Treatment of cement caries in two stages. Tooth cement caries: classification, diagnosis and treatment

caries cement K02.2 (root caries) - a type of caries in which the disease affects the root of the tooth, bypassing tooth enamel and dentin. It often affects the elderly due to the exposure of the roots.

patient model- Patients with permanent teeth. - Healthy pulp and periodontium of the tooth. - The presence of a carious cavity located in the cervical region. - The presence of softened dentin. - When probing the carious cavity, short-term pain is noted. - Pain from temperature, chemical and mechanical stimuli, disappearing after the cessation of irritation. - Healthy periodontal and oral mucosa. - The absence of spontaneous pain at the time of examination and in history. - Absence of pain during percussion of the tooth. - Absence of non-carious lesions of hard tissues of the tooth.

Complaints : food jamming, aesthetic defect, pain from chemical irritants, no complaints.

inspection shallow extensive pigmented carious cavity, probing is painful, percussion is painless, EOD 2-6 Mca. Pain from temperature stimuli disappears immediately after their elimination. On x-ray caries within the cement-dentin border.

Dif diagnostics: 1. Wedge-shaped defect. Localization in the region of the neck of the tooth. The walls are dense. The course is asymptomatic.

1. radiation caries. appear on average 4-5 months after the end of the course of treatment. In the cervical region, there are signs of tooth damage in the form of white spots, and then softening of the enamel. The process quickly spreads to the dentin and cementum of the cervical area. Runs asymptomatic. At the same time, the electrical excitability of the pulp is sharply reduced or practically not determined. Patients with this form of caries usually have xerostomia. Root caries progresses more slowly, since xerostomia is less pronounced with it. Radiation caries affects the tooth tissue along the gingival margin and weakens it so much that it can cause a crown fracture. Root caries is similar in its manifestations to radiation, but is not associated with radiation

2. Chronic fibrous pulpitis. Long-lasting pain reaction. Pain at night. The cavity of the tooth was opened on the radiograph.

3. Chronic forms periodontitis. Percussion is positive, changes on x-ray.

Algorithm and features of sealing In case of cement caries (usually class V cavities), filling is carried out in one or several visits.

Before starting the preparation, it is necessary to determine the depth of the spread of the process under the gum, if necessary, the patient is sent for correction (excision) of the mucous membrane of the gingival margin to open the surgical field and remove the hypertrophied gum area. In this case, the treatment is carried out in 2 or more visits, because after the intervention, the cavity is closed with a temporary filling, cement or oil dentin is used as a temporary filling material until the tissues of the gingival margin heal. Then the filling is done.

General requirements for cavity preparation: - anesthesia; - maximum removal of pathologically altered tooth tissues; - full preservation of intact tooth tissues is possible; - cavity formation. The shape of the cavity should be round. If the cavity is very small, gentle preparation with ball burs is acceptable without creating retention zones. Glass ionomer cements and compomers are used for filling defects. In patients who neglect oral hygiene, it is recommended to use glass ionomer (polyalkenate) cements (vitremer), which provide long-term fluoridation of tooth tissues after filling and have acceptable aesthetic characteristics. In elderly and elderly patients, especially with symptoms of xerostomia, amalgam or glass ionomers should be used. It is also possible to use compomers (Dyract eXtra), which have the advantages of glass ionomers and high aesthetics. Composite materials are indicated for filling defects in cases where the aesthetics of a smile is very important.

Compared with carious lesions of enamel and dentin, cement caries or, otherwise, “subgingival caries” (root caries) is much less common, but unlike them, it is a more aggressive and dangerous form for the tooth. Since the tooth root has a small wall thickness, its destruction by caries often takes place in a fairly short time, up to the development of pulpitis or periodontitis, leading, in turn, sometimes even to the removal of a tooth.

Since cement caries is often combined with cervical caries, for the front teeth, in addition to the risks mentioned, this is also fraught with aesthetic disorders. Dark spots or, especially if they are not eliminated for several years, often provoke psychological complexes, problems at work and in communication with the opposite sex.

In order to avoid all this, it is necessary, as they say, to know the “enemy” in person: that is why even now it is possible and necessary to get understandable and accessible information on how to recognize cement caries in oneself, what symptoms it can be accompanied by and how to treat it with maximum result in saving the tooth. This and much more will be discussed further.

Risk Factors for Cement Caries

Most often (approximately 60-90% of cases) dental caries develops in the elderly due to gum disease of various origins. At the same time, in most cases, a pathological pocket is formed between the gum and the tooth - a place of accumulation of various microorganisms, which not only provoke the destruction of the periodontal attachment, which leads to loosening of the tooth, but also cause the dissolution of the root cement with a deepening in the root dentin (streptococci).

On a note

According to international classification diseases, cement caries comes after carious lesions of enamel and dentin, and is not so common at a dentist's appointment. The classification of carious cavities according to Black (Black) allows us to conditionally classify cement caries as class V - cervical defects of all groups of teeth. Conventionality is determined by the fact that the cervical defect is not always combined with development; in the same way as subgingival caries does not always go beyond the boundaries of the gingival margin to the visible surface of the tooth.

The result of the destruction of cement and dentin by caries is first the formation of a small carious cavity, which sooner or later leads to the penetration of infection into the tooth with involvement of the pulp tissues ("nerve") in inflammation.

Additional risk factors leading to cement caries:

• Cervical or circular caries. If the carious process in the gingival region gains access to the cement of the tooth root, then a kind of “double” caries is formed with two types of localization: above the gum and below the gum. Here, either a violation of the fit of the gum, covering the neck of the tooth, or the exposure of the root for some reason plays a role.
  
• Incorrectly installed crown or violation of the statute of limitations for its fixation. With errors in prosthetics with crowns, it is possible to over-introduce its edges under the gum, or not reach the gum boundaries established by the norms. The result of this is either a gum injury with the formation of local gum disease, or a constant food retention in a place where the crown does not reach the gum edge, which also leads to inflammation. As a result, cariogenic microorganisms can easily penetrate under the gums with the involvement of the root cementum in the process.
  
  
• Violation of oral hygiene. The constant accumulation of plaque in the cervical region of the tooth or a poor-quality crown without proper and regular hygiene often leads to gingival and subgingival caries due to cariogenic factors of dissolving tooth enamel and root cement.

Clinical signs

Depending on the location of the carious focus under the gum, a clinic characteristic of cement caries is also determined. So, with the localization of caries in the periodontal pocket, when inflamed gum closes the root from external stimuli, we are talking about a closed arrangement. In such cases, the clinic of caries of the root cement is not bright. As a rule, a person does not have any painful sensations or they are expressed slightly.

With an open location of cement caries, in addition to the root, the cervical region is also involved in the process of destruction. Depending on the depth of the carious lesion, there may be complaints about:

• violation of aesthetics (especially on the front teeth)
• feeling of discomfort when eating
• the occurrence of pain from chemical (sweet, sour), thermal (cold and hot) and mechanical (when food penetrates under the gum) irritants.

Not so long ago, I had blackness near the gums near the upper tooth and it began to hurt. At first it was not even blackness, but some brown spot, which I could not clean off with toothpaste, but then the gum began to bleed, and the stain began to increase every month. As a result, it became painful for me to drink cold water and brush my teeth because of a sore gum. Since I work as a sales consultant, I have to communicate with people, and anterior tooth with blackness on it is striking, all the more so - it also began to hurt. The dentist said that this is already beginning caries of the root, which must be urgently treated before it damages the nerve. First, plaque and stone were removed from all my teeth, and after 3 days they put a beautiful filling. Now nothing hurts.

Yaroslav, Reutov

Diagnosis of cement caries without leaving home

With a closed location of cement caries, it can be very difficult to independently detect a defect in oneself. In such cases, it is usually detected only during the curettage (scraping) procedure of pathological gingival pockets, or during gingival plastic surgery by a dental surgeon or periodontal dentist. Since the boundaries of the defect do not go beyond the edge of the gums, it is only when pulpitis and pulpitis pains occur that one can independently understand that this tooth has a hidden problem.

It's important to know

The acute form of pulpitis is characterized by severe spontaneous pain that occurs even without external stimuli. Depending on the stage of inflammation of the "nerve" and the protective mechanisms of the body, the duration of pain is determined: from several minutes to 1-2 hours. Most often, the pain intensifies in the evening and at night.

Chronic forms of pulpitis can develop, bypassing the acute stage, and manifest themselves as prolonged aching pains, which can be aggravated by food irritants (often hot). chronic course pulpitis can last up to 2-3 months or more, up to the transition either to an exacerbation of pulpitis with a clinic of acute spontaneous pains, or to periodontitis - inflammation of the tissues surrounding the tooth root, which often leads to its removal.

With an open location of cement caries on the anterior teeth in combination with cervical caries, as a rule, already at the stage of a carious spot without a carious cavity and any symptoms, one can suspect serious problems and consult a doctor. Moreover, in this case we are talking about the comfort of communicating with relatives, friends, colleagues and other people. The appearance of dark dots, a chalky shade of enamel, its cracks and spalls on the border with the gums, makes it possible to determine caries of the cement at the initial stage of development, when it, perhaps, is just “breaking through” into the subgingival region.

With extensive carious cavities extending from the outer surface of the tooth deep under the gum, reactions to cold, hot, sweet, sour, as well as a feeling of soreness, pain when eating, usually appear. Often, the gum moves away from the tooth so much that a caries-affected area of ​​the root cementum and the root itself are visible under it. In such cases, you should immediately contact a specialist for additional studies and confirmation of the diagnosis.

Professional diagnostic methods

With a closed location of caries of the root cement, additional manipulations are required to make a diagnosis using instrumental and hardware methods. As part of the differential diagnosis the following approaches can be applied:

• Removal of supra- and subgingival plaque: cleaning of plaque and calculus from all surfaces of the teeth. Since gum disease is most often provoked by tartar and plaque, to make a correct diagnosis, it is necessary to thoroughly clean the examination area from deposits. For this, manual methods are used (scalers, chisels, curettes, etc.), ultrasonic tips and devices for ultrasonic cleaning of teeth (tip for the dental unit Scaler, Piezon-master, etc.), as well as dental treatment with the Air Flow device.
  
• Careful isolation of the examined root from saliva. For this, a rubber dam is used - as the most the best option for protection against saliva and ease of examination of the root, but you can get by with ordinary cotton rolls.
  
• Probing the root surface. In this case, only a sharp probe is used, which makes it possible to distinguish healthy tissue from caries-affected tissue by the characteristic surface roughness.
  
• X-ray study. It allows not only to detect subgingival cavities in a suspicious tooth or under a crown, but also to identify the slightest gingival defects in the area of ​​contact walls that are tightly adjacent to each other. At the same time, even a slight “darkening” can be seen on the x-ray of the tooth, which indicates that the x-rays easily pass through the tissue affected by caries, which means that the carious process has already affected at least the cement, and at the maximum - the dentin of the root. To detect caries hidden under the gums, a visiograph is widely used - an apparatus that transmits data to a computer and allows you to identify a defect and examine it in an enlarged image or from different angles.

The ideal option is a set of diagnostic measures that combine the data obtained by the patient during self-diagnosis with a description of characteristic complaints, as well as the consistent use of professional diagnostic methods - from the removal of tartar and plaque from all surfaces of the teeth to X-ray diagnostics. This approach in the future allows for a number of additional studies for cement from pulpitis or periodontitis in case of difficulties. Namely: thermometry (the reaction of the tooth to cold water or a heated instrument), EOD (the reaction of the "nerve" of the tooth to a certain current strength, characteristic of a particular diagnosis, using electroodontometry devices), etc.

Modern approaches to treatment and the specificity of the choice of filling material

Modern approaches to the treatment of root caries allow the procedure to be carried out in one or several visits - this largely depends on the clinical situation. If the gum closes the carious cavity, bleeds or is a serious obstacle to a successful filling, then the gum is often corrected (excision) on the first visit.

After removal of the interfering area soft tissue the carious cavity after treatment (or without it) is closed with a temporary filling of glass ionomer cement or ordinary oil dentin. After the gums have healed, the patient is invited for a second appointment and a filling is performed.

Basic principles of carious cavity treatment:

1. Mandatory anesthesia, since root tissues are the most sensitive area for mechanical treatment.
2. Maximum excision of discolored and softened tissues on the root surface using modern techniques.
3. Preservation of areas of the root surface undamaged by caries.
4. The formation of a cavity of a rounded shape.

For the treatment of cement caries, materials are used that are resistant to the influence of gingival fluid, saliva and blood during tooth filling. Such materials are glass ionomer cements and compomers.

From the observations of the dentist

For patients who neglect oral hygiene, it is recommended to use glass ionomer cements, which provide long-term fluoridation of tooth tissues after filling. Most modern glass ionomer materials have acceptable aesthetic characteristics that allow, in certain clinical cases, to be installed even on the anterior teeth.

Light-curing composites can be used in combination with combined techniques, for example, with the open sandwich technique, when glass ionomer cement or compomer is first introduced and distributed in the subgingival cavity, and already in the subgingival region (in the smile zone) a composite filling with increased aesthetic qualities is modeled. Thus, the positive properties of each of the materials used are used to the maximum to achieve long-term fixation of the future filling, its strength and external perfection.

To control the quality of treatment, it is necessary to come for a second appointment after the filling in 2-3 days (for artistic restoration) and, of course, in six months for preventive examination to exclude filling defects and recurrence of caries.

How much can treatment cost

As a rule, private clinics set prices for services based on the complexity of the treatment and the cost of the materials used. In addition to the status of the clinic, the level of its equipment, the training of specialists, etc. cement caries treatment is included in the price list as the most difficult in technical implementation. At the same time, the price is separately fixed for the use of certain devices and preparations during treatment (for example, for excision of gums that have grown into a carious cavity), as well as materials for fillings: glass ionomer cements, compomers, composites, etc.

Combined techniques with the use of a rubber dam to isolate the working area, 4-handed work with a dental assistant, cement caries treatment in 2-3 visits, of course, cost more than a simple filling.

And the use of orthopedic methods of dental treatment (crowns, inlays) together with therapeutic measures (fillings) or without them are several times more expensive.

An attempt to diagnose and treat root cement caries for free (according to OMS) can end in failure - do not forget that this is a difficult case. Due to the workload and poor equipment of most dental departments (especially rural ones) and clinics, there is a high risk of getting a free or cheap filling, which, if the filling technique is violated, will fall out in a few months. In the worst case, an incorrect diagnosis by a doctor can lead to the appearance of already pulpit pains under the installed filling, thereby losing time for retreatment of the tooth or even the tooth itself due to complications.

Dentist advice

For cement caries treatment to be effective, you can choose any dentistry (even state-owned), but it is important to learn from relatives, friends or acquaintances about the level of clinic equipment, reviews about specialists, treatment approaches, long-term results, materials used, etc. If you want to save money, then comfort and service should be the last thing to think about, since well-known companies lay down up to 30-40% of the cost of treatment for this particular category of services.

Useful video about cervical caries and its characteristic features

About gum disease and what they can lead to (about periodontitis)

DEPARTMENT OF THERAPEUTIC DENTISTRY
APPROVE

Head department prof. I.V. Firsova

PRACTICAL LESSON 2 YEARS (4 SEMESTER)

DENTAL FACULTY

(FOR STUDENTS)

TOPIC: Cement caries. Pathoanatomy, clinic, diagnostics, differential diagnostics, treatment.
PURPOSE OF THE LESSON: Motivate students to understand the importance of correct diagnosis and choice of treatment tactics for root caries.
educational goal: Compliance with the principle of informed consent as necessary condition when treating patients.
Formed general cultural competencies (OK):

the ability and readiness to analyze socially significant problems and processes, to use in practice the methods of the humanities, natural sciences, biomedical and clinical sciences in various types professional and social activities (OK-1);

the ability and willingness to carry out their activities, taking into account the moral and legal norms accepted in society, to comply with the rules of medical ethics, laws and regulations on working with confidential information, and to maintain medical secrecy (OK-8).
Formed professional competencies (PC):

ability and willingness to analyze the effect of drugs in the totality of their pharmacological properties in the treatment of various diseases, including dental (PC-28);

ability and willingness to treat diseases of hard dental tissues in patients different ages(PK-30).
LESSON DURATION:
MATERIAL SUPPORT: sets of dental trays with instruments for receiving patients and working on phantoms; dental filling materials; expendable materials; videos, thematic patients, tests, situational tasks; sets of radiographs; presentations for multimedia projector.
LOCATION: educational base of the Department of Therapeutic Dentistry.

LITERATURE:

Main literature

1. 
   Therapeutic dentistry: Textbook. Under the editorship of prof. E.V. Borovsky. - M .: "Medical Information Agency", 2011. - 798 p.
2. 
   Clinical situations with illustrations for the final state certification of graduates of medical universities Russian Federation. Dentistry. Teaching aid. - M .: FGOU "VUNMTS Roszdrav" and OOO "Novlek-M" 2008, 221p.

1. 
   Diagnosis and differential diagnosis of dental caries and its complications: textbook. allowance for students II - V courses stomatol. fak. - 060201 - Dentistry; GBOU VPO VolgGMU of the Ministry of Health of the Russian Federation, Department. therapist. dentistry; [ed.: L.I. Rukavishnikova, A.N. Popova, N.N. Trigolos, E.M. Chaplieva]; ed. I.V. Firsova, V. F. Mikhalchenko. - Ed. 2nd, revised. and additional - Volgograd: [Mega-Print], 2013. - 120 s.
2. 
   Makeeva I.M. Restoration of teeth with light-cured composite materials: practical. hand-in / I.M. Makeeva, A.I. Nikolaev. – M.: MEDpress-inform, 2011. – 368 p.
3. 
   Deep caries (clinic, diagnosis, treatment features): educational and methodological recommendations / Mikhalchenko V.F. Rukavishnikova L.I., Trigolos N.N., Popova A.N. Radyshevskaya T.N., Petrukhin A.G. Volgograd: VolGMU, 2008. - 51 p.
4. 
   Practical therapeutic dentistry: tutorial/Nikolaev A.I., Tsepov L.M. – M.: MEDpress-inform, 2010. – 924 p.
5. 
   Examples of maintaining a medical record in the practice of therapeutic dentistry (Part I. Caries and its complications): teaching aid/Firsova I.V., Popova A.N., Salyamov H.Yu., Morozova M.B.; edited by prof. V.F. Mikhalchenko. - Volgograd: Phoenix LLC, 2011 - 80 p.
6. 
   Dentistry: a textbook for universities / Ed. N.N. Bazhanov, - 7th edition., Revised. and additional, - M.: GEOTAR-Media, 2008. - 416 p. - Access mode:http// www. studmedlib. en
7. 
   Dentistry: a textbook for medical schools and postgraduate training of specialists / ed. V. A. Kozlova. 2nd ed., rev. and additional - St. Petersburg: SpecLit, 2011. - 487 p. - Access mode:http// www. studmedlib. en
8. 
   Therapeutic dentistry. Variable clinical situations with tasks with integrative tasks in a test form (with justification of the correct answers): A textbook for preparing for the final state certification of graduates of dental faculties of medical universities / Edited by prof.G.M. Barera - M .: GOU VUNMTs of the Ministry of Health of the Russian Federation, 2003. - 192 p.
9. 
   Therapeutic dentistry: national guidelines / edited by prof. L.A. Dmitrieva, prof. Yu.M. Maksimovsky. M.: "GEOTAR-Media", 2009. - 912p.
10. 
    Therapeutic dentistry: a guide to practical exercises. / Maksimovsky Yu.M., Mitronin A.V. M.: "GEOTAR-Media", 2011 - 432 p.
11. 
    Therapeutic dentistry: hands. to pract. classes: textbook / Yu.M. Maksimovsky, A.V. Mitronin. - M.: GEOTAR-Media, 2011. - 432 p. - Access mode:http// www. studmedlib. en
12. 
    Typical test tasks for the final state certification of graduates of higher medical educational institutions in the specialty 060105 (040400) "Dentistry". In 2 parts. / Under the editorship of prof. G.M. Barera - M.: FGOU VUNMTs Roszdrav, 2006, 368 p.

QUESTIONS TO REVEAL THE INITIAL LEVEL OF KNOWLEDGE:

1. 
   Etiology, pathogenesis of dental caries.
2. 
   Name the main and additional methods examination, dental patient.
3. 
   Name and write the classification of dental caries according to ICD-10.
4. 
   Pathoanatomy of dental caries.
5. 
   Rules for the preparation of carious cavities.
6. 
   Pain relief in the treatment of dental caries.
7. 
   Cavity preparation for filling.
8. 
   Types of permanent filling materials. Filling tools.
9. 
   Technique for filling carious cavities. Filling finishing.

Any changes in the quantitative or qualitative composition of the oral fluid lead to a decrease in its protective properties. Xerostomia - a decrease in the total volume of saliva - can cause the balance between demineralization and remineralization of the tooth to change towards demineralization. In some cases, temporary dry mouth can become permanent. This may be due to age - as the years go by salivary glands work less efficiently, the composition of saliva also changes. xerostomia as a side effect may cause medications that the patient takes: antihistamines, antidepressants, means to adjust blood pressure, diuretics, narcotics, sedatives, and certain other medications

Root caries develops especially intensively in persons who have undergone radiotherapy in the head and neck area. The resulting xerostomia leads to pronounced changes in the oral mucosa and the rapid occurrence of caries on a significant surface of the exposed dentin.

Cement caries occurs most often in middle-aged and elderly patients (60-90%). It is more common in men than in women and its frequency increases with age as a result of involutive processes, gingival atrophy, dystrophic processes in periodontal diseases or as a consequence of treatment.

Also, the defeat of the cement of the tooth root can be associated with irrational dental prosthetics (wearing removable structures based on teeth that are not covered with crowns). With a pronounced weakening of the immunological system, its cellular link, a rapidly progressive damage to the roots of a significant number of teeth can occur.

Root caries is often accompanied hypersensitivity teeth as a result of root exposure. The most generally accepted theory of its occurrence is hydrodynamic: an increase in the rate of fluid flow from the dentinal tubules, which, in turn, contributes to a change in pressure in the dentin, which activates the nerve endings at the pulp-dentin interface. With hypersensitivity, patients try to avoid discomfort during brushing, as a result of which they devote much less time to hygiene, reducing its quality, which in due time contributes to the occurrence of root caries.

Cement caries is complicated by inflammation of the root pulp, periodontitis, and can also lead to breaking off the crown of the affected tooth.
International Classification of Diseases (ICD-10, 1997)

K02. Dental caries

K02.0. Enamel caries.

K02.1. Dental caries.

K02.2. Cement caries.

K02.3. Suspended dental caries.

K02.4. Odontoclasia.

K02.8. Other dental caries.

K02.9. Dental caries, unspecified.
Pathoanatomy:

Microorganisms and their metabolic products penetrate the acellular fibrous cement, releasing inorganic substances from the cement. At the same time, collagen fibers are preserved, and a thin hypermineralized layer (10-15 microns) in the outer cement is also not affected. However, under cariogenic conditions, a thin layer of cement is rapidly destroyed. It is known that in periodontal diseases, dentin reacts to the influence of irritants by the formation of sclerosed dentin, which slows down the development of caries. In addition, root dentin contains fewer dentinal tubules than coronal dentin. Carious lesions are generally minor but often extend around the root. Dentin caries in the root area is similar in histological picture to crown dentin caries.

carious lesions root Depending on the depth of damage, they are divided into initial, superficial and deep caries of the root cement. Root caries is characterized by both slow and active course.
Initial root caries- defeat of the cement, in which its partial destruction occurs while maintaining the cement-dentin border. It is clinically manifested by a change in the color of the root surface area from light to dark brown and even black.

At superficial caries root destruction of cement and cemento-dentinal connection occurs. A shallow defect is formed, limited by a layer of mantle dentin, which has brown pigmentation different intensity. The depth of such a lesion does not exceed 0.5 mm.

At deep caries root destruction of hard tissues leads to the formation of a pigmented cavity, the bottom of which is separated from the cavity of the tooth only by a thin layer of dentin. Changes in the root pulp are manifested at the stage of superficial caries in the form of a violation of lipid metabolism, and in conditions of deep root caries they are aggravated by the process of destruction of connective tissue cells. Carious root damage with a depth of more than 0.5 mm refers to deep root caries and needs to be filled with a preliminary determination of the viability of the pulp by electrodontometry to assess the need for endodontic treatment.
Differential diagnostics

Cement caries must be differentiated from radiation caries:

Radiation damage to hard tissues of the tooth in the treatment of tumors of the maxillo- facial area appear on average 4-5 months after the end of the course of X-ray radiotherapy. In the cervical region, there are signs of tooth damage in the form of white spots, and then softening of the enamel. The process quickly spreads to the dentin and cement of the cervical region, and, in a relatively short time, the tooth crown is completely destroyed. Clinically, the process of tooth decay is usually asymptomatic. This is due degenerative changes dental pulp. At the same time, the electrical excitability of the pulp is sharply reduced or practically not determined. Patients with this form of caries usually have xerostomia. Root caries progresses more slowly than radiation, since xerostomia is less pronounced with it. Radiation caries affects the tooth tissue along the gingival margin and weakens it so much that it can cause a crown fracture. Root caries is similar in its manifestations to radiation, but is not associated with radiation.

dental caries- (c. dentis radialis) generalized dental caries that develops as a complication after X-ray or radiotherapy of the maxillofacial region; proceeds with pigmentation and softening of the surface layers and the formation of deep cervical cavities.
Algorithm for choosing a filling material for closing root caries

When choosing a material for root filling, it is advisable to divide root caries into:

Open, located above the gingival margin with gingival recession

Hidden, diagnosed in the periodontal pocket, and inaccessible to visual review

According to the depth of the cavity at the root of the tooth (initial, superficial up to 0.5 mm and deep - more than 0.5 mm)

According to aesthetic requirements (frontal teeth or molars), since the course of treatment will fundamentally change.

With initial root caries, it is only advisable to carry out a prevention program and cover the exposed root surfaces with Seal and Protect.

Open root carious cavities are covered at the stage of professional hygiene, hidden - after periodontal tissue surgery.

Superficial and deep, more than 0.5 mm, root caries on contact surfaces can be filled with the following materials:

Open - GIC Vitremer, Ketac Molar, Relyx / 3M ESPE, compomer Dyract AP / Dentsply, ProRoot, amalgam.

Hidden root caries is sealed at the stage surgical treatment: GIC Vitremer, Ketac Molar, ProRoot, fluoride amalgam.

Scheme

indicative basis of action in the diagnosis of cement caries

Situational tasks:
Task number 1.

Patient V., 30 years old, after the examination was given a preliminary diagnosis of root caries. A carious lesion of the tooth root is not accompanied by the formation of a cavity defect, it is not hidden by the edge of the gum. When assessing hygiene oral cavity marked OHIS=1.0; when assessing the condition of the gums GI = 1.1.

Your tactics in this situation.
Task number 2.

Patient A., aged 45, complained of exposure of the necks of the teeth, tooth sensitivity when exposed to cold water. Objectively: gum recession is 2-3 mm, on roots 1.1 and 2.1 there are light brown spots on the vestibular surface, not covered by the gingival margin, slightly rough, slightly painful on probing.

Examine the patient, make a diagnosis, make a treatment plan.
Task number 3.

Patient E., aged 35, complained of a carious cavity in tooth 2.2. Objectively: on the contact surface 2.2. there is a carious cavity at the root, not hidden by the gingival margin, filled with softened dentin, probing is slightly painful, percussion is painless. Make a diagnosis. Make a treatment plan.

a) cementum caries, dentine caries, suspended caries

b) cement caries, dentine caries, root caries

c) beginner, middle, deep

d) cement caries, root caries, odontoclasia.
2. Root caries is characterized by:

a) can flow without the formation of a cavity

b) cannot flow without the formation of a cavity

c) always complicated by pulpitis

d) always goes to the crown of the tooth
3. Risk factors for root caries that affect the environment of the tooth crown include:

a) plaque microorganisms and changes in the amount of gingival fluid;

b) lack of phosphorus intake in the body;

c) tooth crown caries, pregnancy;

d) plaque microorganisms, cariogenic products, lack of fluoride intake into the body, changes in the qualitative and quantitative characteristics of the oral fluid.
4. In carious cavities with root caries, the following are most often found:

a) staphylococci, Pseudomonas aeruginosa, lactobacilli

b) streptococci, actinomycetes, lactobacilli

c) enterococci, treponemas, protozoa

d) actinomycetes, candida, herpeviruses
5. Risk factors for root caries that affect the root environment include:

a) horizontal movements when brushing teeth, bruxism, heredity.

b) poor oral hygiene, adolescence, crowded teeth.

c) periodontal disease, loss of dentogingival attachment, poor oral hygiene, bad habits, elderly age

d) occupational hazards, acidic drinks, gingival hyperplasia
6. The thickness of the cement in the area of ​​the neck of the tooth is:

a) 200-500 microns; b) 100-1500 microns; c) 20-50 microns; d) 2-3mm.

a) cellular cement;

b) cell-free cement;

c) cellular and acellular cement;

d) in the region of the neck of the tooth, cement is usually absent;
8. Rapidly progressing carious lesions of the root surface are characterized by:

b) the surface of the lesion is smooth, shiny, hard; the edges of the cavity are smooth, dense.

c) a defect with a depth of more than 0.5 mm;

9. For carious lesions of the root in the stage of remission, it is characteristic:

a) softened consistency, sharp, uneven edges of the carious cavity

b) the surface of the lesion is smooth, shiny, hard; edges of the cavity are smooth, dense

c) a defect with a depth of not more than 0.5 mm;

d) the defect is located on the root of the tooth, has a V-shape.
10. For filling the carious cavity in the region of the tooth root, the following are shown:

a) amalgams, GIC, microhybrid composites;

b) GIC, amalgams, compomers;

c) GIC, compomers, composites.

d) flowable composites, inlays, microhybrid composites.
11. In the process of preparation and filling of carious lesions of the tooth root, it is necessary to carry out:

a) protection of the gums from mechanical and chemical damage, retraction of the gums to create access to the carious cavity;

b) shortening of the crown part of the tooth, gum retraction, gum protection from chemical damage;

c) gum retraction, injection of cauterizing substances into the gingival sulcus;

d) ensuring the dryness of the surgical field, excluding the stage of necrectomy.

e) ensuring the dryness of the surgical field (protection from blood, gingival and oral fluid, exudate from periodontal pockets);

a) a slow course, the spread of the carious process mainly along the surface of the root, and not into the depths of the tissues, the prevalence of root caries increases with increasing age of patients;

b) the spread of the carious process mainly along the surface of the root, fulminant course, lack of connection with the age of patients;

c) slow course, high prevalence among adolescents;

d) the prevalence of root caries increases with increasing age of patients, carious cavities have the shape of a wedge.
13. X-ray examination for root caries is carried out with the aim of:

a) detection of hidden cavities on the contact surface of the root and (or) under the gum, assessment of the condition of periodontal tissues, exclusion of periapical complications;

b) detection of hidden cavities on the contact surface of the root, detection of denticles in the pulp;

c) exclusion of periapical complications, detection of intraosseous pockets;

d) assessing the condition of periodontal tissues, assessing the mineralization of tooth tissues.
14. With age, the following structural changes occur in cement:

a) thickness reduction

b) increased blood supply

c) an increase in the number of elastic fibers

d) thickening

e) an increase in the number of collagen fibers

5 students participate: patient, medical registrar, therapist, physiotherapist, radiologist.

Patient - applies to the medical registry for registration of a medical card.

Honey. registrar - on the basis of passport data and a medical policy, draws up a medical card and takes it to a general practitioner.

Therapist - finds out the patient's complaints, collects an anamnesis of the disease, examines the oral cavity, fills in the dental formula. Makes a preliminary diagnosis. To clarify the diagnosis, he refers to a physiotherapist and for an x-ray examination (for a hidden cavity, the depth of the tooth cavity)

Physiotherapist - determines the EOD of causative teeth.

Radiologist - makes a description of the x-ray

The therapist - on the basis of the main and additional methods of research, differential diagnostics, makes the final diagnosis and prescribes the method of treatment.

Compiled ass. Marymova E.B.

Root caries is one of the main lesions of the hard tissues of the tooth that occurs after a violation of the dentogingival attachment and the appearance of gingival recession.

cement.

2. PURPOSE OF THE LESSON:

To teach students to diagnose and differential diagnosis of cement caries .

Know: clinic, methods for diagnosing caries cement.

Be able to: differentiate cement caries with other hard tissue diseases.

Own: methods of differential diagnosis of caries.

3. CONTROL QUESTIONS:

1. Determination of caries cement.

2. Cement caries clinic.

3. Methods for diagnosing cement caries.

4. Methods of differential diagnosis of cement caries.

4. ABSTRACT.

Root caries is considered to be a brown cement area without a defect or with different depths of cavities and a pigmented bottom. Restorations extending into the root area should only be considered root caries fillings when the enamel-cement boundary is exceeded by at least 3 mm, while restorations ending in the root area above these limits are not considered root fillings. Secondary caries that occurs along the edges of the filling in the region of the border of the root and crown is not caries of the root surface.

Root caries is localized on the vestibular, oral and approximal surfaces of the root. Data on the incidence of caries of the tooth root of various surfaces and groups of teeth are contradictory. OA Chepurkova found that the frequency of caries of the tooth root is significantly higher on the molars, in addition, the distance of 2-4 mm from the gingival margin is the critical depth in the periodontal pocket for the occurrence of caries of the tooth root.

Carious lesions of the root, depending on the depth of damage, are divided into initial, superficial and deep caries of the root cement. On the basis of localization, carious cavities on the contact surfaces of the root belong to the first class, cavities on the vestibular and (or) oral - to the second. Root caries is characterized by both slow and active course. Regardless of the course of the process, isolated carious cavities in the region of the tooth root almost never form overhanging edges and undercuts. There is a planar lesion of the hard tissues of the root of the tooth (either along the circumference of the root or along it).

Initial root caries is a defeat of the cementum, in which its partial destruction occurs while maintaining the cemento-dentinal border. It is clinically manifested by a change in the color of the root surface area from light to dark brown and even black.

With superficial root caries, the destruction of the cementum and the cemento-dentinal junction occurs. A shallow defect is formed, limited by a layer of mantle dentin, which has brown pigmentation of varying intensity. The depth of such a lesion does not exceed 0.5 mm.

With deep root caries, the destruction of hard tissues leads to the formation of a pigmented cavity, the bottom of which is separated from the tooth cavity by only a thin layer of dentin. Changes in the root pulp are manifested at the stage of superficial caries in the form of a violation of lipid metabolism, and in conditions of deep root caries they are aggravated by the process of destruction of connective tissue cells. Carious root damage with a depth of more than 0.5 mm refers to deep root caries and needs to be filled with a preliminary determination of the viability of the pulp by electrodontometry to assess the need for endodontic treatment.

caries cement occurs most often in patients over 60 years of age and is characterized by damage to the cementum or dentin in the cervical area. Its occurrence is associated with the frequent consumption of carbohydrates and poor oral hygiene in old age in the presence of areas of exposure of the root surface. The latter is explained by age-related atrophy of the interdental septa and periodontal disease. Wherein importance also has a reduced secretion of saliva, which is caused by hormonal changes, taking medications, etc. Root caries develops especially intensively in people who have undergone radiation therapy in the head and neck. The resulting xerostomia leads to pronounced changes in the oral mucosa and the rapid occurrence of caries on a significant surface of the exposed dentin (Segen, 1973).

Diagnosis of root caries in some cases is difficult due to the asymptomatic course of this process, as well as due to the accumulation of a significant amount of dental deposits in the area of ​​​​bare teeth roots.

To diagnose caries of the tooth root, a traditional scheme for examining a dental patient is used. With caries of the tooth root, note:

Absence of complaints, which is typical for this pathology (often pain occurs only with the development of inflammation of the dental pulp);

Complaints about an aesthetic defect (with the localization of the cavity on the vestibular surface of the roots of the frontal teeth;

Discomfort when eating;

Pain from thermal, mechanical, chemical stimuli,

disappearing immediately after the elimination of the stimulus;

Complaints associated with the presence of periodontal disease in the patient, leading to the loss of dentogingival attachment.
In order to identify the risk factors described above, a thorough history is taken.

Assessment of the state of hygiene of the oral cavity, dentition, periodontal tissues and mucous membranes is carried out according to the generally accepted method.

In addition, when examining patients with caries of the tooth root, it is recommended to determine indices characterizing gingival recession (S.Stahl, A.Morris, 1955), loss of dentogingival attachment (Loss of attachment, Glaving, Loe, 1967), dentin sensitivity (KIDCZ, Dedova L.N., 2004), peripheral circulation (IPK, Dedova L.N., 1982), the amount of plaque in the gingival region (PLI, Silness, Loe, 1964). This is necessary to assess the risk of progression of root caries in this patient. It is also possible to determine the RCI index (Katz, 1982), which allows you to more accurately assess the degree of damage to open root surfaces by caries of the tooth root. The remineralization index (Fedorov Yu. A., Dmitrieva I. M., 1977, 1994) allows you to evaluate the mineralization of hard tissues before and after conservative treatment caries. Special attention it is necessary to pay attention to the identification of factors contributing to the development of gingival recession (poor oral hygiene, periodontal disease, dentoalveolar anomalies, age, iatrogenic trauma).

Determination of the gum recession index - IR (S. Stahl, A. Morris, 1955).

The gingival recession index refers to irreversible and fixes the gingival recession.

Periodontal damage is assessed based on the assessment of the index, which is calculated in units or percentages by dividing the number of teeth with the exposure of the cervical part of the tooth by the number of teeth in the subject according to the formula:

The index value is in the range from 0 to 100%.

A mild degree of periodontal pathology corresponds to digital values index up to 25%, medium degree severity - from 26% to 50%, and severe - more than 51%.
Plaque Index Determination - PLI (Silness–Loe, 1964)
Designed to determine the thickness of plaque in the gingival region of the tooth. All or selected teeth are examined, dividing the tooth into 4 parts: distal-vestibular, vestibular, medial-vestibular and lingual surfaces.

A mirror, probe and air are used to dry the tooth. The study does not exclude prostheses or fillings.

Determination of the index of peripheral circulation - IPC (LN Dedova, 1981).
The index of peripheral circulation is estimated on the basis of the ratio of indicators of resistance of gum capillaries and the time of resorption of vacuum hematomas (L.N. Dedova, 1981). The need for its use is due to the fact that in 33.0-35.0% of cases there is a discrepancy between the indicators of the above tests. The indicators of these tests are evaluated in points, their ratio is expressed as a percentage (see table).

Example: the resistance of the gum capillaries in the area of ​​1 tooth in a patient with generalized periodontitis is 10 seconds, the resorption of the vacuum hematoma occurred within 4.0 days:

Based on the indices of the index, the following assessment of the functional state of the peripheral circulation can be carried out:

IPC = 0.8–1.0 (80–100%) - physiological norm;

IPC = 0.6–0.7 (60–70%) - good, compensated condition;

IPC = 0.075–0.5 (7.5–50%) - satisfactory condition;

IPC = 0.01–0.074 (1.07–7.4%) - a state of decompensation.

When probing rapidly progressive carious lesions of the root surface, a softened or "skinny" consistency is detected. The edges of the carious cavity are sharp, uneven. The surface of carious lesions of the root in remission is usually smooth, shiny, hard, the edges of the cavity are smooth, dense.

At the same time, to detect hidden cavities on the contact surface of the root and (or) under the gum, to exclude periapical complications, as well as to assess the condition of periodontal tissues, X-ray method research. At the same time, it is recommended to use a parallel radiography method, bite-wing radiograph (interproximal method), orthopantomogram.

Cement caries must be differentiated from radiation caries: almost all teeth are affected when radiation treatment tumors of the maxillofacial region. It must be remembered that not all bare roots are affected by caries.

1. Make a table of methods for diagnosing cement caries.

1. Therapeutic dentistry: Textbook for medical students / Ed. E.V. Borovsky.- M.: Medical Information Agency, 2009.- 840s.

2. Lukinykh L.M. Dental caries.- N-N.: NGMA.-2001.-214p.

3. Therapeutic dentistry. Ed. L.A. Dmitrieva.- M.: Medpressinform, 2003. - 894s.

4. Therapeutic dentistry. National leadership / ed. L.A. Dmitrieva,

Yu.M. Maksimovsky.- M.: GOETAR.-2009.-910s.

5. Maksimovsky Yu.M. Dental caries.- M.: GOETAR.-2009.-78s.

6. Usevich T.L. Therapeutic dentistry. - Rostov-on-Don: Phoenix, 2003. - 384 p.

7. Tsarinsky M.M. Therapeutic dentistry - Rostov-on-Don: March, 2004. - 416s.
7. LEARNING TASKS

1. Patient V., aged 25, complains of an aesthetic defect, short-term pain from chemical stimuli. When examining the cervical region of the 33rd tooth, there is a limited pigmented area of ​​brown color. Probing is painful. Set the diagnosis. What additional diagnostic methods should be used to clarify the diagnosis?

2. Patient V., aged 27, complains of an aesthetic defect, short-term pain from chemical and thermal stimuli. When examining the cervical region of the 35th tooth, there is an accumulation of dental deposits, under which a limited pigmented brown area is determined. Probing is painful, tissues are softened. Set the diagnosis. What additional diagnostic methods should be used to clarify the diagnosis?

ACTIVITY #20

TOPIC: CEMENT CARIES. TREATMENT OF CEMENT CARIES

Lesson duration ___ min.

1. SCIENTIFIC AND METHODOLOGICAL SUBSTANTIATION OF THE TOPIC:

Root caries is one of the main lesions of the hard tissues of the tooth,

arising after a violation of the dentogingival attachment and the appearance of gingival recession.

2. PURPOSE OF THE LESSON:

Teach students to carry out cement caries treatment, prevent possible complications at the stages of treatment, to study methods of prevention.

As a result of mastering the topic of the lesson, the student must:

Know: peculiarities surgical treatment cement caries.

Be able to: to carry out the stages of preparation and filling in the treatment of cement caries.

Own: methods of surgical treatment of cement caries.

3. CONTROL QUESTIONS:

1. Cement caries treatment.

2. Stages of preparation and filling in the treatment of cement caries.

3. Complications in the treatment of cement caries.

4. Prevention of cement caries development.

4. ABSTRACT.

After the diagnosis of caries of the tooth root and the identification of possible risk factors, therapeutic and preventive measures are planned for this patient.

With deep caries of the root of the tooth, it is necessary, and with superficial caries of the root of the tooth, according to indications, preparation and filling of carious cavities should be carried out. In the process of preparation and filling of carious lesions of the tooth root, located close to the gingival margin, it is necessary to solve the following tasks:

Protection of the gums from mechanical and chemical damage;

Retraction of the gums to create access to the carious cavity;

Ensuring the dryness of the surgical field (protection from blood, gingival and oral fluid, from exudate from periodontal pockets).

K. Melkonyan reports that with the subgingival location of root caries, a flap operation in the area of ​​the causative tooth and cavity filling during surgery are necessary.

The preparation of carious cavities in case of caries of the tooth root has certain features:

Exclusion of the stage of opening the carious cavity;

Carrying out necrectomy without prophylactic excision of intact tissues;

Formation of an additional platform on the oral surface of the tooth root to improve access to the carious cavity on the contact surface of the tooth root (according to indications);

Preparation of the edge of the root cavity with a rectangular ledge to prevent thinning of the edges of the filling (according to indications);

Formation of an oval cavity;

Creation of retention grooves in the dentin on the occlusal and gingival walls (according to indications;

Creating an enamel bevel (2-5mm), if part of the cavity is located in the area of ​​the enamel-cement border.

With an initial and superficial carious lesion in the period of remission, one can limit oneself to preventive measures, provided that the patient complies with medical recommendations. With a rapidly progressive course of root caries, conservative (without filling) or surgical (preparation, filling) treatment is carried out. When choosing treatment tactics, the depth of damage to the hard tissues of the tooth root and the level of patient motivation to maintain the health of the oral cavity are taken into account.

Treatment of initial (without cavity formation) and superficial caries of the tooth root (cavity up to 0.5 mm deep) should be carried out, if possible, without filling. It is therefore recommended to use medications in combination with careful, regular individual and professional oral hygiene. The use of fluorine-containing varnishes and gels with and without the addition of an antiseptic is recommended. High efficiency was shown by preparations containing aminofluoride, 0.4% tin fluoride, 0.05-2% sodium fluoride, 4% titanium fluoride in combination with antiseptics - 1-5% chlorhexidine, 1% thymol, triclosan, as well as systems with controlled release of fluoride.

It is effective to carry out deep fluoridation in the treatment of superficial caries of the tooth root using a dentin-sealing liquid containing fluoride crystals of especially high dispersion and copper ions. At the same time, there are reports in the literature about the advisability of using fluorides in combination with calcium preparations (10% calcium gluconate solution and 0.5-1% sodium fluoride solution in the form of applications, casein phosphopeptide amorphous calcium phosphate paste in combination with sodium fluoride) .

It should be noted that the effectiveness of therapeutic and preventive measures for superficial root caries increases with a combination of physical factors (argon laser, ozone exposure) and fluorine preparations. In a practical aspect, it seems quite reasonable and promising to use protective sealants for exposed dentin, which can prevent abrasion of the necks of the teeth, reduce the number of cariogenic associations of microorganisms on the root surfaces, eliminate or reduce the sensitivity of the dentin of bare roots, and release fluoride ions for a long time.

The question of the choice of filling materials for the treatment of caries of the tooth root has not been finally resolved. This is due to difficulties in providing access to root carious cavities (especially approximal ones), difficulties in achieving dryness of the surgical field, with the peculiarities of fixing seals to dentin and cement, with the presence of significant compression-tension loads in the gingival region of the tooth.

Currently, glass ionomer cements, compomers, and pink-colored composites (according to indications) are considered the most suitable for filling cavities in the region of the tooth root.

According to many authors, the most optimal material for closing defects in root caries is a hybrid two-component triple-curing GIC "Vitremer" by 3M ESPE, in which for the first time the technology of triple curing was applied: light, chemical and glass ionomer reaction.

However, the use of this material for filling open root caries in the area of ​​the anterior teeth does not allow achieving satisfactory aesthetic results, therefore, a number of authors recommend the use of Relyx ARC 3M ESPE composite cement. It is used with the 3M ESPE Single Bond adhesive system and is designed to fix all types of orthopedic and orthodontic constructions when increased bond strength, good aesthetics and high reliability are required.

The most interesting and promising material is a mineral trioxide aggregate based on Portland cement (PRORoot MTA). The curing time of the material after mixing is about 3 hours. The pH value of the material at the time of mixing is 10.2 and rises to 12.5 within three hours of mixing. The compressive strength increases over time, from 40 MPa after 24 hours to 67 MPa after 21 days.

The main properties of the material include:

Reliable edge sealing

High biological compatibility of the material, which promotes the regeneration of mineralized tissues (bone, cementum, dentin);

Ease of use, and, which is especially important when filling carious root lesions, stability in a humid environment, which is determined by the mechanism of Portland cement curing - hydration of calcium silicate compounds.

In our opinion, when choosing a material for root filling, it is advisable to divide root caries into:

Open, located above the gingival margin with gum recession;

Hidden, diagnosed in the periodontal pocket, and inaccessible to visual review;

According to the depth of the cavity at the root of the tooth (initial, superficial up to 0.5 mm and deep - more than 0.5 mm);

By location - class I (only contact surfaces) or class II (vestibular, oral surfaces);

According to aesthetic requirements (frontal teeth or molars), since the course of treatment will fundamentally change.

Algorithm for choosing a filling material for root caries closure.

In case of initial root caries, we consider it expedient only to carry out a prevention program and cover exposed root surfaces with Seal and Protect sealants, calcium and fluorine preparations. Open root carious cavities are covered at the stage of professional hygiene, hidden - after periodontal tissue surgery.

Superficial and deep, more than 0.5 mm, root caries on contact surfaces, we suggest filling with the following materials:

Open-GIC Vitremer, Ketac Molar, Relyx/3M ESPE, Dyract AP/Dentsply compomer, ProRoot, amalgam.

Hidden root caries is sealed at the stage of surgical treatment: GIC Vitremer, Ketac Molar, ProRoot, amalgam containing fluorine.

It is advisable to seal open root caries on the vestibular and oral surfaces - GIC Vitremer, Relyx, 3M ESPE, Ketac Molar, Dyract AP compomer - Filtek Z250 / 3M, ProRoot composites (white). Hidden carious cavities during periodontal surgery are closed by Vitremer, Ketac Molar, ProRoot.

Treatment of open and hidden cavities on the root of the tooth, we propose to carry out during the therapy of periodontal tissues, including:

Carrying out professional oral hygiene (“scaling”) and leveling the root surface (“root planning”), which is carried out using the “Piezon-master 400” system

Elimination of local factors that contribute to the accumulation and activation of the action of the microbial factor: including the filling of open root defects

Functional selective grinding

Splinting of mobile teeth

II stage. Surgery

Correction of soft tissues of the vestibule of the oral cavity

Open curettage

Flap operations

Gingivectomy.

Hidden carious cavities are sealed at the stage of major surgical interventions on periodontal tissues

III stage. Maintenance therapy, which is carried out 2-3 times a year, depending on the severity of periodontal disease, including:

Professional oral hygiene, obligatory hygienic control

Local anti-inflammatory therapy

Carrying out preventive measures aimed at reducing root caries, according to the proposed program

Filling open root defects

Functional selective grinding.

Mistakes and complications arising in the treatment of caries In the treatment of dental caries, the doctor performs a number of different manipulations. If they are not very carefully or incorrectly performed, a number of complications can occur - both during the actual surgical processing, preparation and filling of the carious cavity, and at various times after filling the teeth. Therefore, it is advisable to single out the complications that arise during the preparation and filling of the carious cavity, and the complications that appear after treatment. Mistakes and complications that occur during the preparation and filling of the carious cavity.

Insufficient preparation (treatment) of the carious cavity. When preparing a carious cavity, it is necessary to carefully remove necrotic, pathologically altered tooth tissues. Leaving areas of softened dentin subsequently leads to infection of its underlying areas and the development of secondary caries or inflammation of the pulp - pulpitis. Even if such unpleasant complications do not arise, then the softened dentin absorbs pigments, its color changes, which leads to darkening of the tooth crown. When secondary caries occurs, the tooth tissues surrounding the filling are destroyed, and it falls out.

Many errors can occur when the preparation mode is violated. These include: overheating and burns of hard tissues (especially dentin), overheating of the pulp (heating up to 70 ° C causes its necrosis), etc.

Traumatic preparation leads to severe pain, and if anesthesia is used, then to irritation and inflammation of the pulp. In general, careful observance of the rules for the preparation of a carious cavity allows you to avoid a number of complications.

Perforation of the bottom of the carious cavity occurs when careless or rough preparation of the bottom of the carious cavity with a bur or excavator. It is necessary to take into account the topography of the cavity of the teeth and pulp horns.

When perforation of the bottom of the carious cavity occurs sharp pain due to trauma to the pulp (during the preparation of the cavity under anesthesia, this sign may not be expressed, which causes a certain feeling of carelessness in the doctor). A drop of blood or serosanguineous fluid appears at the perforation site. Due to perforation of the pulp, acute traumatic pulpitis develops (accidental exposure or injury of the pulp). Pulp injury occurs when a coronal pulp is significantly injured with a bur or other tool (excavator). Therefore, this complication is treated in the same way as acute traumatic pulpitis (antiseptic treatment of the carious cavity, the use of pastes with calcium hydroxide, antibiotics, enzymes, etc.).

The tactics of treatment depend on the degree of damage to the pulp: in case of accidental exposure, a conservative (biological method) treatment is carried out, and in case of accidental injury of the pulp, amputation or extirpation of it, depending on the degree of injury, the location of the tooth (incisor or molar), the location of the carious cavity on the tooth crown, age of the patient and other factors.

Perforation of the cavity wall occurs with traumatic preparation and an incorrect assessment of the ratio of the carious cavity and the crown or the common axis of the tooth. In this case, the gum is usually injured, which is accompanied by pain and minor bleeding. It is necessary to carefully examine the perforation site in order to avoid errors. Usually, when the wall is perforated, bleeding from the gum wound is stopped with cotton balls soaked in hydrogen peroxide solution or other hemostatic agents. The perforated hole is carefully prepared according to the rules for preparing a carious cavity and filled with filling material when filling a carious cavity. The use of glass ionomer cements and compomers in such cases is very effective.

Drill damage to adjacent teeth. The degree of damage to the hard tissues of the neighboring (adjacent to the cavity) tooth can be different - from a slight defect in the surface layer of the enamel to its complete absence. Minor enamel defects are treated with fluorine varnish or other fluorine-containing (remineralizing) preparations. Highly good effect achieved when closing such lesions with light-cured adhesive systems of composite materials.

The company "Dentsply" offers a sealant for this purpose - "Seal&Protect". If there is an enamel defect with a violation of the enamel-dentin connection, it is closed with an appropriate filling material (with the preparation of the defect or when using composites without significant preparation of the hard tissues of the affected adjacent tooth).

Gingival injury. In this case, pain in the gums and bleeding from it are noted. Bleeding is stopped with cotton balls soaked in a 3% hydrogen peroxide solution or other hemostatic agent. After that, the treated carious cavity is thoroughly washed, dried and sealed. To prevent this complication, it is necessary to carefully prepare the carious cavity, avoiding injury to the gums, and if necessary, retract the gums.

A number of errors and complications occur during the filling of the carious cavity.

When filling, it is important to choose the right filling material and prepare it. Wrong choice of material leads to cosmetic deficiencies, causes rapid destruction and loss of the seal due to the discrepancy between the strength of the material and the chewing pressure. When preparing a filling material and filling it with a carious cavity, you must carefully follow the manufacturer's instructions. Neglect of these rules dramatically reduces the physical and mechanical properties and strength of the seal, contributes to its rapid destruction, discoloration and other complications.

Overhanging edges of the filling injure the gums, create conditions for the accumulation of food debris between the teeth. This leads to complications (secondary caries, inflammatory diseases periodontium). To prevent complications that may arise when filling a carious cavity, you must carefully follow all the rules for filling the carious cavity with filling material.

Incorrect selection and preparation of filling material often lead to immediate complications. It must be remembered that any violation of the technology for the preparation of filling material and the filling technique causes a sharp violation of the quality of the seal. The choice of material is determined by the clinical situation, and a deviation towards aesthetics to the detriment of strength or vice versa subsequently leads to the destruction of the filling or the violation of the cosmetic effect of the filling.

Errors and complications that occur after caries treatment.

A number of complications can occur at different times (a few months or years) after treatment. Quite often noted inflammation and necrosis of the pulp. The causes of this complication may be traumatic preparation of the carious cavity, in which there is overheating of the pulp, excessive pressure on the bottom of the carious cavity. The appearance of inflammation in the pulp is facilitated by the treatment of the cavity with toxic or irritating (for example, ethyl alcohol) medicines, as well as the vigorous drying of the carious cavity with a stream of cold air. Permanent filling materials can irritate the pulp due to toxic (cements, plastics, composite materials) or thermal (amalgam) action.

Depending on the strength of the irritating factor, inflammation of the pulp can occur in the form various forms acute or chronic pulpitis with corresponding clinical picture. Pulp necrosis develops, as a rule, almost asymptomatically and may first manifest itself as a change in the color of the crown of the tooth (it becomes gray or dark gray). Treatment is carried out according to the rules for the treatment of pulpitis. To prevent such complications, it is necessary to correctly and carefully follow all the rules for the preparation and filling of the carious cavity.

Secondary caries may occur due to insufficient preparation of the carious cavity, when areas of demineralized dentin remain on the walls and bottom of the cavity. Insufficient or incorrect processing of the enamel edges of the cavity leads to a violation of the marginal fit of the seal, the formation of a gap and, in the future, caries. The causes of secondary caries can be the irrational shape of the carious cavity, the ingress of moisture into the cavity during its filling, improper preparation of the filling material.

When secondary caries appears, the remnants of the filling are removed, the carious cavity is prepared and sealed according to the depth, localization and course of caries.

Gingivitis, or inflammation of the gums occurs when filling defects in carious cavities, overhanging edges of fillings, trauma to the gums during preparation and filling (for example, with a matrix, instruments) of a carious cavity.

In the presence of inflammation of the gingival margin, first of all, defective fillings are changed, avoiding injury to the gums. Then, if necessary, carry out drug treatment. Treatment should not be neglected as chronic gingival trauma can lead to more severe periodontal disease such as localized periodontitis.

Acute and chronic apical periodontitis usually develop several days (acute) or months (chronic) after caries treatment. They may be the result of the same causes that cause inflammation and necrosis of the pulp, and are a continuation of the development of this pathological process. Treatment of acute and chronic periodontitis requires endodontic manipulations.

Changing the color of the crown of the tooth(to gray, dark gray) may be the result of insufficient preparation and removal of necrotic dentin, pulp necrosis and chronic periodontitis. Darkening of the crown of the tooth can occur after an amalgam filling, especially if it is not carefully prepared. To eliminate areas of pigmented, necrotic dentin, the filling is removed, a thorough necrectomy is performed, and the cavity is again filled with the appropriate filling material. Pulp necrosis and chronic periodontitis require endodontic treatment.

Excoriation of the gums, which are adjacent to the seal in the cervical region, may be the result of an increased sensitivity of the body to the material from which the seal is made. This is most often noted in cases where the seal is made of plastic or composite materials ( allergic reaction). The cause of excoriation may be a poorly made filling with an unpolished, rough surface. To eliminate such a complication in the case of a "contact allergy", it is necessary to replace the filling with a new one made of inert (not causing allergies) for the patient's body material. If there is a rough surface of the filling, it is enough to carefully process and polish it.

Filling falling out most often occur as a result of violations of the rules for the preparation of filling material and the formation of a carious cavity. The reasons for the loss of the seal may be the wrong choice and violation of the rules for the preparation of the filling material and the filling technique itself, insufficient isolation of the seal from saliva.

The color of the filling does not match the color of the tooth enamel most often worries the patient if it is detected on the anterior teeth and premolars. Sometimes this complication occurs even if the original color of the filling material and enamel match, if the technology for preparing the material and filling is violated. As a result, the filling changes color after some time (usually it becomes yellow, yellow-gray). It can absorb food pigments, etc. Fulfillment of the entire complex of requirements for the preparation of filling material, compliance with the stages of filling allows avoiding this complication. In some cases, to remove the darkened layer of the filling, it is enough to grind its surface. If this does not give the desired result, then the seal is replaced with another of the corresponding color of the material.

Root caries prevention. First of all, they motivate the patient to maintain the health of the oral cavity, give recommendations on hygienic care of the teeth, and advice on nutrition. For patients with root caries and gingival recession, a standard cleaning method with a modified Stillman method is recommended, which allows cleaning the cervical areas of the teeth with minimal trauma to the gingival margin and stimulating blood circulation in it. Interdental brushes and single-beam toothbrushes are recommended as auxiliary hygiene products for cleaning the concave surfaces of the tooth root.

Patients with caries of the tooth root and (or) bare roots are recommended toothpastes, gels and rinses containing fluorine compounds, possibly in combination with antiseptics, sodium bicarbonate. It has been established that dental cement concentrates fluorine to a greater extent than other hard tissues tooth, and chlorhexidine accumulates in the neck of the tooth and acts as a depot for a long time. According to S. B. Ulitovsky, patients with exposed tooth roots should use toothpastes (or gels) with reduced abrasiveness.

In case of sensitivity of the dentin of the exposed roots of the teeth, the recommended pastes should contain agents for the treatment of dentin sensitivity (potassium salts, hydroxyapatite, tricalcium phosphate, etc.). Patients with reduced salivation can be recommended pastes, gels, rinses containing substances found in natural saliva (lysozyme, lactoferrin, saliva proteins).

Patients with periodontal disease are at high risk for root caries. The critical depth of the periodontal pocket for the occurrence of this nosology is a distance of 2-4 mm from the gingival margin.

Individuals undergoing periodontal treatment often have a lack of cementum on the exposed root surface, which becomes thinner as a result of frequent removal of plaque and polishing of the tooth roots. Moreover, this may be a consequence hygiene procedures using abrasive materials and hard toothbrushes.

On the exposed surface of the root, favorable conditions for the development of microbial plaque. Patients with root caries have poor oral hygiene (in 93.3% of cases) and a high plaque cariogenicity index.

The prevalence of cement caries in last years increased. The causes of this disease are the same as those of enamel and dentin caries: plaque microorganisms (the nodal risk factor in the occurrence of root caries is not the amount of plaque, but its qualitative characteristic. While in the microbiological ratio in the occurrence of caries, the tooth crown dominates Strept. mutans, then actinomycetes (Actinomyces viscosus, Actinomyces naeslandii, Actinomyces species), excess sugars (the frequency of carbohydrate intake more than 9 times a day), deficiency of microelements and especially fluorine, smoking, diseases of the gastrointestinal tract; endocrine pathology In such patients, a lower buffering capacity of the oral fluid has also been established.

Any changes in the quantitative or qualitative composition of the oral fluid lead to a decrease in its protective properties. Xerostomia - a decrease in the total volume of saliva - can cause the balance between demineralization and remineralization of the tooth to change towards demineralization. In some cases, temporary dry mouth can become permanent. This may be due to age - over the years, the salivary glands work less efficiently, and the composition of saliva also changes. Xerostomia as a side effect can be caused by medications that the patient is taking: antihistamines, antidepressants, blood pressure medications, diuretics, narcotics, sedatives, and some other medications.

Root caries develops especially intensively in persons who have undergone radiation therapy in the head and neck. The resulting xerostomia leads to pronounced changes in the oral mucosa and the rapid occurrence of caries on a significant surface of the exposed dentin.

Cement caries occurs most often in middle-aged and elderly patients (60-90%). It is more common in men than in women and its frequency increases with age as a result of involutive processes, gingival atrophy, dystrophic processes in periodontal diseases or as a consequence of treatment.

Also, the defeat of the cement of the tooth root can be associated with irrational dental prosthetics (wearing removable structures based on teeth that are not covered with crowns). With a pronounced weakening of the immunological system, its cellular link, a rapidly progressive damage to the roots of a significant number of teeth can occur.

Root caries is often accompanied by increased tooth sensitivity as a result of root exposure. The most generally accepted theory of its occurrence is hydrodynamic: an increase in the rate of fluid flow from the dentinal tubules, which, in turn, contributes to a change in pressure in the dentin, which activates the nerve endings at the pulp-dentin interface. With hypersensitivity, patients try to avoid discomfort during brushing, as a result of which they devote much less time to hygiene, reducing its quality, which in due time contributes to the occurrence of root caries.

Cement caries is complicated by inflammation of the root pulp, periodontitis, and can also lead to breaking off the crown of the affected tooth.

Pathoanatomy of cement caries

Cement caries clinic

With deep root caries, the destruction of hard tissues leads to the formation of a pigmented cavity, the bottom of which is separated from the tooth cavity by only a thin layer of dentin. Changes in the root pulp are manifested at the stage of superficial caries in the form of a violation of lipid metabolism, and in conditions of deep root caries they are aggravated by the process of destruction of connective tissue cells. Carious root damage with a depth of more than 0.5 mm refers to deep root caries and needs to be filled with a preliminary determination of the viability of the pulp by electrodontometry to assess the need for endodontic treatment.

Diff. diagnosis of cement caries

Radiation tooth caries - (c. dentis radialis) generalized dental caries that develops as a complication after X-ray or radiotherapy of the maxillofacial region; proceeds with pigmentation and softening of the surface layers and the formation of deep cervical cavities.

Algorithm for choosing a filling material for closing root caries

With initial root caries, it is only advisable to carry out a prevention program and cover the exposed root surfaces with Seal and Protect.

Open root carious cavities are covered at the stage of professional hygiene, hidden - after periodontal tissue surgery.

Superficial and deep, more than 0.5 mm, root caries on contact surfaces can be filled with the following materials:
- Open - GIC Vitremer, Ketac Molar, Relyx / 3M ESPE, compomer Dyract AP / Dentsply, ProRoot, amalgam.
- Hidden root caries is sealed at the stage of surgical treatment: GIC Vitremer, Ketac Molar, ProRoot, amalgam containing fluoride.

Principles of treatment

Since the carious lesion of the cement is very often located in the immediate vicinity of the gum, its bleeding will interfere with the preparation and placement of the filling. There are two ways here:
The first is the use of a retraction cord that pushes and lowers the gum.
The second is surgical excision of the gums or electrocoagulation.

In the second case, it is necessary to seal within a few days after surgical intervention, as the gum tissue is very quickly restored and grows again.

In the treatment of root lesions, the use of local anesthesia, since cement has a very strong sensitivity (several times higher than the sensitivity of enamel).

After removal of dead tissue, filling is started, most often glass ionomer cements (light curing) are used.

Also, the patient should be explained about the role of adequate oral hygiene and regular visits to the dentist.