How are caries in dentistry treated today?

It has been established that the first attempts at treating caries could have been undertaken about 8,000 years ago, as eloquently shown by the discovered skulls of people in whom their individual teeth were drilled with obviously hand tools. Unfortunately, no manuscripts about the old methods of caries treatment have reached us.

The first records about the successful treatment of teeth affected by caries belong to the times of the Roman Empire, when the emperor physician Archigen actually conducted the treatment procedure, drilling the diseased tooth with a tool similar to today's hand drill.

It is interesting

In the 15th century, in an attempt to cure caries, Giovani Arcolani burned a carious cavity and filled it with gold. Prior to this, for many years, dental treatment was limited only to the removal of affected tissues, often with the tooth itself (if traditional medicine methods did not help).

With the advent of the first drill, which has found practical application thanks to the French doctor Foschar, the treatment of caries has become more effective and very productive for that time.

Every year equipment and materials improved, new approaches and ideas appeared. We will continue to talk in more detail about how caries is treated today and what the patient in the dentist’s Kremlin can expect.

 

And what, actually, we treat?

Caries is a local pathological process, usually starting under plaque as a result of fermentation (fermentation) of carbohydrate food residues by microorganisms (the main role is attributed to anaerobic Streptococcus mutans, although other bacteria also contribute). As a result of the vital activity of bacteria, organic acids are released, which “eats away” tooth enamel and removes minerals from it, which in turn leads to the formation of pores. This focal demineralization of enamel (caries in the staining stage) is the first stage of destruction.

If not timely hold treatment of initial forms of caries, defects of tooth tissues are formed: superficial, middle and deep carious cavities. Such a process of gradual destruction may be asymptomatic, or with the occurrence of short-term pain from external irritants (sweet, cold, etc.), quickly passing after the removal of the source of irritation.

Thus, the treatment of caries involves the restoration of the functional properties of hard tooth tissues: let's say the tooth surface was white, smooth and hard, and instead there was a dark-colored hole in which, moreover, hard tissues lost their hardness. Accordingly, the treatment will be aimed at eliminating this hole, removing the softened tissues and replacing them with full-fledged solid structures, which would be one whole with the tooth.

This is a simplified explanation, but in fact there are many interesting nuances (see below).

 

General principles of caries treatment

Currently, there are two fundamentally different approaches in the treatment of caries:

1. Conservative therapy without preparation (that is, without excision of the tissue by a drill);
2. Treatment with the preparation of hard tooth tissues (that is, the well-known "drilling" of the teeth is assumed).

Conservative techniques are non-invasive treatments for caries. They are used both for the initial forms in the stage of focal demineralization (spot), and for already formed cavities.

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Currently, before the start of dental treatment, including caries, the patient’s informed consent to this procedure is required.Without it, it is impossible to begin manipulations, as a document must first be signed, which explains to the patient the medical and legal aspects protecting his interests. Also, this document will protect the doctor in case of unsuccessful treatment that is not associated with intentional harm. In addition to the agreement, a medical history is filled in the patient's card, where all manipulations related to the treatment of caries are recorded in detail.

Treatment of caries using the technique of tissue preparation consists of the following steps:

1. Preparation of the oral cavity. This may include not only the removal of plaque or stone from the tooth planned for treatment, but also the general conduct of professional hygiene of all teeth.
2. Anesthesia (as needed). In most cases, caries treatment is carried out under local anesthesia, but sometimes, for example, in case of multiple lesions of the teeth or panic in young patients, they are treated under general anesthesia, that is, with “turning off” of the consciousness. This is a more risky option, but it is justified in the event that there are medical indications for it.
3. DissectionThis stage involves the removal of destroyed tissues from the carious cavity and the subsequent medical treatment with special antiseptic solutions. This allows you to create all the conditions so that bacteria do not multiply under the future filling, and it does not fall out due to the recurrence of caries (the so-called secondary caries).
4. The formation of the cavity. This stage is important for creating such a cavity shape that will create additional conditions for holding the filling. Many materials used in the treatment of caries, require a certain configuration of the cavity. However, among modern filling materials there are those that are chemically bound to the tooth and do not require the creation of mechanical means of restraint.
5. The imposition of therapeutic or insulating pads (according to the clinical situation). This stage is especially important for fillings, which are placed on deep caries, when it is required to exert a long-lasting anti-inflammatory and antimicrobial effect on the “nerve” located close enough to the bottom of the formed cavity with the help of special medical pads. Insulating gaskets under the seals are placed in most cases, since almost all materials are irritating to the pulp.
6. Filling cavity.During installation, fillings determine its color (when working with aesthetic materials), isolate the working surface from the rest of the oral cavity with a cofferdam or simple cotton rollers, and then actually insert the material into the cavity according to its instructions. It often uses a number of additional tools that improve the quality and working conditions: matrices to create a gap between the filling and the adjacent tooth, wedges to form an ideal contact point, a retraction thread to correct the gums near the working area, etc.
7. And finally, finishing. After installing the seal, it is necessary to correct the bite, grinding and polishing. It is important that the filling does not traumatize the tooth, does not cause discomfort and pain, does not have burrs, does not accumulate plaque, has a shine characteristic of a normal tooth, etc. For this, for example, use special discs, polishing heads, finiers or polishers.

The following video shows an example of treatment for deep caries:

Treatment of deep caries using a drill

 

Classical methods of therapy with preparation

Long before the advent of modern filling materials, the treatment of caries was carried out using the preparation (invasive method) and the formation of a carious cavity for the materials then used. At the same time, for fixation and reliable retention of seals it was required to fulfill a number of conditions related to:

• with a large preparation area;
• with the need to comply with certain angles of transition of the walls and the shape of the bottom;
• with a specific cavity configuration;
• with the creation of additional cavities and processing of healthy tooth tissues;
• with boring cuts and undercuts.

Such treatment of caries required certain skills, skill and a lot of time.

Below are the "classic" materials that were used before in dentistry and are still used in budget organizations for permanent fillings:

1. Mineral cements (Silitsin, Silidont and some others);
2. Acrylic and epoxy materials (for example, Acryloxide);
3. Metal fillings (amalgams).

Photo of amalgam fillings:

It is obvious that before modern methods of caries treatment appeared,It took years of work with the use of "classic" filling materials - many people still go with such seals.

On a note

During the Great Patriotic War, the surgeon Ivan Shcheglov widely applied the method of healing even the most severe wounds by using lotions with a hypertonic solution of table salt. In just a few days, the wounds became clean, pink, and did not fester, which made it possible to significantly reduce the mortality rate among the wounded. Later, some evidence emerged that Shcheglov's method can also be successfully applied to the treatment of complicated caries, more precisely, to relieve inflammation and severe pain in those conditions when there is no way to use more effective methods.

 

Modern materials for dental fillings

Not one decade has passed since the time of unaesthetic and difficult-to-fix cements and amalgam. Modern dentistry required new solutions in the treatment of dental caries, and they appeared.

First of all, the tendency led to the rejection of over-treatment of the carious cavity and a decrease in the volume of healthy tissues removed by boron, which was previously required only for the mechanical retention of "ancient" fillings.

In addition to the mechanical method of treating the carious cavity with boron (that is, “drill”), other methods have appeared:

• Chemical-mechanical (dissolution of "caries" by chemical means and its removal with hand tools);
• Air-abrasive (sand blasting cavity);
• Ultrasonic cleaning of the cavity;
• Laser preparation.

Adhesive techniques have emerged that are associated with the use of special chemicals (“adhesives”), which make it possible to abandon the routine methods of applying fillings and increase the tensile strength of the material with the tooth surfaces. Materials have been developed that are biocompatible with tooth tissues and reliable adhesion with minimal preparation and the creation of an arbitrary cavity shape.

The most popular classes of materials for the treatment of caries:

• Composites;
• Glass ionomer cements;
• Compomers;
• Ormockers.

However, within each class of materials there are already categories that are only partially used in modern dentistry for the treatment of caries due to the proven inefficiency over the past decades. Some materials have moved into the field of budget dentistry.

Each of the listed materials has its own individual set of properties that can and should be combined to achieve the optimal result of the treatment of caries of dairy and permanent teeth for the long term. At the same time, not one technique was developed for their competent combination and introduction into the cavity.

 

Modern approaches to the treatment of deep caries

Deep caries is always associated with very serious tooth decay. And if the stage of carious stain often does not require mechanical treatment of the cavity (non-invasive treatment method), and with superficial and medium caries it can be limited to sparing preparation techniques with minimal tissue excision, then deep caries usually requires a long-term cavity treatment from the doctor, special preparation modes, imposition of therapeutic and insulating gaskets under the seals.

The possibility of preserving the living pulp (“nerve”) is determined by the performance of a series of manipulations that are important so that after treatment the caries does not reappear under the filling. These manipulations include:

1. Accurate work of burs, taking into account the anatomy of the tooth;
2. Alternating work with high-speed tips and a tip for a micromotor at low revolutions at the bottom of the cavity to prevent the risk of accidental opening of the pulp chamber;
3. The use of caries detectors (indicators) for the recognition of carious tissues in the cavity;
4. Air-water cooling to protect against overheating of the tooth;
5. The use of therapeutic pads based on calcium hydroxide;
6. The use of insulating gaskets (most often these are glass ionomer cements);
7. The use of deep caries treatment techniques in several visits with the control of the therapeutic effect of the used preparations based on calcium hydroxide.

From the practice of the dentist:

The following materials are widely represented on the market for materials for medical pads:

1. Calcium hydroxide-based aqueous suspension (Calradent, Calcicur, Calasept, Calcium Hydroxide, Calcipuipe);
2. Calcium hydroxide-based varnishes (Contrail);
3. Calcium-salicylate cements that work on the principle of chemical curing (Septocalcine Ultra, Calcesil, Dycal, Life, Calcimol, Alkaliner, Reocap);
4. Light-curing materials based on polymers combined with calcium hydroxide (Esterfil Ca, Calcesil LC, Ultra-Blend, CalcimolLC,).

Studies have shown that drugs based on an aqueous suspension of calcium hydroxide exhibit the greatest therapeutic effect, but they are superimposed under a temporary filling and can cure deep caries only in a few visits,in contrast to calcium salicylate cements, which are superimposed immediately under a permanent filling, but their therapeutic effect is less pronounced. Most dentists are inclined to believe that paints and light-cured medical pads have weak antiseptic and anti-inflammatory effects on the tooth pulp.

 

Treatment of caries without a drill

Many people today are concerned about the possibility of caries treatment without the use of a drill. And modern dentistry really has in its arsenal methods that allow it to be done.

We list the main ones:

• Surface treatment of the tooth with remineralizing compounds;
• Using ICON technology;
• ART-technique.

Remineralization therapy is, in fact, the restoration of a partially destroyed enamel crystal lattice, the replenishment of its mineral components during focal demineralization. At home, it is difficult to independently select the desired combination of drugs and their concentration for the safe and effective treatment of caries in the staining stage, so it is highly advisable to consult a dentist.

Remineralizing therapy consists of systemic and local measures. Systemic include, for example, the appointment of fluorinated salt, milk, fluorine-containing tablets, etc. And to the local - the treatment of the tooth surface with special remineralizing solutions or gels containing calcium, fluorine and phosphorus compounds, and sometimes a number of other important minerals in their various combinations for the accelerated mineralization of enamel.

Examples of drugs for the treatment of caries in the stage of white spots:

• Multifluoride;
• Bifluoride;
• Belak F;
• Gluftored;
• Enamel-sealing liquid;
• Belagel Ca / P, Belagel F.

As for ICON technology, it is one of the most promising in the treatment of caries in the staining stage. In addition, for example, with prolonged wearing of braces, demineralization of certain areas of enamel can also occur: in this case, treatment will be required after removing orthodontic appliances.

The essence of the ICON technology: after the infiltrant is applied by the UV lamp of the enamel, the enamel surface acquires the original color, since the liquid based on polymer resins “flows” into the zones of the damaged enamel crystal lattice and actually “clogs” the micropores.The method of infiltration of the affected enamel structures with the compounds included in ICON allows to achieve the result on the first visit.

The main condition for caries treatment with ICON is to apply it only on enamel, since dentin cannot be infiltrated.

In the photos below you can observe some stages of caries treatment using ICON technology:

Now a few words about the so-called ART-method of caries treatment.

The “classical” ART technique is an atraumatic restorative treatment or a non-invasive method for treating caries. It was developed in the Netherlands. Instead of a drill, excavators are used to treat caries - special hand tools that literally “scrape off” carious infected tissue from the bottom and walls of the cavity. Then the cavity is sealed with glass ionomer cement, which releases fluorine into the tissue and stops caries.

Do not flatter yourself and look for a doctor who is ready to treat you with caries with an ART technique. Hand tools are often unable to qualitatively remove all pigmented and infected tissue from the cavity, which often leads to the need for over-treatment of the tooth.By the way, at the same time, WHO recommends ART-methods for active implementation for residents of poor regions, immigrants, refugees, etc.

In some cases, you can apply this technique for people experiencing panic fear of a drill.

 

Promising options for the treatment of caries: sandwich technique

Today, every competent dentist has information about modern filling materials for the treatment of dental caries. The possibility of combining 2-3 different materials during operation gives invaluable benefits, since it allows you to maximize the benefits of each option.

One of the most promising options for the treatment of dental caries is a sandwich technique or, in fact, a sandwich technique.

It is interesting

The justification for using sandwich technology is due to the fact that light-cured composites, or, otherwise, “light” fillings, have several disadvantages:

• High rates of shrinkage or deformation, which leads over time to the appearance of a “pit” at the site of the filling;
• Lack of anti-caries effect;
• Insufficient biocompatibility with the tooth tissues (have a toxic effect on the pulp tissue through the bottom of the cavity).

All these disadvantages are successfully compensated by glass ionomer cements (JRC). Also under the sandwich technique understand the combination of composites and compomers, as well as amalgam and composite, but they are used less frequently.

For example, the following algorithms for applying a strip of glass ionomer cement in the treatment of caries using the sandwich method are possible:

1. Closed sandwich: the gasket does not reach the edges of the cavity, which means it does not come into contact with the oral fluid;
2. Open sandwich: the gasket overlaps one of the walls and is in contact with the oral environment.

Advantages of the technique:

• The possibility of laying of the JRC for a long time to allocate fluoride in the tooth tissue, which reduces the risk of secondary caries;
• Reduced shrinkage of composite fillings, since the JRC reliably compensates for it;
• Improvement of the natural color characteristics of the future filling due to the color of the JRC, imitating darker dentin on the bottom;
• The ability of the JRC to inhibit the growth of cariogenic microorganisms;
• The use of this technique, as often the only reliable method of sealing cervical and subgingival defects, especially when root caries. Due to the poor adhesion of composites to only one dentin,the inability to create a perfectly dry surface of the gingival and subgingival restorations, the JRC allows for creating an ideally strong foundation for them, as well as providing the connection between the main filling and the tooth tissues through glass ionomer cements.

The photo below shows a tooth before and after caries treatment with a sandwich filling:

 

Possible complications of caries treatment: something that should not be known to very sensitive patients

During the treatment of caries with one or a combination of several factors (poor equipment, materials, level of personnel training, complex anatomy of the tooth, uncomfortable located carious cavity, etc.) sometimes complications arise. We list the most popular ones:

• Loss of filling or the occurrence of caries around it. Most often, it is medical errors that provide for the loss of fillings. This is due to poor cleaning of the carious cavity from loose tissues, not removing infected and pigmented dentin and demineralized enamel residues.
• The occurrence of pain in the tooth. In order to cure caries (especially deep) the doctor is required to follow absolutely all instructions,starting from good air-water cooling when preparing the tooth, to gently drying the dentin (the dentin should be “sparkling” or slightly moist) and proper work with medical pads. Overheating of the tooth, drying of the dentin, accidental opening of the pulp chamber, lack therapeutic pads for deep caries and other errors lead to pain in the tooth of a different nature, up to the occurrence of pulpitis or periodontitis due to the death of the damaged "nerve".
• Lack of contact point. In some cases, in the treatment of caries, some doctors do not restore or poorly restore the natural gaps between the teeth, without which the normal functioning of the tooth is impossible. Especially badly it affects the gingival papilla in the gap between the teeth, which is compressed by an irregular filling and constantly bleeds, which leads to local periodontitis - resorption of the bone septum of the alveoli in the adjacent teeth. This fact then can lead to the emergence of the mobility of teeth with the risk of their removal.

The figure below shows schematically examples of errors made by doctors in the treatment of caries (and not the worst):

So that you do not have to “painfully hurt” your teeth, it is important to pay considerable attention to preventing the development of caries. In most cases, it is enough to follow a number of simple rules to get rid of caries forever:

• To clean the teeth with toothpaste brushes containing fluoride, and the interdental spaces - with dental floss, soaked with fluoride compounds, and after each meal.
• Observe the correct technique of cleaning teeth, and if necessary, adjust this skill with a dentist.
• If possible, limit the consumption of carbohydrates (sweets, cakes ...)
• At least 1 time in 6 months to carry out professional cleaning of teeth from plaque, stone and make an individual plan according to the cariogenic situation of the oral cavity and the level of caries resistance (the state of tooth enamel and its mineralization, saliva composition and its quantity).

On a note

Not every person can decide to brush their teeth with a toothpaste immediately after eating. Most people want to prolong the sense of pleasure from delicious food as long as possible. Moreover, the culture of behavior, founded since the times of the Soviet Union,always dictated unreasonable rules: brushing your teeth in the morning and in the evening, forgetting that there are also meals and snacks during the day, when it is important to timely remove the forming plaque and eliminate cariogenic situation in the oral cavity.

Observing these simple rules, you get a weighty chance to keep your teeth healthy until old age and save yourself from caries treatment for life.

 

Interesting video: it looks like the treatment of caries under a microscope

 

Restoration with deep caries on the front upper tooth