Treatment of dental caries

Treatment of tooth decay depends on the severity of destructive processes in the hard tissues of the tooth and the general condition of the body. Conditionally it is possible to single out the bottom of the main approach in treatment - it is invasive and surgical methods.

Treatment of dental caries by non-invasive methods

Non-invasive method is used in the treatment of caries in the stain stage. With this form of caries, patients do not complain about the presence of a defect in the enamel, the appearance of pain under the action of temperature and chemical stimuli.

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

Treatment of dental caries by surgical methods

Along with non-invasive methods of caries treatment, the main at present are surgical techniques. Surgical treatment of dental caries consists of a number of stages:

1. Hygienic treatment of teeth.
2. Determination of tooth color and choice of the coloring of the filling material.
3. Dissection of hard tooth tissues.
4. Isolation of the tooth from saliva.
5. Medicamental treatment of the formed cavity.
6. Applying a gasket.
7. Installation of matrices and wedges.
8. Drying of the tooth surface and acid etching of the enamel.
9. Washing the etched surface of the tooth and drying the surface.
10. Application of an adhesive.
11. Introduction of filling material.
12. Polymerization of the material.
13. Finishing and polishing of seals.
14. Post-bonding or applying fluoride-tread.

Hygienic treatment of the tooth

The first stage involves cleaning the surface of the restored tooth from plaque. For this purpose, abrasive pastes and brushes are used. The abrasivity is marked with RDA indices (KEA). The composition of abrasive pastes includes silica and various aromatic additives. It is advisable to apply pastes that do not contain fluorine (Klint, the company "Voco"). Hygienic treatment of the tooth contributes to the correct selection of the color of the filling material.

Determination of tooth color and choice of the coloring of the filling material

The right color choice involves the following:

• Color selection is best done in natural daylight (12 hours).
• The surface of the tooth should be moist.
• It is not recommended to choose a color longer than 15 seconds.
• When in doubt about the choice of color, a darker material should be used, since during the polymerization the light-reflecting composites lighten.

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

Some materials have their own coloring.

[1], [2]

Treatment of tooth decay: preparation of hard tooth tissues

The method of preventive expansion, proposed by Blak (1914), became most famous and widely spread. During this period, a metal filling material was used in clinical practice - amalgam, which possesses considerable mechanical strength. Metal seals, if properly prepared and correctly sealed, last 10 years or more. In order to preserve the tooth surrounding the seal during this period, a wide excision of caries-susceptible areas of the tooth was required, with the preservation of resistant zones, such as, for example, the hills of the hillocks, during the formation of Class I cavities.

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

The method of prophylactic expansion has not lost its practical value and nowadays when the teeth are filled with amalgam. However, the use of amalgam has many negative aspects: the coloring of the tooth surrounding the tooth, the lack of adhesion to the enamel and dentin, the difference in the coefficients of thermal expansion of the material and the tooth tissues, etc.

In the 40-70s of the XX century, cements were widely used. The duration of preservation of the seal from mineral cement was insignificant, which led to frequent replacement of the seal. And every time during the subsequent treatment of cavities, it was inevitable to remove hard tooth tissues.

The appearance of filling materials from polymers has led to the need to develop a new principle for the formation of carious cavities - the method of preventive filling. It assumes minimal excision of healthy tooth tissues to immune zones with rounded corners of the formed cavity. This method assumes operative treatment of dental caries and non-invasive or invasive prophylactic sealing of fissures, as well as local fluorization of the enamel. In these cases, the condition of the individual caries-resistance of the patient, the features of the filling materials should be taken into account.

In 1994, the Dutch doctor Taso Pilot proposed a technique for removing carious tissues with an excavator, and then filling the cavity with glass ionomer cement. It was called the ART-method, which is based on the properties of glass ionomer cements to release fluorine. The method can be used to provide dental care in difficult conditions, treatment of dental caries in small children, patients with severe obscheomatic pathology.

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

The clinic uses the kinetic air-abrasive preparation technique (KSN-Kinetic Cavity Preparation). Under the influence of the focused ceiling of the abrasive material (aluminum oxide or sodium bicarbonate with particle sizes of 25-50-100 microns), hard tooth tissues are removed to the required level under eye control.

Formation of carious cavities of class I

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 masticatory surface of molars and premolars is the mounds and slopes of the tubercles. Treatment of tooth caries of the cavities of the first class requires a clear solution, how much tissue of the tooth should be removed, determine the location of the contact points of the antagonists. The doctor should decide what to use in this clinical situation for the restoration of tooth tissues: a seal, a tab or an overlay. The solution of this question depends on the volume of the remaining tooth tissues, the thickness of the walls of the carious cavity, and also on the type of filling materials.

Traditionally, the carious cavity is formed as a "box" with straight or oval corners. To isolate the walls of the cavity, basic (more than 1 mm thick) and thin pads covering the bottom and walls of the cavity are created and used to isolate the pulp from chemical irritants, and also provide a link between the tooth walls and the seal. As the insulating material used phosphate cement, polycarboxylate and glass-ionomer cements, as well as liquid-flow composite materials. In the case of composite materials used for sealing cavities of cavities, the cavities and walls are oval shaped, since the composite materials mostly have a significant linear shrinkage and do not have the elasticity of mineral cements, which leads to the formation of voids in the region of the cavity angles. 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 make the bevel of the enamel along the edge of the cavity. When placing an amalgam seal, the enamel bevel is made at an angle of 45. In the case of using a composite material, the bevel of the enamel is not necessary, and the thickness of the composite layer in the occlusal load zones should be at least 2 mm, which is related to the brittleness of the material. To the breaking off of the edge of the filling and the development of secondary caries.The bevel of enamel, in the case of cosmetic requirements, must be done in the absence of contact with the protuberances of the tooth-antagonist.

[3], [4]

Formation of carious cavities of class II

Dental caries of Class II also refers to the frequently occurring and constitutes up to 40% among all localizations. Its development is associated with inadequate oral hygiene, when a dental plaque develops between the teeth on the approximate surfaces, leading to caries.

The carious process develops in the enamel and dentin zone in the form of two successively standing triangles facing the apex outwards. Diagnosis of the initial forms of the caries cavity of the 2nd class makes considerable difficulties, since it is rather difficult to perform a visual inspection with the presence of adjacent teeth. The most informative is intraoral x-ray examination. It allows to identify the focus of demineralization, its boundaries and trace the results of remineralizing therapy.

Treatment of dental caries of Class II can be performed using the tunnel method. The caries of the altered dentin on the approximal part of the tooth is removed through a formed tunnel with the chewing surface. To close the defect in the dentin layer, glass ionomer cement is used, and the enamel layer is restored with composite materials.

With a more pronounced carious process, the opening of the cavity must be started on the chewing surface of the tooth with fissure boron by creating a groove corresponding to the size of the carious lesion, receding from the lateral surface of the tooth. Then the excavator breaks off the thinned portion of the enamel and then forms a cavity.

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

[5]

Formation of carious cavities of III class

A feature of the formation of this carious cavity is the solution of the problem of cosmetic preservation of the palatine and lingual walls. When using mineral cements, the opening of the carious cavity on the palatine side is envisaged. Now, when using composite materials, removal of the thinned vestibular surface is recommended. The bottom of the cavity is formed oval to not open the cavity of the tooth. The angle of the outer surface of the enamel and formed by the post should be straight. For a better transition of the color of the filling and the tooth, one can make a gentle bevel of the enamel.

Formation of carious cavities of IV class

Treatment of tooth decay depends on the size of the crown defect. The doctor first of all must decide which method of treatment is more appropriate in this situation: setting the seal or using orthopedic methods of treatment. It is necessary to first determine the bite and the point of contact with the antagonist. If conditions are created for "knocking out" a future seal by an antagonist, then the use of orthopedic methods of treatment is more appropriate.

For better fixing of the filling material, long gently sloping undulating sections of the enamel are made with a fine-dispersed diamond tool on the labial surface.

[6]

Formation of carious cavities of class V

Treatment of tooth decay V class depends on the affected area, its location above the level, at the level or under the gum. In the first two cases, cavities are formed with an oval convex bottom that repeats the contours of the tooth cavity. For a better fixation of the filling material, it is possible to make a longitudinal section of the enamel. In the case of the spread of caries lesions under the gum, it is advisable to form a cavity under the seal by the type of an open "sandwich". The subgingival cavity is closed with glass ionomer cements, and the visible part of the tooth is restored with composite materials.

Treatment of dental caries of the V class is carried out by means of treatment and cavity formation according to the type of defect and restoration using fluid-impregnated or condensed materials.

[7], [8], [9]

Treatment of tooth decay: isolation of 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 katonovyh rollers. It should avoid the use of cotton wool cicks because of the possibility of getting thin fibers in the filling material.

Treatment of dental caries: medicamentous treatment

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

Treatment of dental caries: application of a lining

Interlining materials are divided into 2 groups:

• Isolating: varnishes, phosphates, glass ionomer cements.
• therapeutic: containing calcium hydroxide hydrate.

Glass ionomers are used for insulating pads: classic two-component ones: lonobond ("Voco"), Ketar bond ("Esre"), and hybrid double-curing - Vitrebond ("3M"), XR-Ionomer ("Kerr"), polymer light curing, glass ionomer filler - Cavalite ("Kerr"), SeptocalL. With ("Septodont").

Recently, as a gasket and to reduce stress in the structure of the enamel seal, liquid-flowing composite materials began to be used. Fluid composites (flowable) have positive properties: high thixotropy, the ability to fill all uneven areas of the bottom of the formed cavity. Liquid-flowing composites have a high elasticity and thus relieve stress in the seal. 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") and others.

Medical pads 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. For the relief of acute process with acute focal pulpitis, Pulpomixine is recommended, with indirect coverage of the pulp in deep caries, especially in the cavities where the filling is subjected to pressure - Contrasil, with vital amputation - Calcipulpe, direct and indirect pulp coating, pulp isolation from the adverse effect of permanent filling of materials - Septocalcine ultra. A wide application for domestic dentists received the preparation Calasept (Sweden).

After the application of the treatment lining, the treatment of dental caries should include closing it with a low-toxic lining material (polycarboxylate, glass ionomer cements). Subsequently, the seal is made from a permanent filling material (amalgam, composite material). Positive treatment of dental caries with the use of a medical lining is possible only if the pulp condition is correctly diagnosed, the antiseptic conditions of the carious cavity are maintained and good tightness is maintained between the filling and the tooth wall.

Treatment of dental caries: installation of a matrix and wedges

This stage of work is performed with defects of teeth II, III, IV and sometimes V class. The use of metal matrices is allowed for a longer time to form the contour of the seals. Transparent matrices and wedges should be used when working with materials of light curing.

Treatment of tooth decay: tooth surface drying and enamel etching

Enamel dressing with gel or 32-37% solution of orthophosphoric acid is carried out according to the instructions for 15-60 seconds. The firm "Saremko" produces microcidal etch gel "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 of the etched tooth surface

Washing of the etched tooth on the tooth cavity is carried out for the same period as the etching.

Drying of the tooth tissues should be carried out to the state of moisture of the tissues, since the present primers of the 4th and 5th generations are hydrophilic. Overdrying of tissues leads to the appearance of postoperative sensitivity and deterioration of fixing 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 primer and adhesive application

To better fix the seal to the dentin, a primer is used that fixes the collagen fibers of the lubricated dentin layer and closes the dentinal tubules, thereby creating a sufficiently dense base for bringing bonding (adhesion) before setting the seal.

The primer is applied to the dentin by an applicator. The monomer penetrates the lubricated dentin layer and forms a micro-mechanical bond, called the hybrid layer. The surface of the tooth after the primer is applied is air dried. Then an adhesive is applied on the surface of the enamel and the formed hybrid layer, which "pastes" the first layers of the filling material to the surface of the tooth. The adhesives are cured by light or chemically.

In V generation adhesives, the primer and adhesive are together in one vial. This material is applied layer-by-layer, air-dried and light-cured. At work it is necessary to strictly observe the instruction.

Treatment of dental caries: insertion of a 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 hardened), for gaskets, for sealing fissures, and for fixing orthopedic structures. Indications for the use of reductive glass ionomer cements are: the need for fast filling of seals in children and adults with significant salivation, the creation of a tooth stump, a sandwich, with the APT method. The material must be administered in one portion. It is more expedient to carry out filling processing in a day. The release of fluoride ions into the surrounding tissues is positive.

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

• classical two-component: lonofil ("Voco"), Ketak-Molar ("Espe"), Flui 11 ("GC");
• classic cermet hardened: Сhelоn-silver ("Espe"), Ketak-silver Apicap ("Espe");
• hybrid two-component double curing: Photac-Fil ("Esre"), Fuyi ("GC");
• hybrid two-component three-cure Vitremer ("3M"),

The compomers are used for significant tooth decay, when reconstituting the root of the tooth, the material can be applied in layers. Composer can restore the frontal teeth with reduced requirements of aesthetics. The material absorbs moisture and expands, which improves the marginal fit to the tissues of the tooth. The material has storage properties to absorb and then release fluorine, for example a P-2000 compomer from 3M.

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

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

Condensed composites have high strength and long-term spatial stability, ease of use and minimal polymerization shrinkage. Fiberglass particles are additionally introduced into their structure, which makes it possible to produce light-polymerization of a material up to 5 mm thick in one irradiation. These include Piramid ("Bisco"), Alert ("Jeneric / Pentron"). The imposition of the filling ends with modeling, the creation of bumps and contours of teeth with the reconstruction of the anatomical form of fissures and its correction by contact with the antagonist. In the case of a significant violation of the occlusal ratio of the teeth, a significant amount of the filling material must be removed. In rare cases, it is necessary to remove a small amount of enamel on the tubers of antagonist teeth. To this dentist forces a significant extension of the antagonist, which leads to the introduction of the hillock 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 tabs in a direct and indirect laboratory way. In the clinic of therapeutic dentistry, the manufacture of tabs is more often performed by a direct method. A cavity is formed, in which the side walls in the upper section have a divergence of 5-8 degrees. The tooth cavity is treated with a separation lacquer or a thin layer of petroleum jelly. It introduces a composite material. The material can be chemical curing or photocuring depending on the amount of material used. After polymerization, the modeled seal is removed from the cavity and polymerized in a cellophane picket in boiling water for 10 minutes. During this time there is a more complete polymerization shrinkage of the filling material, which excludes, when using bonding systems, a stress load on the lateral surfaces of the tooth. Cements are used to fix the insert in the formed cavity.

Lining is essentially a tab, forming the mounds of molars and premolars. The indication of restoration of the teeth by the patches is the thinning of the walls, their lack of the possibility of breaking the mounds of molars and premolars. Formation of the cavity for the lining is identical, as for the tab. The difference is the horizontal removal of the molars and premolars. The form of the lining acquires a T-shape. It is very important to create a bevel of enamel along the outer edge of the tooth surface. After setting the tab, it is necessary to carry out restoration of the occlusal ratio of her bite, additional modeling and polishing.

Another very crucial moment in the process, such as the treatment of dental caries, is the creation of a contact point. The contact point prevents food from entering the interdental space and traumatizing the periodontal tissues. The contact point can be point or flat. The days for the formation of the contact point are metal and polyethylene matrices with matrix holders. The matrix should be pressed tightly with wooden or light-conducting polyamide wedges to the edge of the enamel. The contact point can be modeled using a contact-pro and Contact-pro-2 light guide, a tamper and a light cone. The purpose of all these methods is to squeeze the matrix to the adjacent tooth and fix it in this state. Then, in succession, in small portions of the composite material and the seal is modeled.

When setting an amalgam filling, the bevel of the enamel is made at an angle of 45. In the case of using a composite material, the bevel of the enamel is not necessary.

The thickness of the layer of composite material should be at least 2 mm, which is due to the brittleness of the material. If there is pressure, the 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 should be done in the absence of contact with the tubers of the antagonist tooth. For the restoration of the tooth in grade II, it is advisable to use glass-ionomer cements, liquid-flowing composite materials as a liner, and amalgam, condensable composites and universal hybrid composite materials as permanent fillings.

For the restoration of teeth with Class III cavities, it is advisable to use micro-hybrid and fluid-filled composites, while taking into account the transparency of the material. To eliminate the transparency, it is necessary to create a back wall of the seal and use dentin from a darker opaque material (darker by 0.5-1 colors on the scale "Vita"),

To create the best cosmetics, bonding should be evenly distributed over the surface of the bevel. In case of insufficient fixation of the seal, part of the tissue is removed from the inside of the tooth and the filling material is applied, as in the case of the veneer. Recently, it is more often recommended to apply the composite on the palatine surface so that it serves as a place of contact with the antagonist. When restoring with 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 a body, a side surface and a cutting edge using the color of dentin, an opaque material. A darker color is used when restoring the posterior wall of the tooth with color to the number darker on the scale "Vita". To improve the fixation of the filling material and a smoother transition to the tooth tissues, it is recommended to make the bevel of the enamel.

Treatment of dental caries: polymerization of the filling material

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

Irradiation of the filling material is produced by 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 side of the filling and the enamel walls of the tooth. Currently, for a number of sealing materials produced by the firms Espe, Bisco, as well as the domestic firm Geosoft, they produce halogen lamps of soft polymerization, with variable luminescence power according to the schemes developed by these firms. Overheating of the filling material during polymerization is not permissible.

Treatment of dental caries: finishing and polishing of the fillings

The imposition of a seal, like the treatment of dental caries, results in the elimination of the sticky, oxygen-inhibited surface layer and modeling, the creation of tubercles and tooth contours, with the reconstruction of the anatomical fissure shape and its correction by bite. In the case of a significant violation of the occlusal ratio of the teeth, a significant amount of the filling material must be removed. In rare cases, it is necessary to remove a small amount of enamel on the tubers of antagonist teeth. To this dentist forces a significant extension of the antagonist, which leads to the introduction of the hillock of the opposing tooth and the carious cavity.

To finish the seal, diamond and carbide veneers and polishes, discs of various grain sizes, rubber bands (gray for grinding and green polishing), brushes with polishing pastes are used. Strips are used to process approximate surfaces. Finishing and polishing of the seal is carried out at low speed by rotating tools with water supply to avoid overheating of the material and the formation of microcracks.

Treatment of dental caries and postbonding

The composite material has a rough surface due to inclusion in the structure of the performer. When the seal is polished, microcirculation, cracks and mechanical removal of bonding from the space between the tooth and the seal can occur. To eliminate these defects, in-use lacquers that smooth the surface of the filling and close the cracks.

Application of fluorine-tread

Application of fluoride preparations (varnishes, gels).

[10], [11]

Treatment of dental caries: errors and complications in the restoration of teeth

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

1. Violation of the stages of cavity formation. Especially it concerns the stage of bringing necrotic disease. Incomplete removal of infected tissues leads to the development of secondary caries.
2. Inadequate selection of the filling material leads to loss or cleavage of the filling, a violation of the cosmetic appearance of the tooth, etc.
3. The change in the color of the seal is associated with the reception of food containing dyes for the sick in the first two to three days after the restoration. This is due to incomplete polymerization of 60-80% of the filling material after filling. 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 polymerization technique 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 restoration of teeth can occur when working with adhesive systems when the dentine is overdried and the impregnated dentin layer is not fully impregnated with the primer.
6. Fracture of the filling occurs when it is thinning, when staged or processed, when the thickness of the seal is less than 2 mm.
7. Failure of the seal is associated with improper formation of the cavity and disruptions in the technology of introduction and polymerization of the filling material and the use of adhesive systems.
8. Sealing of the seal occurs due to mechanical disturbance or contamination of the inhibited oxygen layer when the filling material is layer-by-layer.
9. Impaired modeling of the anatomical shape and contact points of the teeth can lead to the development of traumatic or local periodontitis.