. The method can be used to provide dental care in difficult conditions, treating dental caries in young children, patients with severe general somatic pathology.

To treat tooth tissues, a sodium hypochlorite amino acid composition is used - the "Carisolv" method. After softening the dentine, it is removed with a sharp excavator.

The clinic uses the kinetic air-abrasive preparation (KAP) method. Under the influence of a focused ceiling of abrasive material (aluminum oxide or sodium bicarbonate with particle sizes of 25-50-100 microns), hard dental tissues are removed to the required level under visual control.

Formation of class I carious cavities

The fissures of molars and premolars are most often affected by caries. Demineralization of enamel and dentin takes the form of a rhombus. The caries-resistant zone on the chewing surface of molars and premolars are the tubercles and slopes of the tubercles. Treatment of dental caries of class I cavities requires a clear decision on what volume of tooth tissue should be removed, to determine the localization of the contact points of the antagonists. The doctor must decide what to use in a given clinical situation to restore tooth tissue: a filling, an inlay or an onlay. The solution to this issue depends on the volume of remaining tooth tissue, the thickness of the walls of the carious cavity, and the type of filling materials.

Traditionally, a carious cavity is formed in the form of a "box" with right or oval angles. To isolate the walls of the cavity, base (more than 1 mm thick) and thin linings are created that cover the bottom and walls of the cavity and serve to isolate the pulp from chemical irritants, as well as provide a connection between the walls of the tooth and the filling. Phosphate cement, polycarboxylate and glass-ionomer cements, as well as liquid-flowing composite materials are used as an insulating material. In the case of using composite materials for filling carious cavities, the bottom of the cavity and the walls are formed oval, since most composite materials have significant linear shrinkage and do not have the elasticity of mineral cements, which leads to the formation of voids in the area of the corners of the cavity. To prevent injury to the tooth pulp, the bottom of the cavity should repeat the relief of the pulp chamber. In order to improve the fixation of the filling material and a smoother transition of the filling material to the tooth tissues, it is recommended to bevel the enamel along the edge of the cavity. When placing an amalgam filling, bevel the enamel at an angle of 45". In the case of using a composite material, beveling the enamel is not necessary. The thickness of the composite material layer in the occlusal load zones should be at least 2 mm, which is due to the fragility of the material. In the presence of pressure, this can lead to a break in the edge of the filling and the development of secondary caries. Beveling the enamel, in the case of cosmetic requirements, must be done in the absence of contact with the tubercles of the antagonist tooth.

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Formation of class II carious cavities

Class II dental caries is also a common occurrence and accounts for up to 40% of all localizations. Its development is associated with insufficient oral hygiene, when dental plaque develops between the teeth on the approximal surfaces, leading to caries.

The carious process develops in the enamel and dentin zone in the form of two successive triangles facing outward with their apex. Diagnosis of the initial forms of class II caries cavity is quite difficult, since it is quite difficult to conduct a visual examination in the presence of adjacent teeth. The most informative is intraoral X-ray examination. It allows identifying the focus of demineralization, its boundaries and tracking the results of remineralizing therapy.

Treatment of class II dental caries can be done using the tunnel method. Removal of caries-altered dentin on the approximal part of the tooth is performed through a formed tunnel from the chewing surface. Glass ionomer cement is used to close the defect in the dentin layer, and the enamel layer is restored with composite materials.

In case of a more pronounced carious process, the opening of the cavity should begin on the chewing surface of the tooth with a fissure bur by creating a groove corresponding to the size of the carious lesion, stepping back from the lateral surface of the tooth. Then the thinned section of enamel is broken off with an excavator and then the cavity is formed.

Depending on the permanent filling material used, a different approach to cavity formation is used. The use of amalgam involves the formation of a cavity in the form of communicating trapezoids at an angle of 90. When using polymer composite materials, the cavity is formed more rounded on the approximal surface with diverging edges. The most vulnerable place for complications and the development of secondary caries and pulpitis is the gingival wall on the lateral surface of the tooth. The enamel of the gingival wall must be carefully smoothed.

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Formation of class III carious cavities

The peculiarity of the formation of this carious cavity is the solution of the issue of cosmetic preservation of the palatine and lingual walls. When using mineral cements, the carious cavity is opened from the palatine side. Currently, when using composite materials, it is recommended to remove the thinned vestibular surface. The bottom of the cavity is formed oval, so as not to open the cavity of the tooth. The angle of the outer surface of the enamel and the formed post should be straight. For a better transition of the color of the filling and the tooth, a gentle bevel of the enamel can be made.

Formation of class IV carious cavities

Treatment of dental caries depends on the size of the crown defect. The doctor must first decide which treatment method is more appropriate in this situation: placing a filling or using orthopedic treatment methods. It is necessary to first determine the bite and the point of contact with the antagonist. If conditions are created for the future filling to be “knocked out” by the antagonist, then it is more appropriate to use orthopedic treatment methods.

For better fixation of the filling material, long, gentle, wavy cuts of enamel are made with a fine-grained diamond instrument on the labial surface.

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Formation of class V carious cavities

Treatment of class V dental caries depends on the affected area, its location above, at or under the gum. In the first two cases, cavities with an oval convex bottom repeating the contours of the tooth cavity are formed. For better fixation of the filling material, a longitudinal section of the enamel can be made. In case of spread of caries lesion under the gum, it is advisable to form a cavity for the filling according to the open "sandwich" type. The subgingival cavity is closed with glass ionomer cements, and the visible part of the tooth is restored with composite materials.

Treatment of class V dental caries is carried out by processing and forming a cavity according to the type of defect and restoration using flowable or condensable materials.

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Treatment of dental caries: isolating the tooth from saliva

To perform a full restoration, it is necessary to ensure the dryness of the formed cavity. Isolation of the tooth from saliva can be absolute when using elastic sheets (Cofferdam, Quikdam) or relative when using cotton rollers. The use of cotton cynics should be avoided due to the possibility of fine fibers getting into the filling material.

Treatment of dental caries: drug treatment

Traditionally, medicinal treatment of the formed cavity was carried out with a 3% solution of hydrogen peroxide, 70% solution of alcohol and ether. Treatment of deep dental caries, to prevent irritation of the pulp, only treatment with a warm solution of 3% hydrogen peroxide was allowed. Currently, a carious cavity after formation can be treated with bactericidal solutions of 2% chlorhexidine or 1% benzaconium chloride. Good clinical results are observed after treatment of cavities with a 0.01% solution of miramistin.

Treatment of dental caries: application of a lining

Gasket materials are divided into 2 groups:

• insulating: varnishes, phosphates, glass ionomer cements.
• medicinal: containing calcium hydroxide.

Glass ionomers are used for insulating gaskets: classic two-component glass ionomers: lonobond (Voco), Ketar bond (Espe), dual-curing glass ionomers - Vitrebond (3M), XR-Ionomer (Kerr), light-curing polymers containing glass ionomer filler - Cavalite (Kerr), Septocal L. C (Septodont).

Recently, flowable composite materials have been used as a lining and to reduce stress in the enamel-filling structure. Flowable composites have positive properties: high thixotropy, the ability to fill all uneven areas of the bottom of the formed cavity. Flowable composites have high elasticity and thus relieve stress in the filling. Negative properties are high polymerization shrinkage, insufficient mechanical strength and insufficient spatial stability of a large volume of material. These include Revolution (Kerr), Aetiteflo (Bisco), Arabesk Flow (Voco), etc.

Therapeutic liners are used for biological treatment of pulpitis and in case of accidental opening of the pulp horn. There is a differentiated approach to the use of materials containing calcium hydroxide. For example, the company "Septodont" produces a whole range of preparations based on calcium hydroxide. To stop the acute process in acute focal pulpitis, Pulpomixine is recommended, for indirect pulp coverage in deep caries, especially in cavities where the filling is subject to pressure - Contrasil, for vital amputation - Calcipulpe, direct and indirect pulp coverage, pulp isolation from the adverse effects of permanent filling materials - Septocalcine ultra. The drug Calasept (Sweden) has received wide application among domestic dentists.

After applying a therapeutic lining, the treatment of dental caries should include covering it with a low-toxic lining material (polycarboxylate, glass ionomer cements). Subsequently, a filling is placed from a permanent filling material (amalgam, composite material). Positive treatment of dental caries using a therapeutic lining is possible only with correct diagnosis of the pulp condition, compliance with antiseptic conditions of the carious cavity and maintaining good sealing between the filling and the tooth wall.

Treatment of dental caries: installation of a matrix and wedges

This stage of work is performed for dental defects of II, III, IV and sometimes V class. For better formation of the contour of the fillings, the use of metal matrices is allowed. Transparent matrices and wedges must be used when working with light-curing materials.

Treatment of dental caries: drying the tooth surface and etching the enamel

The enamel is etched with a gel or a solution of 32-37% orthophosphoric acid according to the instructions for 15-60 seconds. The Saremko company produces a microcidal etching gel called "Microcid Etgang". During etching, air bubbles appear in the gel. The absence of visible air bubbles indicates the completion of the etching process.

Treatment of dental caries: rinsing and drying the etched tooth surface

Rinsing with etched water over the tooth cavity is carried out for the same period of time as etching.

Drying of tooth tissues should be carried out until the tissues are moisturized, since modern primers of the 4th and 5th generations are hydrophilic. Overdrying of tissues leads to the appearance of postoperative sensitivity and deterioration of the fixation of the filling material from 30 to 6 MP. To eliminate overdrying, special solutions are used, in particular Aqua-Bisco.

Treatment of dental caries and application of primer and adhesive

For better fixation of the filling to the dentin, a primer is used that fixes the collagen fibers of the smear layer of dentin and closes the dentin tubules, thereby creating a sufficiently dense base for bonding (adhesion) before placing the filling.

The primer is applied to the dentin with an applicator. The monomer penetrates the smear layer of the dentin and forms a micro-mechanical bond called the hybrid layer. The tooth surface is dried with air after the primer has been applied. Then an adhesive is applied to the enamel surface and the formed hybrid layer, which “sticks” the first layers of the filling material to the tooth surface. Adhesives are cured by light or chemically.

In the adhesives of the 5th generation, the primer and the adhesive are together in one bottle. This material is applied layer by layer, dried with air and cured with light. When working, it is necessary to strictly follow the instructions.

Treatment of dental caries: application of filling material and polymerization

The emergence of new materials - glass ionomer cements and composite materials - creates a new treatment for dental caries and the possibility of gradually abandoning the use of amalgam in dentistry and replacing it with new chemical materials.

Glass ionomer cements are used for permanent fillings (aesthetic and reinforced), for linings, fissure sealing, and for fixing orthopedic structures. Indications for the use of restorative glass ionomer cements are: the need for rapid filling in children and adults with significant salivation, creating a tooth stump, sandwich, and using the APT method. The material must be administered in one portion. It is advisable to process the filling after 24 hours. The release of fluoride ions into the surrounding tissues is positive.

Glass ionomer cements for permanent fillings are divided into several groups:

• classic two-component: lonofil (“Voco”), Ketak-Molar (“Espe”), Flui 11 (“GC”);
• classic metal-ceramic reinforced: Сhelоn-silver (“Espe”), Ketak-silver Apicap (“Espe”);
• hybrid two-component dual-curing: Photac-Fil ("Espe"), Fuyi ("GC");
• hybrid two-component triple-curing Vitremer (3M),

Compomers are used in cases of significant tooth destruction, when restoring the tooth root, the material can be applied in layers. Compomer can be used to restore front teeth with reduced aesthetic requirements. The material absorbs moisture and expands, which improves marginal adhesion to tooth tissues. The material has accumulative properties to absorb and then release fluoride, for example, compomer P-2000 from 3M.

Composite materials can be divided by particle size: macrofilled (particle size 8-45 μm), microfilled (particle size 0.04-0.4 μm), small particle composites (particle size 1-5 μm), hybrid (mixture of particles of different sizes from 0.04 to 5 μm). Composite materials are divided by curing method: chemical and light curing. It is not recommended to light cure material thicker than 1.5-2.0 mm at a time.

Traditional universal microhybrid materials have positive properties: sufficient aesthetics, good polishing, sufficient mechanical strength of small-thickness fillings. Negative properties include the difficulty of applying large-volume fillings, insufficient spatial stability of the material. These include a large number of materials, including: Valux Plus (3Ms), FiltekZ2S0 (3M), Admira (Voco), Aeli-tefil (Bisco).

Condensable composites have high strength and long-term spatial stability, are easy to use and have minimal polymerization shrinkage. Glass fiber particles are additionally introduced into their structure, which allows for light polymerization of material up to 5 mm thick in one irradiation. These include Piramid (Bisco), Alert (Generic/Pentron). Filling is completed by modeling, creating tubercles and contours of teeth with recreation of the anatomical shape of fissures and correcting it upon contact with the antagonist. In case of significant violation of the occlusal relationship of teeth, it is necessary to remove a significant amount of filling material. In rare cases, it is necessary to remove a small amount of enamel on the tubercles of the antagonist teeth. The dentist is forced to do this by a significant protrusion of the antagonist, which leads to the introduction of the tubercle of the opposing tooth into the carious cavity.

In cases of significant destruction of the crown part of the tooth, it is advisable to make inlays using direct and indirect laboratory methods. In the clinic of therapeutic dentistry, inlays are most often made using the direct method. A cavity is formed, the side walls of which in the upper section have a divergence of 5-8 degrees. The cavity of the tooth is treated with a separating varnish or a thin layer of petroleum jelly. A composite material is introduced into it. The material can be chemically cured or photocured, depending on the amount of material used. After polymerization, the modeled filling is removed from the cavity and polymerized in a cellophane picket in boiling water for 10 minutes. During this time, a more complete polymerization shrinkage of the filling material occurs, which eliminates stress load on the lateral surfaces of the tooth when using bonding systems. Cement is used to fix the inlay in the formed cavity.

Onlays are essentially inserts that form the cusps of molars and premolars. The indication for restoration of teeth with onlays is thinning of the walls, the absence of the possibility of breaking off the cusps of molars and premolars. The formation of the cavity for the onlay is carried out identically, as for the inlay. The difference is the horizontal removal of the cusps of molars and premolars. The shape of the onlay acquires a T-shape. It is very important to create a bevel of the enamel along the outer edge of the tooth surface. After placing the inlay, it is necessary to restore its occlusal relationship according to the bite, additional modeling and polishing.

Another very important moment in such a process as dental caries treatment is the creation of a contact point. The contact point prevents food from getting into the interdental space and traumatizing the periodontal tissues. The contact point can be point or planar. Metal and polyethylene matrices with matrix holders are used to form the contact point. The matrix should be tightly pressed with wooden or light-conducting polyamide wedges to the gingival edge of the enamel. The contact point can be modeled using the light-conducting instrument Contact-pro and Contact-pro-2, a trowel and a light-conducting cone. The purpose of all the listed methods is to press the matrix to the adjacent tooth and fix it in this state. Then, sequentially, in small portions, the composite material is added and the filling is modeled.

When placing an amalgam filling, the enamel is beveled at an angle of 45. When using a composite material, beveling the enamel is not necessary.

The thickness of the composite layer should be at least 2 mm, which is due to the fragility of the material. In the presence of pressure, thinning of the material can lead to a break in the edge of the filling and the development of secondary caries. Incomplete beveling of the enamel in the case of cosmetic requirements must be done in the absence of contact with the tubercles of the antagonist tooth. For tooth restoration in class II, it is advisable to use glass-ionomer cements, liquid-flowing composite materials as a lining, and amalgam, condensable composites and universal hybrid composite materials as a permanent filling.

For restoration of teeth with class III cavities, it is advisable to use microhybrid and flowable composites, while it is necessary to take into account the transparency of the material. To eliminate transparency, it is necessary to create a back wall of the filling and use dentin from a darker opaque material (darker by 0.5-1 color shade on the "Vita" scale),

To create the best cosmetics, the bonding should be evenly distributed over the bevel surface. In case of insufficient fixation of the filling, part of the tissue is removed from the inner side of the tooth and the filling material is applied, as when creating a veneer. Recently, it has been more often recommended to apply the composite to the palatal surface so that it serves as a place of contact with the antagonist. When restoring with a composite material, it is necessary to take into account the thickness of the tooth, the anatomical shape and the color range, since caries can occupy several color zones. It is necessary to form the body, the lateral surface and the cutting edge using the color of dentin, opaque material. A darker color should be used when restoring the back wall of the tooth with a color one number darker on the "Vita" scale. To improve the fixation of the filling material and a smoother transition to the tooth tissues, it is recommended to bevel the enamel.

Treatment of dental caries: polymerization of filling material

In case of using light-curing material, the composite is introduced into the cavity in layers in the form of a "herringbone", with the treatment of each layer of the material with a polymerization halogen lamp. The composite material is introduced into the cavity in layers no thicker than 2 mm. The surface of each layer should remain shiny, since the surface of the composite is inhibited by oxygen and does not harden. Violation of this layer by saliva, various liquids leads to the appearance of layering of the filling material and loss.

The filling material is irradiated with a halogen lamp with a power of at least 300 mW/cm2, as close as possible to the filling material, simultaneously for 40 seconds from the filling and enamel walls of the tooth. Currently, for a number of filling materials produced by the companies "Espe", "Bisco", as well as the domestic company "Geosoft", halogen lamps of soft polymerization are produced, with variable luminous power according to the schemes developed by these companies. Overheating of the filling material during polymerization is not allowed.

Treatment of dental caries: finishing and polishing of fillings

The application of a filling, as a treatment for dental caries, ends with the removal of the sticky, oxygen-inhibited, surface layer and modeling, creating tubercles and contours of the teeth, recreating the anatomical shape of the fissures and correcting it according to the bite. In the case of a significant violation of the occlusal relationship of the teeth, it is necessary to remove a significant amount of filling material. In rare cases, it is necessary to remove a small amount of enamel on the tubercles of the antagonist teeth. The dentist is forced to do this by a significant protrusion of the antagonist, which leads to the introduction of the tubercle of the opposing tooth and a carious cavity.

Diamond and hard-alloy veneers and polishers, disks of various grain sizes, rubber bands (gray for grinding and green for polishing), brushes with polishing pastes are used for finishing the filling. Strips are used for processing the approximal surfaces. Finishing and polishing of the filling is performed at low speed with rotating instruments with water supply to avoid overheating of the material and formation of microcracks.

Treatment of dental caries and post-bonding

The composite material has a rough surface due to the inclusion of the performer in the structure. When polishing the filling, micro-scratches, cracks and mechanical removal of the bonding from the space between the tooth and the filling may be noted. To eliminate these defects, in use cover varnishes that level the surface of the filling and close the cracks.

Application of fluoride protector

Application of fluoride preparations (varnishes, gels).

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Treatment of dental caries: mistakes and complications in dental restoration

Failure to comply with the conditions for the implementation of each stage affects the service life of the seal.

1. Violation of the stages of cavity formation. This is especially true for the stage of necrotomy. Incomplete removal of infected tissues leads to the development of secondary caries.
2. Inadequate selection of filling material leads to filling falling out or chipping, damage to the cosmetic appearance of the tooth, etc.
3. The change in the color of the filling is associated with the patient's intake of food containing dyes in the first two to three days after restoration. This is due to incomplete polymerization of 60-80% of the filling material after the filling is placed. The final polymerization process ends within a few days.
4. Depressurization of the space between the filling and the tooth is associated with a violation of the technology of adhesive systems and the method of polymerization of the filling material. Depressurization of the space between the filling and the tooth leads to infection of the tooth tissues and the development of secondary caries.
5. Postoperative sensitivity after dental restoration may occur when working with adhesive systems due to overdrying of dentin and incomplete impregnation of the smear layer of dentin with primer.
6. A filling fracture occurs when it becomes thinner during placement or processing, when the filling thickness is less than 2 mm.
7. The loss of a filling is associated with improper formation of the cavity and violations of the technology of introduction and polymerization of the filling material and the use of adhesive systems.
8. The delamination of the filling occurs due to mechanical damage or contamination of the inhibited oxygen layer during the layer-by-layer introduction of the filling material.
9. Violation of the modeling of the anatomical shape and contact points of the teeth can lead to the development of traumatic or local periodontitis.