Medical treatment of the carious cavity. Medical treatment Clinical picture of acute pulpitis

The main goals of drug treatment of carious cavities:

Cleansing the cavity from dentine sawdust, oral fluid and other contaminants;

Bactericidal effect on the microflora in the cavity and parietal dentin;

Drying out the cavity.

It is produced with warm physiological antiseptics - 0.02% solution of furacilin, 0.05% solution of ethacridine lactate, 0.06% solution of chlorhexidine bigluconate, 0.5% solution of dimexide, 0.05% solution of novocaine with enzymes. Then the cavity is thoroughly dried. Optimum drying with warm air. If there is no warm air, then the cavity is first treated with alcohol, and then with ether.

Now practical dentistry is provided with multifunctional medications that remove the “smeared layer”, providing ideal adhesion for subsequent filling, both for root and crown fillings: preparations based on EDTA (ethylenediaminetetraacetic acid) - Canal plus and Largal ultra from Septodont, Styptic and Netispad Spad company.

9) Applying a medical pad.

Materials for medical pads should:

Provide anti-inflammatory, antimicrobial, odontotropic action;

Do not irritate the dental pulp;

Provide strong sealing of the underlying dentin, bonding with tooth tissues, cushioning and permanent filling materials;

Correspond to the physico-chemical properties of permanent filling materials.

In the treatment of deep caries, as a rule, they are limited to the imposition of a medical pad with a long odontotropic and antiseptic effect.

Currently, the Russian dental market presents several groups of drugs intended for the application of medical pads:

Materials based on calcium hydroxide:

Calcium hydroxide - Ca (OH) 2 - is a base that is slightly soluble in water; upon dissociation, it forms a small amount of calcium and hydroxide ions. It has a strongly alkaline reaction (pH - 12), which provides the main biological and medicinal effects of this substance. Applied to the surface of the peripulpal dentin (which, due to its anatomical structure, has increased permeability), calcium hydroxide diffuses through the dentinal tubules and penetrates into the pulp. This ensures a long-term therapeutic odoptogroppoe and antimicrobial action.

Preparations based on calcium hydroxide stimulate the formation of replacement dentin, prevent the penetration of pathogenic microorganisms into the dental pulp, and due to the high pH value, have an anti-inflammatory effect.

At present, materials of this group are used most often. They are available in various dosage forms:

A. Calcium hydroxide aqueous suspension: Calcicur, Calasept, Calcipulpe, Superlux Calciumhydroxid-Liner, Calradent.

B. Varnishes based on calcium hydroxide: Contrasil.

C. Calcium salicylate chemically cured cements: Calcimol, Dycal, Life, Septocalcine Ultra, Reocap, Calcesil.

D. Light-curing polymeric materials containing calcium hydroxide: Calcimol, Ultra-Blend, Calcesil LC.

· Zinc-eugenol cements:

Eugenol is an antiseptic of plant origin. It is 70% clove oil. When zinc oxide and eugenol are mixed, cement is formed, which hardens within 10-12 hours. Cement hardening is based on the chemical reaction of zinc eugenolate formation. CEC is used in therapeutic dentistry for applying medical pads and temporary fillings.

In Russian dentistry, zinc oxide powder and eugenol are traditionally used to prepare this cement. More convenient for manipulation are branded preparations of this cement, which also contain hardening substances. Of the imported drugs supplied to the Russian market, the most famous are Zinoment (VOCO), Kalsogen Plus

and "Savitec" (Kerr).

When using zinc oxide eugenol cement as a lining under materials that require condensation in the cavity (phosphate cement, amalgam), the medical lining is deformed. In this case, it is advisable to apply a temporary zinc-eugenol filling on the first visit, and on the second visit (after 1-3 days) remove the excess CEC, leaving only a thin layer of it at the bottom of the cavity, and apply

permanent filling.

We remind you that materials containing eugenol should not be used in combination with composites, as this substance interferes with the polymerization process of their organic matrix. This fact is associated with a decrease in the interest of dentists in zinc-eugenol cements as materials for medical pads.

Combined medicinal pastes

They include several groups of medicinal substances and are prepared ex introductory taking into account the clinical situation, compatibility, availability in the medical institution and the individual preferences of the doctor.

The main groups of medicinal substances used in the preparation of combined medicinal pastes:

1. Odontotropic agents - substances that stimulate the formation of replacement dentin and remineralization processes in the zone of demineralized "carious" dentin - calcium hydroxide, fluorides, calcium glycerophosphate, dentin or bone filings, hydroxyapatites (natural and artificial), "Algipor", collagen, etc.

2. Anti-inflammatory drugs - glucocorticoids (prednisolone, hydrocortisone), less often - non-steroidal anti-inflammatory drugs (salicylates, indomethacin, etc.).

3. Antimicrobial agents - chlorhexidine, metronidazole, lysozyme, sodium hypochlorite, ethonium paste (7% ethonium in artificial dentin). The feasibility of including antibiotics in a medical pad is currently controversial.

4. Proteolytic enzymes - profezim, imozimaza, stomatozyme, especially in combination with other substances (chlorhexidine), are quite effective in the treatment of deep caries and acute focal pulpitis.

5. Other means - hyaluronidase, EDTA, dimexide (DMSO), kaolin, zinc oxide, novocaine, various oils (cloves, sea buckthorn, peach, eucalyptus, oil solutions of vitamins, etc.).

Combined pastes, as a rule, do not harden, do not have sufficient mechanical strength, and lose their activity relatively quickly. Therefore, we recommend using them as a temporary material during the period of "active" treatment, followed by replacement with calcium salicylate or zinc eugenol cement.

A number of leading manufacturers of dental products produce a range of materials for therapeutic pads. This allows you to purposefully choose one or another drug, taking into account a specific clinical situation.

In the treatment of deep caries, if all softened dentin is removed from the bottom of the strip, filling is carried out in one visit with the imposition of a medical lining of calcium salicylate cement. With very deep carious cavities, especially in young patients, when there are no clinical signs of pulpitis, and the complete removal of softened dentin threatens to open the tooth cavity, it is allowed to leave a small amount of softened dentin at the bottom of the carious cavity. In this case, the treatment of caries is carried out in several visits, with the imposition of a medical pad either from a preparation based on a suspension of calcium hydroxide, or from zinc oxide eugenol cement. The cavity for the period of treatment is closed with a temporary filling, and the patient is under dynamic observation with constant monitoring of the state of the pulp (EOM, thermodiagnostics, etc.).

After the remineralization of the affected dentin and the formation of replacement dentin from the side of the pulp, if there are no signs of chronic pulpitis, a permanent filling is applied with a therapeutic pad of calcium salicylate cement.

10) Applying an insulating pad: more often glass ionomer cements are used, in extreme cases phosphate cements. The goal is to isolate the dentin and pulp from toxic substances contained in some filling materials, to create a barrier to the heat and cold conductivity of the filling (especially from amalgam), to increase the adhesiveness of weakly adhesive filling materials, to create additional fixation points for permanent filling material at the bottom of the carious cavity.

Currently, taking into account the function of the insulating gasket, the features of the overlay and the materials used, its various options are distinguished.

A. Base gasket (from the English base, basis) is a thick (more than 1 mm) layer of lining material. Purpose:

1. Protection of the pulp from thermal irritants (for example, when filling with amalgam).

2. Protection of the pulp from chemical irritants (for example, when filling with mineral cements and polymeric materials).

3. Creation or preservation of the optimal geometry of the carious cavity while maintaining retention properties.

4. Reducing the volume (quantity) of a permanent filling material (in order to reduce the polymerization shrinkage of the filling; creating a “cushion” under the filling, compensating forces arising from chewing; saving expensive composite, etc.).

B. Thin-layer gasket (liner, liner gasket, from English - lining, gasket). Purpose of this gasket:

1. Isolate the pulp from chemical irritants.

2. Provide a connection between the walls of the cavity and the permanent restorative material.

Medical treatment is an important step in preparing the cavity for filling.

The main goals of drug treatment of carious cavities:

- cleaning the cavity from dentinal sawdust, oral fluid and other contaminants;

- bactericidal effect on the microflora in the cavity and parietal dentin;

- drying of the cavity.

For a long time, solutions of potent antiseptics, such as phenol, were used for drug treatment of carious cavities.

In our country, in the “pre-composite era”, 3% hydrogen peroxide solution, 96 ° alcohol were used for medical treatment of carious cavities before filling, and the cavity was dried with medical ether. Deep cavities, in order to avoid irritation of the pulp, were washed with warm solutions of weak antiseptics: 1% hydrogen peroxide, 1% chloramine solution, 0.1% furacilin solution. It was recommended to dry deep cavities with warm air.

With the advent of composites, approaches to medical treatment of cavities have changed significantly. Alcohol and ether for the treatment of cavities are not recommended due to toxicity and low drying ability (Petrikas A.Zh., 1997). In addition, there are concerns that alcohol and ether can reduce the adhesion of the composite material, and alcohol destroys the polymer matrix of composites (Borisenko A.V., Nespryadko V.P., 2001). At present, when filling with composites for the purpose of drug treatment, it is recommended to irrigate the cavity with warm low-concentration antiseptics from a syringe. For these purposes, use a 3-5% solution of sodium hypochlorite, 0.06-0.1% solution of chlorhexidine, 3% hydrogen peroxide solution, 0.02% solution of furacilin, etc. etc. The cavity is dried with an air jet from a “gun” or with a sterile cotton ball.

It should be recognized that processing in this way, firstly, is not effective enough, and secondly, it is technologically complicated, especially since some of the listed drugs have a very unpleasant taste and smell (for example, sodium hypochlorite) and require immediate removal of their oral cavity ( the use of a rubber dam and a “vacuum cleaner” is required). In addition, concerns are currently being expressed about the use of agents that release atomic oxygen or chlorine (hydrogen peroxide, sodium hypochlorite) for drug treatment of the cavity. It is believed that these gases can penetrate into the parietal dentin and inhibit the process of polymerization of the adhesive system of the composite, violating the properties of the "hybrid layer".

Some experts, in addition to the listed drugs, recommend the use of agents that dissolve the smeared layer, for example, citric acid, EDTA, etc. We consider a special holding of this stage inappropriate. This is due to the fact that different materials have different mechanisms of connection with the tissues of the tooth, and in some cases, the removal of the "smeared layer" will not benefit, but harm. If the filling material forms a bond with the dentin of the tooth due to the removal or transformation of the "smeared layer", then the set of this material includes special preparations for these purposes and their use is provided for by the instructions.

Many dentists limit themselves to washing the cavity with water from the “gun” and drying it with air. After that, they begin the filling process, relying on the fact that etching the walls of the cavity with phosphoric or maleic acid will have a bactericidal effect. In addition, there is evidence that in dentine sealed with an adhesive system and (or) filling material, the active life of the microflora stops. This approach is acceptable, but it does not exclude the risk of developing inflammatory complications in the pulp associated with the invasion of microorganisms into it from the infected dentin adjacent to the cavity.

We consider it appropriate to use the following method of antiseptic treatment of the cavity before filling:

1. Abundant washing of the cavity with water, water-air spray and drying from the "gun" of the dental unit. It is desirable that not tap water is supplied to the “gun”, but there is an autonomous supply of distilled water from a special container.

2. Drug treatment of the carious cavity with a 2% aqueous solution of chlorhexidine. For these purposes, you can use a solution purchased at a pharmacy, however, in our opinion, it is most convenient to use the preparation "Consepsis" (Ultradent) for these purposes (Fig. 184). It is a 2% solution of chlorhexidine bigluconate containing mild flavors and having a pH of 6.0. Another version of this drug - "Consepsis V" - has a thicker consistency. These drugs are produced in syringes complete with disposable Black Mini Brush or Dento-Infusor cannula brushes (see Fig. 185).

"Consepsis" is applied to the walls and bottom of the cavity with a cannula brush for 30-60 seconds. They can also treat the surrounding tissues of the tooth and the adjacent gum. As needed, the drug is gradually squeezed out of the syringe.

3. The drug is gently inflated and dried with air. It is not recommended to wash it off.

4. After that, the enamel and dentin are etched, the adhesive system is applied and the cavity is sealed in accordance with the instructions for the filling material.

Effective use of the adhesive system and qualified, technologically correct filling provide long-term sealing of the dentin surface and impermeability at the border of the filling / tooth tissue. This prevents the reinfection of dentin, the development of recurrence of caries and complications from the dental pulp.

When filling with composites, it is also allowed to first etch the cavity, then disinfect it with Consepsis, and then apply an adhesive. In this case, the drug is introduced into an already etched cavity, gently inflated with air and not washed off. Studies have found no difference in adhesion strength when using Consepsis before and after etching. This strength does not depend on whether the preparation was washed off with subsequent drying of the cavity, or it was dried without washing off with water (data from Ultradent).

Another way to disinfect dentin in the area of ​​the bottom of the carious cavity is to apply a medical pad based on a suspension of calcium hydroxide to the bottom of the cavity for several days under a bandage. Of course, it should be recognized that this method is quite lengthy and laborious, but its use is fully justified in some difficult clinical situations.

It is possible to enhance the bactericidal effect on the parietal dentin before filling with composites by using etching gels containing bactericidal components. An example of such a preparation is a gel based on 35% phosphoric acid "Ultra-Etch AB", Ultradent, containing the antibacterial preparation acetylpyridine chloride.

According to the literature data, drug treatment of the cavity before filling with composite materials can reduce the number of pathogenic bacteria in the parietal dentin, reduce the risk of "postoperative" sensitivity and inflammatory complications from the dental pulp.

LECTURE PLAN:

molars

molars

molars

ISO color coding of endodontic instruments

Endodontic tips

Chemical expansion

Root canal treatment

Drug treatment (washing) of root canals

Basic manipulations in root canals

Stages of application of arsenic paste (I visit)

II visit

From this article you will learn:

• how to get rid of caries,
• video of teeth preparation with a drill,
• how to treat caries - standards in dentistry.

• Caries in the white spot stage(Fig. 1) -
  this is the most initial stage of caries, which is reversible, and the only one that does not require traditional filling. In this case, one or more white spots can be seen on the surface of the tooth crown, which indicate the presence of areas of demineralization of the tooth enamel. There is no actual defect yet, but the white spot has a rough surface and lacks the shine characteristic of healthy enamel. This form of caries is treated with holding.

• Superficial form of caries(Fig. 1) -
  if the enamel demineralization in the area of ​​the white spot continues, then the enamel structure is destroyed and a carious defect is formed (so far within the enamel layer). In Fig. 1, it can be seen that in the center of some white chalky spots there are already small carious defects. This form of caries is treated with traditional fillings.

• (Fig. 2) -
  in this case, caries extends deeper than the enamel layer, affecting the upper layers of dentin. Enamel has a very high density, and therefore, as soon as the carious process spreads to the softer underlying dentin, the size of the carious cavity begins to increase rapidly. This article will focus on the treatment of medium caries, as the most common form with which patients come to the dentist.

• Deep form of caries(Fig. 3) -
  in this case, caries extends to the deep layers of dentin, and the pulp of the tooth (the neurovascular bundle) is separated from the bottom of the carious cavity only by a narrow strip of healthy dentin. This form is distinguished by a special treatment technique. You can read about how to treat caries with a deep carious tooth lesion in our review:.

How to treat caries: stages

To get rid of caries, you need to make an effort on yourself, because although modern drills do not vibrate like perforators, they still make us wait for a sudden onset of acute pain - while drilling out carious tissues. Fortunately, they allow the dentist to properly anesthetize the teeth during treatment - in contrast to the ineffective novocaine and lidocaine, which were widely used earlier.

Proper treatment of dental caries in dentistry consists of a series of successive steps, each of which has a clear goal. But nevertheless, the most important thing is the complete removal of caries, because. if the removal of tissues affected by caries is incomplete, it will immediately develop under the filling and will certainly lead to the development and the need to remove the nerve from the tooth. See further on the video - how the hard tissues of the tooth affected by caries are removed.

Dental caries treatment: video 1-2

Details about the stages of treatment of medium caries -

But before proceeding to the drilling of carious tissues, which you could see in the video above, you still need to perform a number of procedures as a preparation of the tooth for treatment, as well as anesthetize it with an injection of a local anesthetic. For lovers of anesthesia in a stronger way - there are methods of general anesthesia.

Tooth cleaning from plaque (Fig. 4) -

before starting treatment, it is necessary to hygienically clean the tooth, as well as adjacent teeth - from plaque and calculus. For this purpose, ultrasonic nozzles are used to remove massive dental deposits, as well as special brushes and abrasive pastes to remove soft microbial and pigment plaque.

1. Determining the color of the tooth on a special scale (Fig. 5) -
   
   hygienic treatment of the tooth also contributes to the fact that the doctor will be able to accurately select the color of the filling material. In this case, the filling will match the color of the tooth, and not stand out against the background of the tooth's own tissues. This is especially important for teeth that are visible when smiling.
2. Anesthesia (Fig. 6) -
   does it hurt to treat caries: for painless drilling of carious tissues in case the tooth is alive, local anesthesia is necessary. Modern painkillers in dentistry, for example, or ubistezin, allow you to make the intervention absolutely painless. Depending on the amount of anesthetic administered and the method of anesthesia, the anesthesia time can last from 40 minutes to several hours.

   The dentist must definitely drill out the enamel edges hanging over the carious cavity, and also remove all carious dentin. If you leave even a small amount of dentin affected by caries and put a filling on top of it, then very soon you can expect complications - the rapid development of caries under the filling and the destruction of the tooth crown, followed by the development of pulpitis and periodontitis (site).

   In Fig. 8, the dotted line shows the approximate boundaries of the removal of tooth tissues. Thus, the cavity is given a relatively regular shape and you can proceed to the next stages of treatment. It should be noted here that recently there are more and more new methods of tooth preparation that help to do without traditional drilling. Recently it has become possible.

3. Tooth isolation from saliva –
   this is a very important step! After the carious tissues are drilled out, and before starting filling the tooth, the doctor must carefully isolate the tooth from saliva and even the patient's wet breath. These factors will greatly affect how long the filling will last. Previously, cotton and gauze balls were used for isolation, which were wrapped around the tooth from all sides. It should be noted that this is a very unreliable and ineffective protection.

   For the last 10 years, a rubber dam has been used for these purposes. The latter is a thin "handkerchief" made of latex, in which holes are made for the teeth. This scarf is stretched over the teeth (Fig. 9-10), after which 1-2 special metal clasps are installed on the necks of the teeth, which hold the rubber dam near the gums. The edges of such a latex scarf are attached to a special frame (Fig. 11), and we see the result - a group of teeth is completely isolated from the oral cavity.

4. acid etching of enamel (fig.13) -
   this is necessary so that the adhesive (something like glue) that will be applied to the surface of dentin and enamel in the next step can penetrate deep into the tooth tissue. For this, a gel based on phosphoric acid is used. After etching, the entire gel should be thoroughly rinsed off and the tooth surface slightly dried.
5. Treatment of dentin and enamel with adhesive –
   for better fixation of a permanent photopolymer filling, enamel and dentin are treated with a special adhesive, which (after absorption) is illuminated by a photopolymerization lamp.
6. Applying a gasket under a filling (Fig.14 b,c) –
   an insulating gasket, usually made of glass-ionomer cement, is applied to the bottom of the cavity. The need for a lining material under the filling is explained by the complex mechanisms of polymerization shrinkage of the filling material and other factors (we will not dwell on them).
7. filling –
   dental filling is necessary to restore the shape of the tooth, its aesthetics, as well as to restore chewing efficiency. For this, as a rule, photopolymer composite materials are used. They are applied in layers and each layer is illuminated with a special lamp, which allows the material to harden.
8. Grinding and polishing of the tooth –
   after the shape of the tooth is restored with the help of filling material, it is necessary to grind and polish the filling, because she is rough and uneven. The final polishing gives the filling a shine and aesthetics comparable to the aesthetics of tooth enamel. This completes the treatment of medium caries.

Filling a carious defect: video 3-4

Please note that dentists use special metal strips (matrices) and wedges to restore the side walls of the teeth. In addition, tooth filling in both cases is carried out using a rubber dam.

Caries treatment: photo

Treatment of dental caries on a specific example. All the main stages of caries treatment are shown in Fig. 15-23. Explanations for each photo appear when you click on it.

Tooth filling: photo

All defects, subject to reimbursement by tabs, different authors divide into different classes (D.N. Tsitrin, L.V. Ilyina-Markosyan, etc.)
V. S. Kurylenko bases division of teeth with defects, reimbursable tabs, the method of forming retention points. Based on this feature, she divides all defects into defects of pulpless teeth and teeth with live pulp. Depulpless teeth defects constitute class I, and defects of teeth with live pulp - class II. Class II is further divided into four subclasses.

To subclass I include defects in chewing teeth, in which the cavities are located on one proximal, chewing-proximal or two proximal surfaces.

II subclass combines anterior teeth defects, in which the cavities are located on the proximal surface and there are no cutting corners. Subclass III includes defects of all groups of teeth, in which the cavities are located on any surface, except for the proximal one, namely on the chewing surface (the so-called central cavities), vestibular, lingual or cervical. Subclass IV includes atypical cavities, i.e., cavities that cannot be assigned to any of the first three subclasses.

Treatment of tooth cavities.

Noting in the medical history the state of the pulp, the group of teeth and the class to which the teeth belong according to the localization of defects, the doctor proceeds to the next stage - the treatment of the cavity. This stage consists of several moments: opening of the cavity, necrotomy of softened dentin, cavity formation, creation of retention points.

It should be noted that cavity preparation to replace it with some kind of micro-prosthesis - a filling or an inlay - is not a simple mechanical manipulation, but should be considered as an event, the purpose of which is "suspension of the mechanisms that destroy enamel and dentin by restoring normal trophism of dental tissues."

When forming a cavity the doctor first of all proceeds to open it, pursuing the goal of making the cavity accessible to free manipulation in it in the process of its formation. At this stage, the usually existing small gap is widened and all overhanging edges are removed. In this case, an enamel knife, round or fissure bur is used. An enamel knife is set perpendicular to the overhanging edge and the edge is demolished with a hammer blow.

Borom act from the inside outward, thus removing the edges undermined by caries and devoid of dentinal support. If there is a dense overhanging enamel edge, it is drilled with a small round bur and the rest is cut off with a fissure bur.

Opening the cavity start to form it. The elements of the cavity are the walls and the bottom of the cavity. In the central cavity, there is a bottom facing the pulp chamber perpendicular to the longitudinal axis of the tooth, and four walls: 1) buccal, 2) lingual, 3) mesial, directed towards the midline, and 4) distal, opposite to it.

In the cervical cavity also has a bottom and four walls. The bottom is directed to the pulp chamber, coincides with the longitudinal axis of the tooth and is perpendicular to the cervical wall. The walls are as follows: 1) cervical, 2) opposite cervical, 3) mesial and 4) distal.

In the proximal cavity three walls are distinguished: 1) cervical, 2) lingual, 3) buccal and the bottom of the cavity, directed towards the pulp chamber and coinciding with the longitudinal axis of the tooth.

Cavity formation technique is reduced to the formation of a flat flat bottom and the creation of a sheer position of the walls. The outlet of the cavity should be equal in area to the bottom of the cavity or somewhat wider. Sheer walls, a flat bottom and an outlet with a larger area than the bottom surface are necessary for the wax reproduction to come out freely and not be deformed after removal from the cavity, as this will ensure that the future insert fits exactly to the walls of the cavity and its introduction into the cavity without special fitting.

cavity formation is carried out using carborundum heads, a bur having the shape of an inverse cone or a fissure bur with a cut end (blunt) of the appropriate size.

When processing cervical walls special attention should also be paid to the following. Since the carious cavity on this wall often goes deep under the gingival margin and overlaps with the gum, in these cases it is necessary to press the gum with cotton wool or gutta-percha and release the gingival wall so that it is easily visible. Thus, the opening and formation of cavities to be sealed with tabs is carried out.
Concerning necrotomy softened dentin, then it is produced simultaneously with the formation of the cavity.