Carious cavity treatment. Medication of the carious cavity Medication of the cavity

The main goals of drug treatment of carious cavities:

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

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

Drying the cavity.

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

9) The imposition of a medical pad.

Materials for treatment pads should:

Provide anti-inflammatory, antimicrobial, odontotropic action;

Do not irritate the tooth pulp;

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

Correspond to the physical and chemical properties of permanent filling materials.

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

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

Calcium hydroxide materials:

Calcium hydroxide - Ca (OH) 2 - is a base that is poorly 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 therapeutic effects of this substance. Applied to the surface of the peri-pulpal dentin (which, due to its anatomical structure, has increased permeability), calcium hydroxide diffuses through the dentinal tubules and penetrates into the pulp. At the same time, a long-term therapeutic odoptogropic and antimicrobial effect is provided.

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

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

A. Aqueous suspension of calcium hydroxide: Calcicur, Calasept, Calcipulpe, Superlux Calciumhydroxid-Liner, Calradent.

B. Calcium hydroxide varnishes: Contrasil.

B. Chemical curing calcium salicylate cements: Calcimol, Dycal, Life, Septocalcine Ultra, Reocap, Calcesil.

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

Zinc-eugenol cements:

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

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

and "Cavitec" (Kerr).

When using zinc oxide-eugenol cement as a gasket for materials that require condensation in the cavity (phosphate cement, amalgam), the treatment pad is deformed. In this case, it is advisable in the first visit to apply a temporary zinc-eugenol filling, and in the second visit (after 1-3 days) to remove 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 of their organic matrix. This fact is associated with a decrease in dentists' interest in zinc-eugenol cements as materials for medical pads.

Combined medicinal pastes

They include several groups of medicinal substances and are prepared ex 1etroge, 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 sawdust, 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 substances - chlorhexidine, metronidazole, lysozyme, sodium hypochlorite, etonium paste (7% etonium in artificial dentin). The expediency of including antibiotics in the composition of the therapeutic pad is currently controversial.

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

5. Other products - hyaluronidase, EDTA, dimexide (DMSO), kaolin, zinc oxide, novocaine, various oils (clove, 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 wide range of materials for treatment 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, the filling is carried out in one visit with the imposition of a therapeutic pad made 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 therapeutic pad either from a preparation based on a suspension of calcium hydroxide or from zinc oxide eugenol cement. For the period of treatment, the cavity is closed with a temporary filling, and the patient is under dynamic observation with constant monitoring of the pulp state (EOM, thermal diagnostics, etc.).

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

10) Applying an insulating gasket: glass ionomer cements are more commonly used, in last resort phosphate cements. The goal is to isolate dentin and pulp from toxic substances contained in some filling materials, to create a barrier to the thermal 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 pad, the features of the imposition and the materials used, its various options are distinguished.

A. The base lining (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 with the preservation of retention properties.

4. Reducing the volume (amount) of permanent filling material (in order to reduce the polymerization shrinkage of the filling; creating a "pillow" under the filling to compensate for the forces arising from chewing; saving expensive composite, etc.).

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

1. Isolate the pulp from chemical irritants.

2. Provide a bond between the cavity walls and the permanent restoration material.

Medication treatment is one of the most important stages in the preparation of the cavity for filling.Basic goalsdrug treatment : - cleansing the cavity from oral fluid, dentin sawdust and other contaminants;- bactericidal and bacteriostatic effect on the microflora located in the cavity and parietal dentin;- drying the cavity.For a long time, solutions of aggressive antiseptics, for example, phenol, were used for drug treatment of carious cavities.In our country in the "pre-composite era" for the drug treatment of prepared cavities before filling, they used96% alcohol, 3% hydrogen peroxide solution, and the cavity was dried with medical ether. Deep cavities, in order to avoid irritating effect on the pulp, were washed with warm solutions (30-35 °) of weak antiseptics:1% chloramine solution, 1% hydrogen peroxide, 0.1% furacilin solution. Drying deep cavities was recommended with warm air.

With the advent of composite materials, approaches todrug treatment cavities have changed. It is not recommended to use alcohols and ethers for the treatment of cavities due to their high toxicity and low drying capacity (Petrikas A.Zh., 1997). In addition, there are concerns that alcohols and ethers can reduce the adhesion of composites, and alcohol destroys the polymer matrix of composites (Borisenko A.V., Nespryadko V.P., 2001). Currently, when filling with composites for the purpose of drug treatment, it is recommended to use the irrigation of the cavity with warm antiseptics of low concentrations from a syringe. For these purposes, use 3-5% sodium hypochlorite solution,3% hydrogen peroxide solution, 0.06-0.1% chlorhexidine solution, 0.02% furacilin solution, etc. etc. Drying of the cavity is carried out with a jet of air from a "pistol" or a sterile cotton ball.It should be recognized that treatment in this way, firstly, is not effective enough, and secondly, it is technologically difficult, 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 ( it is necessary to use a rubber dam and a "vacuum cleaner"). In addition, at present, there are concerns about the use of agents that emit atomic oxygen or chlorine (hydrogen peroxide, sodium hypochlorite) for drug treatment of the cavity. It is believed that these gases can penetrate the parietal dentin and inhibit the polymerization of the adhesive system of the composite, disrupting the properties of the "hybrid layer".Some experts, in addition to the listed drugs, recommend the use of agents that dissolve the lubricated layer, for example, citric acid, EDTA, etc. We consider it inexpedient to carry out this stage in a special way. This is due to the fact that different materials have different mechanisms of connection with the tooth tissues, and in some cases the removal of the "smeared layer" will bring harm rather than benefit. 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 confine themselves to rinsing the cavity with water from a "pistol" and air drying it. After that, they begin the filling process, counting 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 dentin, sealed with an adhesive system and (or) filling material, the active vital activity of microflora stops. This approach is permissible, but it does not exclude the risk of developing inflammatory complications from the pulp associated with the invasion of microorganisms into it from the infected dentin adjacent to the cavity.We consider the following method of antiseptic treatment of the cavity before filling to be appropriate:1. Abundant rinsing of the cavity with water, water-air spray and drying from the "pistol" of the dental unit. It is desirable that the "gun" is supplied not with tap water, but with an autonomous supply of distilled water from a special container.

Fig. 184 ... Preparation based on 2% chlorhexidine solution "Consepsis", Ultradent:

A - IndiSpense syringe (30 ml);

B - 1.2 ml syringes with cannulas for direct application of the drug into the cavity.

2. Medical treatment of a carious cavity 2% chlorhexidine aqueous solution. For these purposes, you can use a solution purchased in a pharmacy, however, it is most convenient, in our opinion, to use the drug "Consepsis" (Ultradent) for these purposes (Fig. 184). It is a 2% solution of chlorhexidine bigluco-note 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 brush-cannulas "Black Mini Brush" or "Dento-Infusor" (see Fig. 185)."Consepsis" is applied to the walls and bottom of the cavity with a cannula brush for 30-60 seconds. It can also be used to treat the surrounding tooth tissue and adjacent gums. As needed, the drug is gradually squeezed out of the syringe.3. The preparation is gently inflated and air-dried. It is not recommended to wash it off.

A b

Fig. 185 ... Cannula-brushes Black Mini Brush (a) and Dento-lnfusor (b), Ultradent.

4. After that, the enamel and dentin are etched, the adhesive system is applied and the cavity is filled in accordance with the instructions for the filling material.Effective use of the adhesive system and qualified, technologically correct filling ensure long-term sealing of the dentin surface and impermeability at the filling / tooth tissue interface. 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 adhesion. In this case, the drug is introduced into the already etched cavity, gently inflated with air and not washed off. Research found no difference in adhesion strength with Consepsis before and after etching. This force does not depend on whether the preparation was washed off with subsequent drying of the cavity, or it was dried without rinsing off with water (data from the "Ultradent" company).Another way to disinfect dentin in the area of \u200b\u200bthe 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 the bandage. Of course, it should be recognized that this method is quite long and laborious, but its use is quite justified in some difficult clinical situations.It is possible to enhance the bactericidal effect on parietal dentin before filling with composites by using etching gels containing bactericidal components. An example of such a drug is a gel based on 35% phosphoric acid "Ultra-Etch AB", Ultradent, containing an antibacterial drug acetylpyridine chloride.As evidenced by the literature data, drug treatment of the cavity before filling with composite materials can reduce the number of pathogenic bacteria in parietal dentin, reduce the risk of "postoperative" sensitivity and inflammatory complications from the dental pulp.

Medication treatment is an important stage in the preparation of the cavity for filling.

The main goals of drug treatment of carious cavities:

- cleansing the cavity from dentin sawdust, oral fluid and other contaminants;

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

- drying the cavity.

For a long time, solutions of potent antiseptics, for example, phenol, have been used for drug treatment of carious cavities.

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

With the advent of composites, the approaches to drug treatment of cavities have changed significantly. It is not recommended to use alcohol and ether for the treatment of cavities due to toxicity and low drying capacity (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 the composites (Borisenko A.V., Nespryadko V.P., 2001). Currently, when filling with composites for the purpose of drug treatment, it is recommended to use the irrigation of the cavity with warm antiseptics of low concentrations from a syringe. For these purposes, use 3-5% sodium hypochlorite solution, 0.06-0.1% chlorhexidine solution, 3% hydrogen peroxide solution, 0.02% furacilin solution, etc. etc. Drying of the cavity is carried out with a jet of air from a "pistol" or with a sterile cotton ball.

It should be recognized that treatment in this way, firstly, is not effective enough, and secondly, it is technologically difficult, 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 ( it is necessary to use a rubber dam and a "vacuum cleaner"). In addition, at present, there are concerns about the use of agents that emit atomic oxygen or chlorine (hydrogen peroxide, sodium hypochlorite) for drug treatment of the cavity. It is believed that these gases can penetrate the parietal dentin and inhibit the polymerization of the adhesive system of the composite, disrupting the properties of the "hybrid layer".

Some experts, in addition to the listed drugs, recommend the use of agents that dissolve the lubricated layer, for example, citric acid, EDTA, etc. We consider it inexpedient to carry out this stage in a special way. This is due to the fact that different materials have different mechanisms of connection with the tooth tissues, and in some cases the removal of the "smeared layer" will bring harm rather than benefit. 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 confine themselves to rinsing the cavity with water from a "pistol" and drying it with air. After that, they begin the filling process, counting 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 dentin, sealed with an adhesive system and (or) filling material, the active vital activity of microflora stops. This approach is permissible, but it does not exclude the risk of developing inflammatory complications from the pulp associated with the invasion of microorganisms into it from the infected dentin adjacent to the cavity.

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

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

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

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

3. The preparation is gently inflated and air-dried. 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 filled in accordance with the instructions for the filling material.

Effective use of the adhesive system and qualified, technologically correct filling ensure long-term sealing of the dentin surface and impermeability at the filling / tooth tissue interface. 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 the already etched cavity, gently inflated with air and not washed off. Research found no difference in adhesion strength with Consepsis before and after etching. This force does not depend on whether the preparation was washed off with subsequent drying of the cavity, or it was dried without rinsing off with water (data from the company "Ultradent").

Another way to disinfect dentin in the area of \u200b\u200bthe 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 the bandage. Of course, it should be recognized that this method is quite long and laborious, but its use is quite justified in some difficult clinical situations.

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

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

Medical treatment of a carious cavity is the next stage in preparing it for filling with filling material after preparation. Its main goals are cleaning the carious cavity from dentin sawdust, saliva, microbes; bactericidal effect on microorganisms that remain in dentin; drying of hard tooth tissues

Previously, 96% ethyl alcohol, 3% hydrogen peroxide solution was used for this purpose. To dry the cavity, ether was used, with deeper defects - a stream of warm air, then it was treated with a heated mixture of antiseptics with a weak concentration of the active substance (0.1% furacilin solution, 1% hydrogen peroxide). However, with the advent of modern composite filling materials, alcohol and ether for the treatment of carious cavities have ceased to be used, since they worsen the adhesion of the filling to the tooth tissues and have a toxic effect.

Now for the medical treatment of defects, warm solutions of antiseptics are most often used, which are injected into the cavity with a syringe. Their main active ingredients are chloramine, furacilin, chlorhexidine, hydrogen peroxide. Drying is carried out with a stream of air or sterile cotton wool.

It must be admitted that not all of the above solutions are effective enough. For example, sodium hypochlorite has a very unpleasant taste and odor. It is also believed that sodium hypochlorite and hydrogen peroxide inhibit the polymerization of composite materials, since they release atomic oxygen and chlorine, which penetrate into dentin.

It is best to choose the following drug treatment algorithm:

1. First, it is necessary to rinse the carious cavity with water and dry it with a puster (a special device of the dental unit). Some dentists limit themselves to this stage, but its implementation is not enough to completely disinfect the defect;
2. Next, go directly to drug treatment. For this, it is recommended to use a 2% aqueous solution of chlorhexidine. It can be purchased at a pharmacy kiosk or you can use a specialized dentistry product such as Ultradent's Consepsis. It is produced in special syringes with disposable tips for applying the substance and has a pleasant taste. This gel is applied for 30-60 seconds.
3. The drug is inflated with a puster along the walls of the carious cavity. You do not need to wash it off;
4. All subsequent procedures for filling the defect are performed (etching with phosphoric acid, applying adhesive, composite material)

In some cases, it is possible to use special etching gels that contain antibacterial substances for drug treatment. This allows you to save time and combine the two stages of carious cavity preparation together.

There is another way to disinfect dentin: a healing material containing calcium hydroxide is applied under a temporary filling for several days. This technique provides high-quality disinfection of the cavity, but it is quite laborious.