Dental renaissance. How to fill the emptiness in your mouth? Hole in the tooth and emptiness Rules for treating the disease

In the lives of some patients, there are situations when a once treated tooth is offered to be removed. This is not because the surgeon has nothing to do, and he does not want to lose his qualifications. And not because of the prosthetist, who also wants to work. It's all in the tooth, in the roots and even in the bone surrounding it. If a nerve was removed from a tooth, and the canals were filled not with gutta-percha, but with pastes (or something else), then after a few years any paste, we repeat - any, even the very best - will partially erode, dissolve, evaporate, dissolve due to influence of oral humidity. Why? - about it .

Like this. Voids will appear, and as you know, there are no voids in nature, so sooner or later some kind of microflora will get there, worse if it is very evil - doctors call this pathogenic. In these micro- and macrocavities, she lives calmly, reproduces, thanks fate and someone else for the happy chance that she was given. And for her he is very happy - after all, no one touches her there, neither antibiotics nor anything else will affect her. Why? Let's explain: the nerve in the tooth has been removed? Deleted. Along with it, blood and lymphatic vessels that could deliver an antibiotic or other drug there are also removed. But they are no longer in the tooth. And to “no”, there is no trial. No one touches this very flora and fauna in the tooth, no one gets it. It becomes as if invisible to the body - it is visible on x-rays and can look like this:

And since she has no competitors for a place to live, and antimonopoly laws do not work in her body, she feels excellent. It bears fruit and multiplies. And if you still don’t go to the doctor, then the process continues. Let's describe it in more detail. The more bacteria, the higher their birth rate, the higher the birth rate, the more bacteria... This process can be described until the morning..., regardless of traffic. So, if it is very, very harmful, then the tooth begins to bother its owner with calls for help, but if it is not very pathogenic, then such a neighborhood remains for several years unnoticed by anyone. Sounds good? The tooth doesn't bother me. And everyone is happy. Except the body. The fact is that the good mood of the microflora leads to its high fertility. And the children need to be put somewhere, placed in good places under the “sun”. Therefore, at first the inflammation grows in breadth and can form a fistulous tract, from which exudate emerges from time to time. If there is a blood vessel nearby, he uses it to send his idiots into life, that is, through the blood to other organs and tissues, which contributes to the appearance of new sores and relapses of chronic ones. Another option is when the upper molars believe that the Maxillary sinus is close and accessible, and send the products of inflammation into it. This is how odontogenic sinusitis appears...

Conclusion: the dentist should be interested not only in the hole, which you yourself showed him at the 15th minute of the examination, humanely removing the gum from the cavity, but also in the patient’s entire oral health, at least asking you thoroughly about all the teeth and taking x-rays of all long-treated teeth , examines the oral cavity for hidden odonotogenic infection.

The body, as the ancients noted, is a complex thing. And he takes the infection not for a relative, but for “an alien political element whose actions are aimed at undermining the established legal order” (press quote from the 40s). And, armed with all sorts of special cells, he tries to drive her out. The number of militant cells in the blood increases, they attack the source of inflammation, learning at the same time which cell to attack and which not by their “clothes” (protein structure) and “eternal battle, they only dream of peace. It should be noted that microbes have a jacket (protein structure) somewhat similar to the protein structure of heart muscle cells, and the body, having mistakenly confused microbes with heart muscle cells, as a result of military operations begins, in vain, to “wet” (an expression borrowed from the president of 1/6 of the land ) myocardial cells. Cardiorheumatism begins, etc., which we do NOT wish for you either. I can imagine how our beloved manager would tear us to pieces. Department of Pat. physiology for such a primitive interpretation of his life’s work, but we cannot explain it more clearly. We are not writers, not pathophysiologists, not steelworkers, and not carpenters, and we have no bitter regrets!

The entire above-mentioned process of struggle for a bright future occurs with the titanic work of the kidneys, liver and everything that normally should fight only with alcohol, and not with the nasty results of inflammatory foci in the teeth.

There is a theory of “oral sepsis”, which says that except for a couple of diseases that are caused by love, all other diseases are not only from the nerves, but also from the teeth. This surprised general therapists a lot when recovery rates from various diseases improved dramatically after dental treatment.

How to prevent this? Filling the canal tightly, up to its apex and without voids, with gutta-percha, and not with any paste – that’s it. If the canal was filled with paste, refilling it with gutta-percha is two steps.

When the inflammation has reached a large size, should it be removed or treated? We cannot answer for you. You decide. There are some nuances here. If you remove it, then everything is clear - there is no tooth, no problems with inflammation. It is only necessary to subsequently restore its absence either with a bridge or an implant. But if you treat, then it’s more complicated: the doctor receives a tooth with chronic inflammation for treatment, which appeared not a week ago, but for several years nested in the root and bone, affecting them not in the best way. Is it possible to treat it in one visit? Theoretically, yes, by removing all tissues saturated with inflammation along with the tooth. In practice, it turns out that if the canal is thoroughly cleaned and thoroughly sealed immediately on the same visit, then we will not remove all the microflora from the canal and bone, which will lead to pain after filling, which may go away on its own in a week or two. This is the best case scenario. What about the worst? Losing my tooth again. Previously, such teeth were treated using the open method, that is, the canal was cleared of paste and everything else, and the tooth with its canal(s) remained open, without a temporary filling. This implied that the microflora and its metabolic products would leave the tooth and its canal on their own. But where? Yep, into the oral cavity, improving the smell and having several routes to choose from: into the gums, other teeth or into the stomach. And it’s good if the patient did not have gum or stomach diseases. And in order to push the inflammation to evacuate from the body, the patient was recommended to rinse his mouth with soda with iodine and salt.

Modern treatment has taken a slightly different path: the canal is not only cleaned, but also expanded to remove hard-to-reach microtubules filled with inflamed elements. At the same time, the doctor cleans the canal, but not with tap water, but with special solutions, greatly enhanced by the influence of an ultrasonic instrument. Is it possible to fill a filling with gutta-percha, which doctors love? Not yet. How to act on the remaining microscopic canals of the tooth? Ultrasound and solutions do not count - they must be used without fail. There are other special means for this. Namely pastes for temporary filling. We emphasize that for temporary, for permanent – ​​neither, nor!!! They will act on the remaining inflammation. How? With its composition. Something particularly strong and corticosteroid again? Not at all. This paste consists of calcium alone, which, by the way, is very close to humans (remember what bones and teeth are made of), therefore it does not cause allergies, addiction, withdrawal symptoms or other side effects. So simple? Yeah. The effect is that its pH is high, that is, it creates an alkaline environment around itself in which any microflora dies, since it gravitates towards acids. At the same time, in principle, there is no negative effect on humans, since the environment in the oral cavity, its organs and tissues is also alkaline. Another bonus of calcium is that it helps bones recover - after all, it is an excellent calcium donor. And there is no need to look for bone tissue somewhere else - it is here, nearby. A fairy tale, and nothing more. This is not a fairy tale, it works well. It only takes time for calcium to do its good work, so it is left in the tooth canal for 3 days for a full effect on the remaining microflora in chronic periodontitis.

The same calcium preparation can also be used on those teeth that were previously removed. Do you see the X-ray?

There is a large inflammation on one of the roots, which did not bother the patient in any way for several years. Previously, such teeth were removed. There are now several treatment options.

The first is treating the tooth with a calcium-containing preparation. But this is not quick, since the inflammation did not appear yesterday and has managed to grow significantly in volume, so treatment may take several months. How does it go? - the tooth canal is cleaned, a preparation is introduced into it, which is replaced every 3 weeks. Replacement with new portions is necessary due to its dissolution, diffusion into the root and bone tissue, so its effect weakens. Does it hurt or not? In half of the cases, the tooth does not react at all to the intervention, in the other half it may be slightly disturbed for several days. In 3-5%, the inflammation may not respond to treatment and the tooth reacts strongly when biting. In this case, the canal is washed again and filled with paste. Here are two examples of treating such teeth:

This is the chewing tooth of a young man, 25 years old. The treatment was carried out for three months. The calcium-containing medication was changed every three weeks. After treatment in 2002, this tooth is standing without exacerbations or problems.

In this case, the patient is about forty. Due to the need to go to another country for permanent residence, there was no time for long-term treatment. It was carried out over a month and a half.

If this does not help, you have to get rid of the inflammation with the help of a surgeon - there are two options.

The first is hemisection - removal of diseased roots in multi-rooted teeth while preserving healthy ones, which are subsequently restored and can be used in prosthetics, which makes it possible to not process a healthy adjacent tooth when making a bridge. And this, you see, is good, very good, because healthy roots do not leave a person and continue to fulfill their assigned role, the neighboring tooth is not touched by the caring hand of an orthopedist (that is, it is not treated for a crown) and this procedure was done without the implantation of an implant, which can take root , or maybe... Why remove something that can serve faithfully for many years?

Here is an example of root preservation in a two-rooted tooth with chronic periodontitis (one root is preserved, the other is removed):

And the last method is trivial parting with the tooth, that is, removal, when the previously listed options are unacceptable.

Today I want to continue to present you with my own clinical cases, from which you can more clearly understand some of the details of endodontic treatment.

In one of the previous posts, I showed one of the main reasons for the development of chronic inflammation in the bone tissue around the tooth root, namely, canals missed during primary treatment. Today I will show 2 more cases, approximately similar, when I had to deal not only with errors during the initial root canal treatment, but in addition to this, with an incorrectly chosen technique for restoring “dead” teeth.

Case one. Quickie...

A patient approached me with a request to try to “save” the lower 6th tooth from removal. This is what it looked like in the mouth.

The blue arrow shows the anchor pin showing through the composite filling. Black arrows indicate violations of the fit of the filling to the tooth. The patient often notices the problem only when there is a “hole” in the tooth, or when the tooth is completely falling apart. Such fillings, which at first glance last for several years, are no less dangerous because microflora from the oral cavity can penetrate through the cracks for a long time without any symptoms into the tooth and root canals. This is exactly what happens formation of granulomas and cysts at the tops of the roots.

What do we see here? Well, firstly, the tooth anatomy is completely absent. The huge cavity is plastered over (there’s no other word for it) without the slightest attempt to create on the tooth the surface relief necessary for chewing with tubercles and grooves between them. The anchor pin shines through the material, which is designed to hold this “slap” inside the tooth. Secondly, along the edges of the filling there is noticeable staining of the border, i.e. The filling has long been leaky, which means that the microflora of the oral cavity leaks inside, causing relapse of caries and an inflammatory process in the bone tissue around the root. Thirdly, we can see only 2 preserved walls of our own teeth, which are also quite thinned. Considering that the tooth has been dead for a long time, the restoration method clearly chosen was unsuccessful. And at the same time it was executed very poorly. The fact is that our chewing teeth experience quite serious loads when chewing (according to various sources, about 100 kg per cm 2), and the remaining tonic walls can crack at any moment. Often the crack goes deep under the gum and eventually the tooth has to be removed. Therefore, if a tooth is pulpless and has significant damage (as in our case), then it must be restored with a crown. Only in this case will you be insured against any unpleasant surprises. But for this tooth this is only half the story. There was no less problem inside.

On an X-ray of a tooth, we can see several underlying problems. The red line outlines the outline of a bone tissue defect caused by chronic inflammation. The white dotted line shows a void in the canals that were not adequately expanded and sealed. The white arrow marks the position anchor pin, “strengthening” the filling. You can see that this pin only enters the canal a few mm, and therefore does not serve the function of holding the restoration. In this case, it is not clear who is “strengthening” whom; rather, the seal is holding the pin. And finally, a pink arrow marks a filling hanging over the gum, which leads to food getting stuck between the teeth and gum inflammation. In general, a whole bunch of medical “jambs”.

This X-ray image shows, first of all, “empty” root canals and a fairly large focus of inflammation (what is often called a granuloma, cyst) at the top of one of the roots. In general, a whole bunch of mistakes and imperfections were concentrated in one tooth; in a word, this is an example of the dentist’s dishonest work. I always try to speak well of my colleagues or remain silent, but in this case we have to face the truth - it was the dentist who ruined the tooth. Initially there were no objective difficulties for high-quality work here. But now they have appeared. The future prognosis for such teeth is always based on 2 main problems - how successful canal re-treatment will be and how successful will be the attempt to adequately restore the tooth after that. Having assessed the likelihood of long-term success of these two components, you can decide whether to “save” the tooth from the surgeon’s forceps. After all, in any case, treatment costs money, and it is impossible to guarantee the result. One can only guess the likelihood of success. In this case, the channels did not appear impassable. And it was still possible to restore the tooth with a crown, even despite the high degree of destruction. Therefore, the decision was made to begin treatment. To begin with, the anchor pin was removed from the canal using ultrasound.

Then, not without difficulty, all 4 canals of this tooth were processed.

A control x-ray was taken immediately before filling.

This is what the final result looks like in the picture.

The canal treatment protocol in this case is standard, and is described by me. The first part of the rescue task was completed. Now this tooth will be under observation for 3-4 months. After this period, a control x-ray will be taken, which should show how successful our attempt was save a tooth from extraction, namely, we expect a decrease in the focus of inflammation around the root. If this tendency is clearly noticeable, only then will a final decision be made to restore the tooth with a crown. And next in line for this patient is the “twin” neighbor of this long-suffering 6, the 7th lower tooth. What can I say?.. Recognizable handwriting of the previous doctor.

Case two. About the benefits of computed tomography in root canal treatment...

In the second case, everything started out quite similar.

In this case, everything is like a carbon copy, although this is a different patient. Here it also shines through (and actually sticks out) (indicated by a black arrow). And despite the fact that the filling holds quite securely in the cavity and does not think of falling out, it has long been leaky, as evidenced by the staining of the border between the filling and the tooth (blue arrow) and the general darkening of the tooth. As in the first case, this leakage leads to the penetration of microflora into the tooth and the development of granulomas on its roots.

The same leaky filling, the same anchor pin... but the hard tissues are preserved much better than the first case. Along the entire perimeter of the tooth, the cavity boundary is located above the level of the gum, which means that at least the prognosis for the longevity of the restoration will be quite optimistic.

After removing the old filling and anchor pin, you can see what is happening inside the tooth under the seemingly good filling.

In the photo immediately after removing the filling and removing the anchor pin the reason for the darkening of this tooth is visible. In the canals, in addition to the filling material (orange-colored gutta-percha), there is a noticeable large amount of “dirt” that has seeped into the tooth for a long time through a leaky filling. However, the patient was not bothered by anything. Therefore, it is important that even if you do not have any symptoms, you show your teeth to the dentist at least once a year. Then you can avoid serious problems. Also, this situation is clear evidence that if the tooth remains standing for many years after treatment, does not bother you, and the filling has not fallen out, then this is not a reason to think that the treatment was carried out efficiently.

As for root canals, this is where the main difficulties were. Both canals were not very well processed and sealed, as a result of which marks appeared on both roots. granulomas.

This image also clearly shows the defects of the previous treatment. The black dotted line shows the outlines of the two roots of the problem tooth, the red line shows the untreated and unfilled areas of the root canals, the blue line shows the boundaries of the inflammatory process in the bone tissue.

But a regular X-ray produces a flat, 2-dimensional image, with different structures superimposed on each other, and the complex anatomy of the canals cannot always be seen. Which is what happened in this case. One of the channels had a double bend. During the previous treatment, the doctor, for some reason, was unable to see and pass this bend, but rested against the walls of the root, creating the so-called. "step".

This figure shows a diagram of the formation of a “step” - one of the most unpleasant complications in endodontics, which a dentist can do with his own hands. The blue arrow shows the true direction of the tooth canal. The red arrow shows the straight part of the canal that the doctor was able to process with instruments. The green arrow shows that very “step”, i.e. the dentist loses the true direction of the canal and creates an artificial passage. During repeated treatment, the instrument, as a rule, also rushes along the most direct path and getting back into the bend of the natural canal in order to completely process it is very problematic.

This is a rather unpleasant complication, because... during repeated treatment, it is very difficult to “feel” again the real course of the natural canal. Without this, it is impossible to count on the success of treatment. Imagine that you need to feel, with your eyes closed, thread the thread into the smallest eye of the needle... In this case, the eye of the needle is located deep in the channel with a diameter of only 1-2 mm. This is approximately what the endodontist encounters every time in such cases. Solving such problems requires great skill, good equipment, spatial thinking, a fair amount of patience (and on the part of the patient too), well, and a bit of luck.

In this case, in order to more clearly imagine what structure each channel has, we made computed tomogram (CT) of teeth. Thanks to this x-ray method, we have the opportunity to trace in 3 dimensions the structure of any part of the dental-facial system, incl. and root canals. In our case, we got the following pictures.

A tomogram allows you to “split” a tooth into parts and look at each root separately, and unlike a conventional x-ray, we can examine any structure in detail, since there is no overlap of different formations on each other. This is the palatal root of our tooth shown separately. And in this picture, its “trickiness” is now visible in all details - a double bend in the middle, which became a stumbling block during the previous treatment. A dark halo around the root apex is a granuloma around the palatal root.

Now we see the buccal root separately. It does not stand out in anything special. A regular straight root with the same straight canal. However, it was also not adequately processed, and we also remember that the seal was leaking. Therefore, as a result, there is also inflammation at the apex in the form of a dark halo.

This is another projection of the same tooth. Since the tomogram gives us a 3D image, we can look at the tooth from any side. In this case, it’s as if we cut it lengthwise into 2 halves, but in a different plane. And now we can clearly see the tooth cavity with two diverging canals.

After this, it became clear in which direction the tools needed to be bent in order to find the “eye of the needle” of the real channel. This is what the tools looked like after several attempts.

This is only half of the pile of tools that eventually had to be thrown away. This is a clear demonstration of why complex repeat endodontic treatment This is so time- and resource-intensive, and, accordingly, why it is so expensive.

But the main thing in all this is that if you manage to save your natural tooth from removal, then it’s worth it. Because with all the advancement of implantation technologies today, the coolest and best “implant” is your own tooth. And therefore, it is not surprising that many patients are willing to preserve their teeth, despite the fact that the cost of canal retreatment and subsequent tooth restoration is comparable to the cost of installing an average price category implant.

This picture shows how, after many attempts, we managed to find the true course of the channel. The red arrow shows the same "step" in the channel, which we managed to bypass and where the tool initially rested.

Photo of an absolutely clean tooth cavity after thorough washing, first of all, with sodium hypochlorite (“bleach”) and ultrasonic cleaning. Now the canals are ready for filling.

Final photo after completion of treatment. Both canals are sealed to the apex. The whole process took about 2.5 hours (for 2 visits). Now all that remains is to wait for the inflammatory process to disappear.

In this case, from an endodontic point of view, everything ended well for the tooth. In the future, after about 3 months, a control photograph will be taken to ensure the effectiveness of the treatment. Namely, we will wait for a decrease in the foci of the inflammatory process in the bone tissue, i.e., simply put, the dark spots around the tips of the roots should become smaller. In this case, such a tooth can be safely restored and count on its long service life.

This is what some look like errors and ways to eliminate them in root canal treatment. And here it is easy to notice that it is much easier and cheaper to prevent punctures during the initial treatment than to correct them later.

When a person experiences aching or throbbing pain in a tooth, which intensifies when biting, or when eating hot food, he is perplexed: after all, a pulpless (deprived of nerve) tooth should not hurt? It turns out, maybe, and in such a way that there is no strength enough to endure these torments. During such an exacerbation, patients feel that the tooth has grown - lengthened. Often, with severe aching pain, swelling of the face occurs, the so-called gumboil. Local lymph nodes (under the jaw, behind the ear) on the affected side enlarge, become painful on palpation, and the temperature may rise to 37-37.5 C. Sometimes the patient complains of itching. The tooth may be mobile, when pressing on the gum next to the sore tooth, it may release pus. A fistula (whitish lump) may form on the gum near the aching tooth, from which the purulent contents of the cyst are released. Most often, after the process of freeing the site of inflammation from pus begins, the pain becomes less intense. The doctor makes a diagnosis of periodontitis. However, there are situations when patients have no complaints, and periodontitis is discovered by chance at an appointment with a therapist while replacing a filling or restoring a damaged tooth. . Complications are possible in the form of perimandibular abscess, osteomyelitis of the jaw.

Description

There are several causes of periodontitis. The main reason for the development of this disease is poorly treated tooth canals during the treatment of pulpitis or a complication of caries, when the infection penetrates the tooth canals and spreads to the periodontium, damaging it. However, it often develops against the background of well-treated root canals due to heavy load on the tooth, trauma, allergic reaction to medications, toxins... Inflammation of the gums can also provoke the development of periodontitis. Periodontal inflammation is the result of exposure to microorganisms, or more precisely, toxins that they produce during their vital activity and during the decay of pulp and periodontal tissue.

Chronic periodontitis can be asymptomatic (do not bother) and manifest itself in case of weakening of the body. Chronic periodontitis in the acute stage manifests itself in the same way as acute periodontitis.

First aid

With periodontitis, the inflammatory focus is localized in the area of ​​the apex of the tooth root (in the jaw bone). Increased pressure occurs at the site of inflammation - this is what causes severe pain when pressing on the tooth. To reduce pain, it is necessary to reduce this pressure and create an outflow of contents from the inflammatory focus. To do this, you need to rinse your mouth with a solution of table soda (1 teaspoon of soda per glass of very warm water). The more often, the greater the chance that the outflow of purulent contents will begin. Heat should not be applied to the sore spot. Until this happens, you can take analgesics (Ketanov, ibuprofen) to relieve pain. When the contents of the “cyst” break out, rinsing with soda can be alternated with rinsing with a weak solution of furatsilin, chlorhexidine, potassium permanganate (potassium permanganate).

Diagnostics

At the appointment, the dentist-therapist listens to the patient’s complaints, conducts an intraoral examination and refers the patient for an x-ray examination. Most often, a targeted x-ray is sufficient to clarify the diagnosis, but an orthopantomogram may also be required. If necessary, the doctor may refer the patient for a dental CT scan. An X-ray examination of periodontitis reveals changes in the tissues surrounding the tooth root: expansion of the periodontal fissure (the space between the bone and the tooth root), the presence of cystic formations, granulomas (the formation of a connective tissue capsule filled with granulations.)

Treatment

A radical method of combating periodontitis is to remove the tooth, and with it the source of inflammation - the cyst. But many, naturally, are in no hurry to get rid of it, but ask to be “cured.” Whether conservative treatment makes sense is determined based on the radiograph. With its help, the doctor determines whether the root canal has been filled, what size the “cyst” reaches, and how damaged the tooth is. If it turns out that treatment is advisable, the patient must be warned that it consists of several stages and can last for 2 - 3 months, so it is worth being patient and strengthening the immune system, since the dentist only helps the body eliminate inflammation, mainly with the pathological process The body copes on its own.

During the treatment, the doctor removes the infected tissue that has filled the root canal and thoroughly cleans it using modern, durable, flexible and very thin instruments and technology. If the canal was sealed a long time ago using old technology, it is difficult to unseal it, reach the source of inflammation and eliminate it using conventional instruments. In such situations, a special apparatus is used to carry out the depophoresis procedure. This is one of the methods of physiotherapy; it consists in the fact that, with the help of a small current, ions of the medicinal substance permeate the entire root tissue and affect the granuloma.

A special medicinal paste containing calcium is temporarily placed in the cleaned canal. Thanks to the action of the paste, the acidic environment created by microorganisms is neutralized due to the alkaline properties of calcium. Sometimes the composition of such preparations (pastes) includes iodine derivatives, and in the case of an acute process or exacerbation, after creating an outflow of contents from the site of inflammation, “intraradicular medicinal preparations” containing antibiotics are used. When the condition has stabilized, endodontic treatment is carried out under X-ray control. Only after this the canal is processed again and filled very tightly.

In the treatment of periodontitis there is always a risk of not getting the desired result, therefore, as a rule, it is carried out without a guarantee.

Very large cysts are more difficult to treat and success is less likely. And if the crown part of the tooth is so destroyed that it can no longer be restored, it makes sense to remove the tooth. In some cases, and they are becoming less common, the patient’s root canal is filled with Soviet cement. It is impossible to unseal and completely process it, to reach the source of inflammation and eliminate it; the tooth also has to be removed.

In the case where a cyst (granuloma) has formed in the area of ​​the apex of the tooth root, but it does not respond to conservative treatment, the tooth can be saved by using tooth-preserving surgical treatment.

Corono-radicular separation allows you to cut the crown of the tooth into two parts at the place where the roots diverge, thus giving the surgeon the opportunity to clean out the granulation tissue through the resulting gap. This operation is performed, as a rule, on large chewing teeth - molars, and is sometimes called premolarization, since as a result the molar turns into two premolars.

Hemisection- an operation in which one of the roots is cut off and removed along with the adjacent part of the tooth. Recommended mainly for chewing teeth of the lower jaw.

Amputation- cutting off the entire root of the tooth at the place of its origin, without violating the integrity of the coronal part of the tooth. It is used on teeth with several roots, mainly on the molars of the lower jaw, sometimes on the premolars of the upper jaw.

Resection of the apex of the tooth root- the most commonly used operation for periodontitis. During it, the tip of the tooth root is cut off, the cyst is removed, and the periodontium is cleared of pathological tissue. If necessary, retrograde filling is carried out - the canal is filled from the end, then bone-forming material is laid and a suture is applied.

The use of these techniques allows doctors to preserve teeth, which just a few years ago everyone, even young people, had to part with. However, firstly, not all surgeons know them, and secondly, many dentists consider such treatment inappropriate and suggest removing the periodontitis tooth and installing an implant in its place. Therefore, you will have to look for a clinic where you can preserve your own tooth for at least 5-6 years.

Prevention

Prevention of periodontitis is timely, high-quality treatment of caries and pulpitis. But often, in order to protect teeth from this disease, doctors recommend “re-treating” teeth whose canals were sealed 10, or even 20 years ago. We are talking about the so-called resorcinol-formalin teeth, which are distinguished by a peculiar brownish coloration of the crown. From the point of view of modern dentistry, this is poor-quality treatment and is fraught with the development of complications such as periodontitis. Therefore, if teeth treated using the resorcinol-formalin method require replacement of a large filling or they need to be prepared for prosthetics (tooth restoration with a crown), it is necessary to remove the old material and re-treat the canals along the entire length, and then fully fill them, followed by restoration of the crown part of the tooth.

Doctor Peter

By the term “internal caries,” the average patient at a dental clinic usually understands a disease that affects the tissue deep under the tooth enamel. At the same time, doctors know that, by and large, any caries affects the internal tissues of the tooth, which are softer and more easily damaged than enamel. Therefore, the phrase “internal caries” can be applied to almost any case of the disease and, by and large, is a tautology.

In some cases, they talk about internal caries when they mean a pathological process under a crown or a poorly installed filling. Here, caries inside the tooth develops completely unnoticed by both the doctor and the patient, and reveals itself only when the pathological process covers the enamel around the filling (crown) or when pain appears. But again, this is still the same ordinary caries, just with a non-standard localization.

In most cases, at the first examination of teeth, their walls (surfaces) affected by caries are striking. These are often not carious cavities at all, but simply gray, tarnished enamel that has lost its healthy appearance due to demineralization.

Often, the dentist sees a certain “tunnel” in the space between the teeth, but the probe may, due to the density of the interdental space, not pass into the hidden internal carious cavity. Usually, the doctor shows the patient in the mirror the grayish shades of the enamel against the background of developed internal caries and begins treating the tooth after anesthesia.

When a bur touches gray enamel, in almost 90% of cases it breaks off within a couple of seconds and the bur falls into the internal cavity with an abundance of carious, pigmented, infected and softened dentin. If the anesthesia is administered correctly by the doctor, there is absolutely no pain.

The doctor cleans and seals the tooth strictly according to the caries treatment protocol. If the tooth already has a connection with the pulp chamber (the cavity where the nerve is located), then the doctor performs depulpation and filling of the canals, followed by a permanent filling in one or two visits.

The photo below shows a tooth in which deep internal carious cavities are visible under bright light:

The following photo shows, that is, localized in the area of ​​​​the natural relief of the teeth. Such darkening inside also often hides significantly destroyed tissues that are not immediately detectable during a normal examination:

At home, such “internal caries” is almost impossible to detect. It will reveal itself only if there is extensive damage to the dentin and pain appears in the tooth when the pulp is included in the pathological process. That is why preventive visits to the dentist are so important, who, using special methods, will be able to detect caries in any location and treat the tooth before it requires pulp removal (nerve removal).

Reasons for the development of deep caries

The causes of caries in deep tooth tissues are similar to those for caries with any other types of its localization. The disease develops due to the following factors:

1. The constant presence of acids in the oral cavity, both those that came here with food (fruits, vegetables), and those produced by bacteria that consume the remains of almost any carbohydrate food - flour, sweets, cereals.
2. Reduced secretion of saliva or its low bactericidal activity. This may be caused by other diseases or metabolic disorders.
3. Mechanical and thermal damage to tooth enamel.
4. Hereditary factors.

Typically, caries develops under the influence of a complex of several such factors.

In any case, it is in the deep parts of the tooth, located under the enamel, that caries develops most quickly due to the greater susceptibility of the tissues here to the action of acids. Therefore, there are often situations when, under a barely noticeable (or even completely invisible to the naked eye) hole, there is a large cavity destroyed by the carious process.

On a note:

This is why the enamel almost always breaks off (comes off in pieces) when a large carious cavity has already formed, affecting the layers of softened, infected dentin. That is, the enamel can hold the load for a long time, hanging over a hidden carious cavity, often without giving it away.

Features of diagnosing caries inside a tooth

Caries inside a tooth is much more difficult to diagnose than regular caries, which has manifestations on the surface of the enamel. It can definitely be noticed when using the following diagnostic methods:

In addition, advanced internal caries causes pain in the patient, which is mild at first and occurs mainly when chewing hard food and getting very cold foods on the tooth, and intensifying as the disease progresses. If a tooth begins to ache regularly without visible damage, you should definitely go to the dentist for an examination.

The following methods can be used as auxiliary methods for diagnosing and confirming caries inside the tooth:

Rules for treating the disease

In all cases of caries development inside a tooth, its treatment requires opening the enamel, removing the affected dentin and filling the cleaned cavities. In its advanced form, internal caries leads to the need to remove the nerve and fill the canals.

Even more serious are situations when a very significant amount of tissue is damaged by caries from inside the tooth, and it either after their removal or simply due to softening, splits. In this situation, it is often necessary to remove a tooth according to indications, followed by installation of an implant at the request of the patient, or to make do with modern prosthetic techniques.

On a note

There is a difference between a split and a split, so tooth-preserving techniques may involve, for example, restoration of a tooth on a titanium (anchor, fiberglass) pin after thorough intra-canal treatment + installation of a crown (metal-ceramic, stamped, solid-cast, etc.), may involve tooth preparation under the tab, installing the tab + crown. There can be many options.

Sometimes the damage is quite extensive, but it is possible to save the roots of the tooth by removing the pulp from them. In such cases, it is possible to get by with installing a crown.

In any case, after detecting a carious cavity, the doctor cleans it out with a bur. If such tissues come close to the pulp, their removal can be painful and is most often done using local anesthesia.

From dental practice

There are ambiguous situations when the pulp area has not yet been opened when cleaning the carious cavity, but the patient already begins to experience pain during the doctor’s work. It is impossible to say for sure whether it is worth carrying out depulpation here or not. Without depulpation after installing the filling, when chewing, it may begin to disturb the nerve endings and cause pain. Some doctors are inclined to depulpate such a tooth so that they do not have to carry out repeated work if, after installing the filling, the patient begins to experience pain. Other dentists explain the situation to the patient in detail and make a decision together with him. It should be borne in mind that many patients are very sensitive to the preservation of their teeth in a “living” form and are willing to take risks in order to walk around with a tooth with preserved pulp for several more years, if after a simple filling there is no pain.

In general, even with deep caries, the nerve has to be removed, according to statistics, in less than a third of cases, and the removal of the tooth itself due to deep caries is generally a rather rare situation.

Prevention of deep caries

You can avoid the development of caries deep inside the tooth if you regularly undergo preventive examinations at the dentist and detect the appearance of the disease at the stain stage. With this approach, it is highly likely that depulpation will be avoided, and in the absence of hidden caries, it will even be possible to do without opening the tooth and filling it.

To prevent the appearance of even the earliest signs of caries, the following preventive measures must be observed:

• brush your teeth thoroughly at least twice a day - after breakfast and before bed;
• rinse your mouth after eating;
• do not get carried away with sweets and candies;
• remove food debris stuck between teeth;
• Avoid contact of too hot or too cold foods and drinks with your teeth.

If you are predisposed to dental caries, you should consult your doctor and, on his recommendation, take calcium and fluoride supplements in the form of tablets or special solutions.

An additional preventive measure can be chewing gum containing xylitol instead of sugar. They should be chewed for 10-15 minutes after eating to increase saliva production and clean the spaces between the teeth.

Taken together and systematically applied, such preventive measures will provide reliable protection against tooth damage, and even when the first signs of caries appear, the doctor will be able to eliminate the pathology before it spreads into the deep tissues under the enamel.

Interesting video: tooth preparation and restoration with deep caries

An example of a two-stage method for treating deep caries