Lecture 3
Theme. “Dental caries. Classification. Morphological changes of hard tissues of teeth on the different stages of caries from data of radial, electronic and polarization microscopy. Clinic, diagnostics and differential diagnostics of caries. The use of physical methods for diagnostics of caries”
Caries of teeth: etiology, pathogenesis, clinic,
diagnostics, treatment.
Caries of teeth is a pathological process, which appears after eruption of teeth, is characterized by demineralization and softening of hard tissues of teeth with subsequent formation of defect as a cavity.
Caries of teeth is the key problem of dentistry, very interesting in theoretical and exceptionally important in a practical relation.
In obedience to the nomenclature of WOHP for the estimation of staggered of teeth use three basic indexes a caries:
1. Prevalence of disease. It is an index, by the percent of persons, which have the carious, stopped and remote teeth in that or other settlement, district, city, area which is determined.
2. Intensity of defeat of teeth is determined a caries on the number of the teeth staggered a caries. For this purpose the committee of experts of WOHP for dentistry (1962) was offered for adults to use the index of CSR (C is a carious tooth, S – stopped, R – a tooth is remote); for children with a temporal or suckling bite – cs (c – carious, s – stopped); for children with a variable bite – CSR+cs. To facilitate the comparative estimation of morbidity a caries on the different contingents of the world, WOHP in 1980 year suggested to select 5 degrees of staggered depending on CSR for children 12 years:
1) very low – from 0 to 1,1;
2) low – 1,2 – 2,6;
3) moderate – 2,7-4,4;
4) high – 4,5-6,5;
5) ever-higher – 6,6 and higher.
For the receipt of reliable information at determination of prevalence and intensity of decay of teeth the groups of population must look around taking into account age and floor, climatic geographical and socio-economic terms. Usually children inspect in age 5-6, 12 years, 15 years, adults 35-44 and 65 years. The groups of ages of most models of population is 12- and 15- of children of summers.
3. Increase of intensity or morbidity. Determined for the same person or contingent through a certain term (1, 3, 5, 10 years). Difference in the value of index between the first and second reviews and makes the increase of intensity of caries.
By an epidemiology dental inspection it is possible to define prevalence and intensity of basic dental diseases, quality of sanation of cavity of mouth, efficiency of prophylaxis of caries of teeth and illnesses of paradontium, level of the hygienical state of cavity of mouth, and also find out the necessity of every caries of teeth, illnesses of paradontium and mucous cavity of mouth inspected in treatment. Such inspection allows to work out an individual plan of medical and prophylactic measures for every patient.
Etiology
For explaining etiology and pathogeny of caries of teeth about 400 theories, the known from which was instrumental in the accumulation of information which allowed express the certain completed opinion on this issue, are offered.
Not deciding in detail on all present theories, those over are below brought, even partly, give explaining to the origin of the most widespread pathological process – to the caries.
Theories of origin of caries of teeth
1. Miller’s chemically – parasite theory of caries (1884.). At one time this theory was progressive, had confession and wide enough distribution. In our time this theory of caries was fixed in basis of modern conception of pathogeny of caries.
In obedience to this theory, carious destruction takes place two stages: a) demineralization of hard tissues of tooth. Suckling acid which appears in the cavity of mouth, as a result of milk sour fermentation of tailings of carbohydrates of meal dissolves the inorganic matters of enamel and dentine;
b) there is destruction of organic matter of dentine by the proteolytic enzymes of microorganisms.
Together with such factors, as microorganisms and acids, Miller acknowledged existence of factors of contributory infringements. He specified the role of amount and quality of saliva, factor of feed, drinking-water, underlined the value of the inherited factor and terms of forming of enamel.
2. Entin’s physical and chemical theory of caries (1928). Entin pulled out the theory of caries on the basis of research of physical and chemical properties of saliva and tooth. He considered that tissues of tooth were semi penetrate membrane, which osmotic currents, conditioned the difference of osmotic pressure of two environments which contact with a tooth, pass through: blood from within and saliva outwardly. According to his opinion, at favourable terms osmotic currents have centrifugal direction and provides the normal terms of feed of dentine and enamel, and also hinder operating on the enamel of external unfavorable factors. In same queue centripetal motion of matters, that from the surface of tooth to pulp, considered pathological and little direct connection with the diseases of the nervous and endocrine systems, heredity, violation of mineral exchange, terms of feed, way of life, labor, physiology mutual relations which result in violation, in the system pulp – tooth – saliva. At unfavorable terms centrifugal direction of osmotic currents relaxes and acquires centripetal direction which violates the feed of enamel and facilitates operating on her of harmful external agents (microorganisms), causing a caries. Negative sides of Entin’s theory: did not know that at centripetal motion of matters in an enamel took place feed of enamel by mineral salts from saliva, and the method of exogenous prophylaxis of caries is thereon founded – on the surface of enamel with the purpose of to fill up stocked coverage of teeth by fluorine varnish , causing of remineralization matters (appliques) them in an enamel – remtherapy; and also method of treatment of caries in the stage of spot: appliques are on the staggered area of enamel of remineralization matters.
3. Lukomskij’s biological theory of caries (1948). The author of this theory considered that such endogenous factors, as a lack of vitamins D, B, and also failing and wrong correlation of salts of calcium, phosphorus, fluorine in a meal, absence or lack of ultraviolet rays violate mineral and albumen exchanges. Investigation of it is a disease of odontoblast, which at first weaken and become inferior then. A size and amount of odontoblasts diminishes that results in a metabolic disturbance in an enamel and dentine. Demineralization comes at first then there is a change of composition of organic matters. Negative sides of this theory: there are not proofs, that odontoblasts is the trophic centers of tooth; a theory does not explain the role of sugar in development of caries, localization of carious defeats and prophylactic action of fluorine; it is not proved that odontoblasts inferior at a caries. Even in a healthy contact tooth it is possible to meet degeneration of odontoblasts as their atrophy.
4. Sharpenak’s theory (1949). Sharpenak explained reason of origin of caries of tooth local impoverishments of enamel by squirrel as a result of their speed-up disintegration and deceleration of resinthesis that certainly results in the origin of caries in the stage of white spot. Deceleration of resinthesis is conditioned absence or low maintenance of such amino acid and reason of strengthening of proteolysis is a high temperature of surrounding air, hyperthyreosis, nervous excitation, pregnancy, tuberculosis, pneumonia, accumulation of acids in tissues of organism (in particular, at the insufficient entering organism of vitamins of group B, plenty of acid accumulates in tissues) which results in strengthening of disintegration of albumen. Cariogenic action of carbohydrates of Sharpenak explains that at their large mastering the necessity of organism rises in the vitamin of B1, which can cause avitaminosis and strengthening of proteolysis in the hard substances of tooth. Negative sides of theory: it was not confirmed experimentally, that at caries in the stage of spot begins proteolysis albumens; an author underestimated the role of microorganisms, local cariogenic factors, and over-estimated the role of general factors.
5. Shatts’s and Martin’s proteolysis theory of caries (1956). Authors explained perception of enamel to the defeat a caries stability of calcium – albumens complexes. An enamel of tooth is the not negative structure of organism, which through functional features mineralized more than other tissues. Thus mineral and organic components of enamel are in close biochemical connection. Firmness of the last can be broken at penetration in the enamel of different active chemical agents, in particular proteolysis. Development of carious process is examined in 2 stages: a) proteolysis, at which a break of connections is between squirrel and minerals of enamel as a result of operating of bacterial proteolysis enzymes on albuminous components; b) when destruction of mineral part of hard tissues of tooth is from formation of complex connections of ions of metals with acid ion of acids, salts of organic acids, amino acid, squirrel and intermediate products of disintegration.
Negative sides of theory: presently there are not proofs of the first phase of carious process for Shatts – Martin.
6. Platonov’s trophic nervous theory The author of this theory examined the caries of teeth as trophic nervous process, which, according to his opinion, develops only then, when the feed of hard tissues of tooth is violated.
By the basic Platonov’s pathogenic factor counted violation of the nervous adjusting of trophic of dental tissues. However today known it is that teeth with remote mash in time to 17 continue normally to function. Delete of mash however much one of methods of treatment the complicated forms of caries does not cause structural and functional changes in the enamel of tooth, last continues to function as a valuable organ. The permanent dynamic co-operating with a mouth liquid provides hard tissues of devitalized tooth high mineralization which is answered by large acid proofness and structural homogeneity.
Modern conception of etiology of caries
Based on historical theories presently considerable successes obtained in the study of etiology and pathogeny of caries of teeth.
The confessedly mechanism of origin of caries is making progress demineralization of hard tissues of teeth under the action of organic acids formation of which is related to activity of microorganisms.
In the origin of carious process take part great number of etiologic factors, that allows to consider caries a proteolysis disease.
Basic etiologic factors is:
1) microflora of cavity of mouth;
2) character and diet, maintenance of fluorine in water;
3) amount and quality of saliva selection;
4) common state of organism;
5) the extreme operating is on an organism.
All above-stated factors were adopted cariogenic and subdivided into general and local, such which act important part in the origin of caries.
General factors:
1) Inferior diet and drinking-water;
2) Somatic diseases, change in the functional state of organs and systems, are in the period of forming and ripening of tissues of tooth.
3) The extreme operating is on an organism;
4) Heredity, stipulating the full value of structure and chemical composition of tissues of tooth. Unfavorable genetic code.
Local factors:
1) Dental name-plate and dental deposit which is insulated microorganisms;
2) Violation of composition and properties of mouth liquid;
3) Hydrocarbons are sticky food tailings of cavity of mouth;
4) Resistance of dental tissues, conditioned a valuable structure and chemical composition of hard tissues of tooth;
5) Rejection in biochemical composition of hard tissues of tooth and inferior structure of tissues of tooth;
6) State of pulp of tooth;
7) The state of the tooth – jaw system is in the period of book-mark, development and eruption of the second teeth.
Cariogenic situation is created then, when any a cariogenic factor or their group, operating on a tooth, do him receptive to the action of acids. Certainly, a starting mechanism is microflora of cavity of mouth at the obligatory presence of carbohydrates and contact of two factors with tissues of tooth.
In the conditions of reduced resistance of dental tissues a cariogenic situation develops easier and quick.
Clinically in the cavity of mouth a cariogenic situation appears the followings symptoms:
1) bad state of hygiene of cavity of mouth;
2) abundant dental deposit;
3) dental tartar;
4) congestion of teeth and anomaly of bite;
5) bleeding of gums.
Firmness of teeth to the caries or caries resistance is provided:
1) by chemical composition and structure of enamel and other tissues of tooth;
2) by the presence of pellicle;
3) by optimum chemical composition of saliva and mineralization of its activity;
4) by the enough body of mouth liquid;
5) by the low level of permeability of enamel of teeth;
6) good masticatory loading and self cleaning of surface of teeth;
7) by properties of dental deposit;
8) by the good hygiene of cavity of mouth;
9) by the features of diet;
10) correct forming of rudiments and development of dental tissues;
11) timely and valuable ripening of enamel after eruption of tooth;
12) by the specific and unspecific factors of defence of cavity of mouth.
Receptivity of teeth to the caries:
1) inferior ripening of enamel;
2) diet with the deficit of albumens, macro– and microelements, surplus of carbohydrates;
3) water is with the insufficient amount of fluorine;
4) absence of pellicle;
5) composition of mouth liquid, its concentration, viscidity, amount and speed of completion;
6) biochemical composition of hard tissues of tooth which determines motion of caries, as a dense structure at minimum spaces of crystalline grate slacks up caries and vice versa;
7) state of vascular-nervous bunch;
8) the functional state of organs and systems of organism is in the period of forming and ripening of tissues of tooth;
9) wrong development of tooth is as a result of somatic diseases of commons.
Pathogeny
As a result of the frequent use of carbohydrates and insufficient care of cavity of mouth cariogenic microorganisms are densely fixed on pellicle, forming a dental deposit. At the use of sticky meal tailings of her harden in the retention points of teeth (fissures, pits, contact surfaces, stopping, prosthetic appliances) and added fermentation and rotting. On formation of dental deposit influence:
1) an anatomic structure of tooth and interrelation of him is with surrounding tissues;
2) structure of surface of tooth;
3) food ration and intensity of mastication;
4) saliva and gingival liquid;
5) hygiene of cavity of mouth;
6) a presence of stopping and prosthetic appliances is in the cavity of mouth;
7) tooth – jaw anomalies.
A soft dental deposit has a porous structure which provides penetration inward of his saliva of liquid components of meal. This soft amorphous matter, densely adjoining to the surface of tooth. An accumulation in the deposit of the finished goods of vital functions of microorganisms and mineral salts slows this diffusion, as porosity disappears. And this already new matter is a dental name-plate, deleting which is possible only violent, but also that is not fully. Under a dental name-plate there is an accumulation of organic acids – milk, ant, oily and other. The last are the products of fermentation sugar most bacteria in the process of their growth. Exactly a basic role belongs to these acids in appearance on the limited area of enamel of demineralized area. Neutralization of these acids does not take place, as there is limitation of diffusion both in a dental deposit and from him.
There are streptococci in a dental deposit in particular Str. mutans, Str. sanguis, Str. salivarius, which characteristic anaerobic fermentation is for. In this process substance for bacteria mainly are carbohydrates, and for the separate cultures of bacteria – amino acid. Leading role in the origin of caries taken a saccharose. Exactly she causes the most rapid decline of pH from 6 to 4 for a few minutes. Especially intensively there is a process of glycolysis at hypomyxia, xerostomia, during sleep. And activity of process of fermentation depends on the amount of carbohydrates which are attracted. It is set that in the period of consumption of surplus the sugars amount of deposit is considerably multiplied.
Composition of meal, its consistency, influences on formation of name-plate. It is proved that a dental name-plate quick appears during sleep, than during a meal, as saliva selection and mechanical action is instrumental in deceleration of formation of dental name-plate.
The microorganisms of dental deposit are able to be fixed, raise on hard tissues of tooth, metal, plastic, to product geteropolysugars, that contain different carbohydrates – glicans, levans, dextrans, which a no less important role is taken:
1) glicans provide adhesion of bacteria with each other and by the surface of tooth which conduces to growth and bulge of dental deposit.
2) Levans is energy and enormous amount of organic acids sources, high adhesion own.
3) Dextrans also are product of enormous amount of organic acids which have demineralization influence on the enamel of tooth due to good adhesion.
Pathological anatomy
Stage of white spot (Macula of cariosa)
5 glowed in a white carious spot:
1st – superficial, characterized most stability, the amount of (OH) groups is multiplied in the crystal of hydroxide apatites, maintenance of fluorine diminishes, a volume of microspices is 1,75-3% at a norm 1%. There are areas of demineralization in this area and remineralization;
2nd – subsuperficial, in this area there is diminishing of maintenance of calcium as compared to a norm, the volume of microspices is multiplied to 14%. Permeability of enamel grows sharply;
3d – central, it is an area of maximal changes, yet maintenance of ions of calcium more goes down as compared to a norm, a volume of microspices is 20-25%. An area is characterized the high level of permeability;
4th – intermediate, in this area a volume of microspices is 15-17%.
5th – internal layer or area of brilliant enamel, it is an area of relative prosperity, a volume of microspices is 0,75-1,5%.
In all areas the crystals of hydroxide apatites test those or other changes:
· Violation of orientation of crystals is in the structure of hydroxide apatites;
· Change of form of crystals and their sizes;
· Loosening intercrystalline connections;
· Appearance of untypical for a normal enamel crystals;
· Diminishing of mіcro hardness of enamel is in the area of white spot and pigmented spot.
It is necessary to mark that changes from the side of pulp, in particular in a structure and state of odontoblasts, in vessels and nervous completions at a caries in the stage of white spot not discovered.
Superficial caries (Caries of superficialis)
At a superficial caries the area of destruction of enamel is determined without violation of enamel – dentine connection and without changes in a dentine. There is destruction of enamel – dentine connection at progress of process, and there is the next stage of carious process.
Middle caries (Caries of media)
A middle caries is characterized three areas which appear at research of cut of tooth in a light microscope: 1st – to disintegration and demineralization; 2nd – transparent and to the intact dentine; 3d – reparative dentine and changes in pulp of tooth.
In 1st area – evidently tailings of the blasted dentine and enamel with plenty of microorganisms. Dentine of tube is extended filled bacteria. Dentinal the sprouts of odontoblasts are added fatty dystrophy. Softening influence and destruction of dentine more intensive takes place along enamel – dentine connection which is clinically determined the overhanging edges of enamel, by an entrance pin-hole in a carious cavity. Under the action of enzymes which are selected microorganisms, there is dissolution of organic matter of demineralized dentine.
In 2 there is destruction of dentinal sprouts of odontoblasts to the area, where an enormous amount of microorganisms and products of their disintegration is. Under the action of enzymes, microorganisms which are selected is dissolution of organic matter of demineralized dentine. For peripheries of carious cavity dentinal tubules broaden and deformed. The layer of contracted transparent dentine – area of hypermineralization in which dentinal tubules are considerably narrowed and gradually pass to the layer of reparative (unchanged) dentine is deeper disposed.
In 3 to the area the layer of reparative dentine which differs from a normal healthy dentine the less oriented location of dentinal tubules appears according to the hearth of carious defeat.
Some changes the expressed of which depends on the depth of carious cavity are also determined in pulp of tooth. At caries in the stage of white spot and superficial caries of changes in a vascular-nervous bunch does not appear. And here at a middle caries the expressed morphological changes take place iervous fibers and vessels of pulp. The layer of reparative dentine which differ the less oriented location of dentinal tubules appears according to the hearth of carious process. On that ground some authors name him a irregular dentine. At a light microscopy also disorientation and diminishing of amount of odontoblasts appears in an area according to the hearth of defeat.
Deep caries (Caries of profunda)
At research of cut of tooth with a deep carious cavity in a light microscope appear, as well as at a middle caries, three areas: 1st – to disintegration and demineralization; 2nd – transparent and to the intact dentine; 3d – reparative dentine and changes in pulp of tooth.
It should be noted that at a deep caries more expressed changes appear in pulp of tooth, than at the middle depth of cavity both in hard tissues of tooth and in pulp of tooth. In a vascular-nervous bunch changes have likeness with sharp inflammation, up to complete disintegration of axial cylinders of nervous fibres.
Classifications of carious process
1. Topographical.
a) a caries is in the stage of spot (white, pigmented);
b) superficial caries;
c) middle caries;
d) deep caries.
2. Anatomic.
a) caries of enamel;
b) caries of dentine;
c) caries of cement of root of tooth.
3. For localizations.
a) fissured;
b) proximal;
c) near neck.
4. On character of flow.
a) fleeting;
b) slowly fluid;
c) stabilized.
5. On the degree of activity.
I – a caries is compensated;
II – subcompensated;
III – decompensated.
Caries of enamel, dentine and cement
Black’s classification of caries for localizations:
a 1st class is carious cavities in the area of natural fissure of molars and premolars, and also in blind pits of chisels and molars;
a 2nd class is carious cavities, located on the contact surfaces of molars and premolars;
a 3d class is cavities, located on the contact surfaces of chisels and canines without violation of integrity of cutting edge;
a 4th class is cavities, located on the contact surfaces of chisels and canines with violation of integrity of corner and cutting edges of crown;
a 5th class is cavities, located in the near neck areas of all groups of teeth.
Black’s classification of carious cavities
Clinical picture
Initial caries (stage of spot)
At an initial caries can take place complaints about feeling of soreness of the mouth. On a cold irritant, as well as on the action of chemical agents (sour, sweet), the staggered tooth is irresponsive. Demineralization of enamel at a review appears the change of its normal color on the limited area and appearance of mat, white, light – brown, umber spots with a black tint. A process begins from the loss of brilliance of enamel on the limited area. Usually it takes place near the neck of tooth next to gums. The surface of spot is smooth, the edge of probe slides on her. A spot is painted solution of metilen dark blue. Pulp of tooth reacts on a current by force 2-6 mcА. At dental transillumination it appears regardless of localization, sizes and pigmentation. Under act of ultraviolet rays in the area of carious spot there is extinguishing of luminescence, incident to hard tissues of tooth.
Superficial caries
For the superficial caries of origin of brief pain from chemical irritants (sweet, salt, sour) is a basic complaint. Possibly also appearance of brief pain from the action of temperature irritants, more frequent at localization of defect in the necks of tooth, in an area with the most thin layer of enamel, and also at cleaning of teeth by a hard brush.
At the review of tooth on the area of defeat a shallow defect appears within the limits of enamel. He is determined sounding of surface of tooth on the presence of roughness of enamel. Quite often a roughness appears in the cent of vast white or pigmented spot. At localization of cavity on the contact surface of tooth sticking of meal and inflammation of tooth – gingival papilla takes place – was swollen, hyperemia, bleeding at a touch. Considerable difficulties arise up at diagnostics of superficial caries in the area of natural fissure. In such cases a dynamic supervision – repeated reviews is assumed through 3-6 months. The defect of enamel always appears at transillumination, even hidden. On a background bright luminescence of intact tissues of tooth distinctly evidently shade, proper the defect of enamel. At electroodontodiagnosis deviation does not appear from a norm. A defect, noncommunicative on the contact surface of tooth, is determined roentgenologic.
Middle caries
At a middle caries patients can not produce complaints, but sometimes pain arises up from the action of mechanical, chemical, thermal irritants which quickly pass after the removal of irritant.
At this form of carious process integrity of enamel – dentine connection is violated, however under the cavity of tooth the thick enough layer of dentine is saved. A shallow carious cavity filled the pigmented dentine which is determined at sounding softened, appears at the review of tooth. At presence of the softened dentine in a fissure probe stays too long, sticks in her. At chronic motion of caries a dense bottom and walls of cavity, wide entrance opening, appears at sounding. At the sharp form of caries is plenty of the softened dentine on walls and day of cavity, sharp and fragile edges. Sounding painfully for enamel – dentine to connection. Pulp of tooth reacts on strength of current of 2-6 mcA.
Deep caries
Patients grumble about brief pains from mechanical, thermal, chemical irritants which quickly pass after the removal of irritant.
A deep carious cavity appears at a review, with the overhanging edges of enamel, filled the softened pigmented dentine. Sounding of bottom of cavity, painfully on all area. Pulp of tooth reacts oormal strength of current of 2-6 mcA, but there can be a decline of excitability to 10-12 mcA. If a carious cavity is located so, that from her food tailings are heavily removed and washed, a tooth can be ill more great while, while these irritants will not be remote. Percussion of tooth is painless.
Differential diagnostics
Caries is in the stage of spot
Obvious differences have spots at a caries and endemic fluorosis. It touches both chalk similar and pigmented carious spot. A carious spot is usually single, fluorosis spots are plural. At fluorosis of spot pearl are white, on a background a dense enamel – suckling color, is localized on the so-called «immune areas» – on the lip, surfaces of languages, nearer to the humps and cuttings surfaces of teeth, strictly symmetric on the of the same names teeth of right and left side, and have an identical form and coloring. Carious spots are usually disposed on the proximal surfaces of teeth, in the area of fissure and necks of teeth. Even if they appeared on symmetric teeth differ both a form and place of location on a tooth. Carious spots usually appear for people, inclined to the caries. Such spots are combined with other stages of caries, and for fluorosis the characteristic expressed firmness to the caries. Unlike caries fluorosis spots especially often appear on chisels and canines, teeth, proof to the caries. Diagnostics is helped by painting of teeth by solution of metilen dark blue: a carious spot is dyed only.
It is necessary to differentiate from hypoplasia enamel. At hypoplasia evidently glassy spots of white color are on a background the refined enamel. Spots are disposed as «chainlets», surrounding crown of the tooth. Such chainlets are can be disposed on one and for a few at different levels of crown of the tooth. Identical a form defeats are localized on symmetric teeth. Unlike carious spots the spots at hypoplasia is not dyed metilen dark blue and by other dyes. Hypoplasia is formed yet to eruption of tooth, its sizes and colorings do not change in the process of growth of tooth.
Superficial caries
A superficial caries is differentiated with an initial caries. Unlike initial at which evidently there is a spot and integrity of surface of enamel is not broken, for a superficial caries there is a characteristic defect of enamel.
It is also necessary to conduct diagnostics with erosion of enamel. Unlike a superficial caries, erosion of enamel has a form of oval, length of which is located transversal on the most protuberant part of vestibular surface of crown. The bottom of erosion is smooth, brilliantly, dense. The scopes of defect white have a tendency to distribution in breadth, instead of deep into, as at a caries. Erosion of enamel is more frequent observed for the people of middle ages simultaneously striking a few teeth, usually immune to the caries. Quite often a process takes symmetric teeth. From anamnesis know the surplus use of lemon, juices and fruit, sour meal.
A superficial caries is differentiated with hypoplasia of enamel. At the hypoplasia surface of tooth is smooth, dense, defects are localized at different levels of symmetric teeth, instead of on the characteristic for a caries surfaces of crowns of the teeth.
The erosive form of endemic fluorosis, as well as superficial caries, is characterized a defect within the limits of enamel. The differences of defects are obvious. At fluorosis the defects of enamel are localized as a rule on the vestibular surface of crowns of the front teeth, immune to the caries. Erosions, located chaotically on a background the changed enamel, differ strict symmetry of defeat which is not combined with caries. To such teeth not peculiar hyperesthesia. As an erosive form of endemic fluorosis is formed only at the use of water with ever-higher maintenance of fluorine (more than 3 ml/l), the signs of fluorosis are observed in most habitants of region.
Middle caries
A middle caries is differentiated with a wedge-shaped defect, which is localized near the neck of tooth, has dense walls and characteristic form of wedge, without symptoms flows; with chronic apex periodontitis, which can flow also without symptoms, as well as middle caries: absence of feelings of pains is at sounding for enamel – dentine scopes, absence of reaction on temperature and chemical irritants. Preparing of tooth at a middle caries painfully, and at periodontitis is as pulp necrotized. Pulp of tooth at a middle caries reacts on strength of current of 2-6 mcA, and at periodontitis – on a current by force more 100 mcA. On a sciagram at chronic apex periodontitis even expansion of periodontal crack, destructive changes, appears in bone fabric in the area of projection of apex of root.
Deep caries
Conducted with that the diseases of teeth which have an alike clinical picture, namely: with a middle caries, which a characteristic less deep carious cavity, located approximately within the limits of own dentine, is for. A bottom and walls of cavity is dense, sounding painfully for enamel – dentine scopes, while at a deep caries cavity – within the limits of near pulp dentine, sounding painfully on all bottom, temperature irritants cause pain that quickly passes after the removal of irritant.
A deep caries must be differentiated with a sharp hearth pulpit, which characteristic sharp involuntary pains which increase in the evening and at night are for. Sounding of bottom of carious cavity is painfully in one point, more frequent in the area of projection of hearth of inflammation of pulp. At the deep caries of sounding of bottom painfully evenly on all surface of near pulp dentine, involuntary pains are absent.
It follows also to conduct differential diagnostics with a chronic fibrous pulpitis, for him characteristic presence of deep carious cavity, filled the softened dentine. At sounding of bottom of carious cavity it is possible to find out a report with a pulp chamber, sounding of this area sharply painfully, pulp bleeds, the decline of excitability of pulp is marked on strength of current to 25-40 mcA. At the deep caries of sounding painfully on all bottom, pulp reacts on strength of current of 2-12 mcA.
Treatment
Initial caries (stage of spot)
The white or light – brown spot is the display of making progress demineralization of enamel.
The capacity of dental tissues is proved for renewal in the initial stages of caries which is provided mainly the mineral matter of tooth – crystal of hydroxide apatites that changes the chemical structure. At the loss of part of ions of calcium and phosphorus in the favourable terms of hydroxide apatites can by diffusion and adsorption of these elements from saliva of recommence to the initial state. Thus there can also be new formation of crystals of hydroxide apatites from adsorbed dental tissues of ions of calcium and phosphate.
Remineralization is possible only at the certain degree of defeat of dental tissues. The border of defeat is determined saving of albuminous matrix. If an albuminous matrix is stored, through incident to her properties she is able to unite with the ions of calcium and phosphate. In future the crystals of hydroxide apatites appear on her. At an initial caries (stage of white spot), at a partial loss by the enamel of mineral matters (demineralization), but an albuminous matrix, capable to remineralization, is saved.
Penetration of matters in an enamel takes place in 3 stages:
1) transferring of ions from solution in hydroxide apatites layer of crystal;
2) from a hydroxide apatites layer on the surface of crystal;
3) from the surface of crystal of hydroxide apatites in the different layers of crystalline grate – inwardly crystalline exchange.
If the first stage lasts minutes, third are ten of days.
It is known that fluorine at the direct operating on the enamel of tooth is instrumental in proceeding in its structure. It is proved that not only in a period of enamelogenesis, but also after eruption of tooth in the superficial layers of enamel the proof appears to the action of aggressive factors of cavity of mouth of fluorine apatites. It is set that fluorine is instrumental in the acceleration of besieging in the enamel of calcium as fluorine apatites, that is characterized very proof stability.
Remineralization therapy of caries of teeth is carried out different methods, as a result there is proceeding in the superficial layer of the staggered enamel.
The row of preparations, which the ions of calcium, phosphorus, fluorine, conditioned remineralization of enamel of tooth enter in the complement of, is presently created. The most wide distribution was got by a 10% solution of gluconate of calcium, 2% solution of fluoride of sodium, 3% solution of remodent, fluorine containing varnishes and gels.
To today a method of proceeding in enamel is popular on the Leus’s – Borovskij’s method.
The surface of teeth is carefully purged mechanically from a dental deposit by a brush with tooth-paste. Then process a 0,5-1% solution of peroxide of hydrogen and dry out the stream of air. Farther on the area of the changed enamel impose wadding tampons, moistened a 10% solution of gluconate of calcium on 20 minutes, tampons change through each 5 minutes. Then the applique of a 2-4% solution of fluoride of sodium follows on 5 minutes. After completion of procedure it is not recommended to adopt a meal during 2 hours. The course of remineralization therapy consists of 15-20 appliques which conduct daily or in a day. Efficiency of treatment is determined on disappearance or diminishing of hearth of demineralisation. For more objective estimation treatment can be used method of painting of area by a 2% solution of metilen dark blue. Thus as far as remineralization surface of layer of the staggered enamel intensity of its painting will diminish. At the end of course of treatment it is recommended to use fluorine varnish which is inflicted on the carefully dried up surfaces of teeth a brush, valid for one occasion dose of not more than 1 ml, necessarily in a warmed-up kind.
Superficial caries
A superficial caries is a relative certificate to stopping. For children and teenagers a superficial caries does not require operative treatment in most cases. Quite often superficial defects at caries, located within the limits of enamel, do not require stopping. In such cases sufficiently from to polish a rough surface, conduct remtherapy. However at localization of defect in the natural deepening (fissures) or on the contact surfaces of preparing of cavity and its subsequent stopping necessarily. Stopping can be imposed without insulating of gasket.
Middle caries
At a middle caries, preparing of cavity is obligatory.
Treatment consists of instrumental treatment of enamel and dentine, formative walls and bottom of carious cavity, and its subsequent filling by a gasket and permanent stopping.
Treatment of middle caries is taken to the observance of general principles and stages of preparing and stopping.
Deep caries
At treatment of deep caries of preparing of hard tissues of teeth is obligatory.
Preparing of bottom and walls of carious cavity is carried out about crepitation. If to leave on the day of carious cavity a dentine is softened, the process of demineralization will proceed under stopping. It is possible to abandon crepitation a dentine pigmented in the Black’s cavities of a 1,2 class in obedience to principle of biological expedience, which in Black’s cavities 3,4,5 classes malfunction, as a pigmented dentine which examines with x-rays through an enamel will not allow to obtain an ideal cosmetic effect at stopping of tooth composite stopping materials.
Farther conducted antiseptic treatment of present cavity. Used heat solutions of antiseptics, not to injure pulp of tooth: 0,06% clorhexidin bigluconate, 5% solution of demexide, 1% solution of etonij, enzymes are with a 1% solution of novocaine.
Then conduct drying and depriving of fat of prepared of carious cavity. Sterile wadding tampons are used. Application of alcohol and ether for depriving of fat and drying of cavity impermissible, as they are strongly irritable matters.
A medical gasket is farther imposed, necessarily in a warm kind and only on the bottom of prepared of carious cavity, in thick not more than
A medical gasket must:
1) To stimulate the reparative function of pulp of tooth;
2) To have the bactericidal and antiinflammation operating on pulp of tooth;
3) To anaesthetize;
4) Not to annoy pulp of tooth and mucus shell of cavity of mouth;
5) To have good adhesion to tissues of tooth;
6) To be plastic;
7) To maintain pressure after hardening.
All above-stated properties are owned by domestic and foreign preparations which contain a hydroxide calcium:
· calmetsin;
· material dental lining;
· Dycal of firm Dentsply;
· Calcipulpe of firm Septodont;
· Life of firm Kerr;
· Calcimol of firm Voco;
· Reocap of firm Vivadent.
C success is use for treatment of deep caries plastic pastes which contain eugenol:
1. biodent;
2. zinc eugenol cement;
3. Cavitec of firm Kerr;
4. Eugespad of firm Spad.
On the bottom of prepared and the medicinal treated carious cavity the thinnest layer is impose a medical gasket, farther by a thin layer and only on the bottom of carious cavity a gasket is imposed from glass ionomer cement, covering medical material. After imposition of medical and insulating gaskets topographically we translate a deep carious cavity in the cavity of middle depth. Farther all stages of stopping of deep carious cavity answers treatment of cavities of middle depth; washing off of phosphorus acid; drying of carious cavity, causing of dentinal adhesion (primer) – 2-3 layers; causing of enamel adhesion on walls, bottom of carious cavity, finired enamel – consistently to 2-3 layers (every layer is polymerized 20-30 cut); bringing of stopping material of light consolidation; polymerization of every layer; polishing, polishing of stopping.
General stages of preparing and stopping of teeth
1. Anaesthetizing: infiltration, explorer, intraligamentous anesthesia, electro–anaesthetizing, seal–anesthesia; after shows – inhalation, intravenous anesthesia.
2. Opening of carious cavity: a delete of overhanging edges is enamels which do not have support on a dentine the spherical is used or fissured the drills of small sizes.
3. Expansion of carious cavity: broadens the drills of largenesses, delete of the softened and pigmented dentine, drills, power-shovel (for the delete of the softened dentine); a criterion is a light, hard dentine; exception – pigmented, crepitation dentine on the day of carious cavity at a deep caries.
4. Necrectomy: it is a final delete of the staggered tissues of enamel and dentine. It is expedient to use spherical and fissured the drills.
5. Forming of carious cavity: it is creation of the best terms for fixing of stopping material. There are general principles of forming of carious cavity, namely:
· Walls of carious cavity must be sheer and dense;
· Bottom – flat and crepitation at sounding;
· A corner between walls and bottom of the formed cavity must make 90°;
· The formed cavity can have the most various configuration: three-cornered, rectangular and etc
· Any formed carious cavity must have an optimum amount of retention retaining points which would provide stopping the best fixing;
· Preparing of all cavities must be conducted with the observance of principle of biological expedience;
6. Finising: smoothing of edges of enamel; conducted diamond or by the fissured drill on all depth of enamel under the corner of 45° on all perimeter of carious cavity. The got slant (falc) guards stopping from a change at masticatory pressure.
7. Medicinal treatment of carious cavity: conducted warm physiology antiseptic – 0,02% solution of furatsilin, 0,05% solution of etacridin lactat, by a 0,06% solution of clorhexidin bigluconate, by a 0,5% solution of dimexid, 0,05% solution of novocaine with enzymes. Then a cavity is carefully dried out. Optimum drying by warm air. If there is not warm air, at first a cavity is processed an alcohol, and then ether.
8. Imposition of insulating is gaskets: GIC is more frequent used cements as a last resort cements of phosphate. Purpose – to insulate a dentine and pulp from toxic matters which are contained in some stopping materials to create an obstacle warm – and cold of conductivity of stopping (especially from an amalgam)to promote adhesion of poorly adhesion stopping materials, to create the additional points of fixing for permanent of stopping material on the day of carious cavity.
9. Imposition of the permanent stopping: for this purpose a cavity must be ideally dried up, the choice of stopping material must be conducted with knowledge of physical and chemical properties each of them, stopping must be rounded, fully to proceed in the anatomic form of tooth, have a micro contact with the row of teeth, stopping material must to a full degree imitate a color and transparency of enamel of tooth, for stopping of Black’s cavities for 2-4 classes necessarily there is application of matrices-hubcaps or plates of celluloids, which allow to avoid overhanging of stopping and hit of stopping material in intradental interval and in a gingival groove.
10. Polishing and stopping of stopping: the metallic stopping are from amalgama and Gallodent M is polished in 24 hours (in the following visits) after complete consolidation of stopping. Polishing is conducted by finishers, and polish – polishers. Stopping are from the composite stopping materials polish the diamond coniferous forests, lateral surfaces – strips, polish – by brushes with poly paste, by the circles of rubbers and cups. The plastic stopping polish the disks of papers with a carborundum abrasive, lateral surfaces – strips, polished – felt rollers or brushes with poly paste.
There are two basic methods of preparing of carious cavity.
One of them was offered G.V. Black as early as the end of a 19 age. His base principle is prophylactic expansion (“Extension of for prevention” is “expansion of warning advice”) that multiplying the scopes of cavity (due to the delete of intact areas of tooth, sensible to the caries) is to the caries resistance areas.
Rightness of preparing of carious cavity serves as a criterion:
· 1. Visual estimation of topography and form of cavity.
· 2. Visual estimation of color of walls of cavity.
· 3. Estimation of hardness of walls of cavity is by sounding.
It is needed to mark that all these criteria are in a greater or less degree subjective.
The indicators of caries were developed: 0,5% solution of basic fucsin (water solution, shown at a middle and deep caries) and 1% red solution acids in propilengkicol (sour solutioot shown at a deep caries is considered more clear), which paint with a clear enough border only the layer of external carious dentine. Fusayama was offered new, pathoanatomical principle of preparing of carious cavity which consists in a complete delete only of layer of external carious dentine.
The detectors of caries are produced or in a pipette for direct introduction to the carious cavity or in a bottle.
It is necessary to inflict solution on the walls of cavity and after 10 seconds to wash off water. The criterion of rightness of preparing of carious cavity is visual control of painting of walls of cavity after 10-15 seconds after treatment of caries an indicator.
For today, it is the most objective test of estimation of quality of preparing of carious cavity.
Thus, application of modern method of treatment of caries is impossible without the use of detector of caries. The detector of caries must be used and at the method of prophylactic expansion.
As known, macro patanatomіya of caries has the features. A carious cavity (possibly a 1 class) forms two cones: a small cone is in enamels and large cone in a dentine, reverse the grounds to the enamel – dentine border.
It is related to that a carious defect passing an enamel achieves less mineralized fabric – dentine – and begins more active to spread in a width. Besides, near enamel – dentine border poorly mineralized are located integlobular spaces. That is why, even after the stage of prophylactic expansion there can be areas of the infected dentine in the area of enamel – dentine border. Usually at sounding of cavity the dentist pays attention to its bottom and caot mark the area of softening influence on the middle of lateral wall. Application of indicator of caries is control of complete delete of the infected dentine. Experience of application of detector of caries in a clinic, where the method of prophylactic expansion is mainly used, confirmed that even after the complete and final preparing, by the detector of caries the small areas of external carious dentine appear in the area of enamel – dentine border.
Conclusions:
· 1. Application of detector of caries is necessarily at any method of preparing of carious cavity, and guarantees the rightness of implementation of this stage of treatment of caries.
· 2. Use of detector of caries does not require the special skills and studies.
· 3. Low prime price of indicators of caries substantially will not influence on the cost of dental treatment (an average cost of imported is a caries of detector 30-35 $ for 6 ml).
· 4. Upgrading treatment, confidence of doctor in the rightness of the actions will allow attract new patients in a clinic.
· 5. Use of detector of caries must enter in the standard of dental treatment of caries.
· 6. Indicator of caries can be also applied for the exposure of the hidden cracks in an enamel or dentine; for localization of bee-entrances of channels of roots.
· 7. «American model» of adopting patients is actively inculcated lately, when one doctor-dentist works on a few arm-chairs. Implementation of part of manipulations is passed to the assistant of doctor, it is very important here, that every stage of treatment had clear criteria of rightness and completeness. It is especially important on such reception of the use of detector of caries.
· 8. Treatment of middle and especially deep caries can cause complication. Some foreign dentists use video in order to have monitoring of treatments of manipulations proofs of rightness of the conducted treatment in the case of origin of judicial trials. Estimation of preparing of carious cavity by the indicator of caries it is possible to represent by a intraoral video camera and use as proof in a court, as it is the world-acknowledged criterion of quality of treatment of carious cavity scientifically-grounded.
· 9. With appearance of new technologies in dentistry in the future possibly perfection of indicators of caries.
Conclusion
Most dentists are a familiar with researches of Fusayama and modern method of treatment of caries. But the indicators of caries did not find wide application. Possibly, it is related to that doctors are sure in the method of prophylactic expansion. Take advantage of detector of caries, and YOU will be satisfied of his necessity.
