The concept of the activity of the carious process according to grapevine. Acute caries - when there is bloom in the mouth, but no smell. Forms of the disease in children and adults

The carious process is a disease that affects dental tissues, characterized by their destruction with the formation of cavities. In the modern world, every person has met him at least once. The disease is widespread due to the unbalanced diet of a large population.

Several indicators are used for epidemiological studies: incidence, caries prevalence and intensity. They compare different regions, with the help of this the quality of treatment and prevention of the disease is determined, and an individual treatment plan is drawn up for the patient.

What are caries statistics?

The prevalence and intensity of caries, its increase are the main statistical indicators of the disease. Prevalence is expressed as a percentage and is found using an algorithm. The number of people with carious lesions of dental tissues is divided by the number of subjects, and the data obtained is multiplied by 100.

The disease index shows the development of the disease individually for each patient. It is determined by the number of affected and already treated teeth. To calculate the index of a group of people, it is necessary to determine individual indices and then find their arithmetic mean.

However, scientists suggest that the figures for the intensity of the disease calculated using the existing algorithm do not correspond to reality. They do not take into account the disease in the early stages of development, therefore they are somewhat underestimated, not reflecting the real intensity of caries.

The increase in incidence is determined individually for each person after a certain period of several years. The increase in dental caries is the difference between the results of the first and second examination.

Reduction of caries - reducing the increase in the intensity of the disease. It is calculated using the following algorithm: the index of increase in the intensity of dental caries in the group where preventive measures were carried out is subtracted from the index of increase in the control group.

Forms of the disease in children and adults

There are several types of disease according to the rate of development:

At the same time, acute caries has many varieties. According to the intensity and degree of destruction of dental tissues in adults and children, the following forms of acute caries are distinguished:

compensated;
subcompensated;
decompensated.

Assessment of caries activity according to the WHO method is complex and should be explained in increasingly clear language. The compensated type of acute caries is characterized by slow development. The patient's dental tissues undergo minor destruction, which does not cause discomfort.

The subcompensated form of caries is characterized by an average flow rate. This form of the disease is more active than the previous one, but sometimes the disease can go unnoticed.

Decompensated is the most dangerous type of acute form of the disease; it is often called blooming or multiple. Dental tissues are destroyed in the shortest possible time; within a month they can completely decompose. Usually several chewing elements are affected at once. The decompensated form of caries is characterized by severe destruction of internal dental tissues.

Estimation of caries prevalence

To ensure an objective assessment of the prevalence of the disease, all cases of the disease, starting from childhood, are taken into account. Current WHO statistics are as follows:

in preschool children, the prevalence is about 86%;
in schoolchildren, the prevalence of dental caries reaches 84%;
in adults it reaches almost 100%.

Disease intensity

To assess the intensity of caries, the KPU index is important - the sum of carious, filled and extracted teeth in one patient. Each letter of the abbreviation corresponds to the status of the chewing element. To evaluate several people, the average KPU index is divided by the number of subjects. Currently it is about 7 USD.

It is difficult to assess the intensity of caries according to the WHO scale, since there are indicators exclusively for people aged 12 and 35-40 years. However, according to a rough estimate, today, both among adults and children, caries prevalence rates reach almost 100%.

Intensity increase

Growth data is calculated individually. WHO recommends assessing the condition of teeth for the intensity of caries in accordance with the following requirements:

3 years – assessment of primary teeth;
6 years – first indigenous;
starting from 12 years – permanent teeth.

In children, the increase in the intensity of caries is determined at intervals of one year. In adults - from five to ten years.

Methodology for determining reduction

Reduction – reducing the increase in the intensity of caries. The method for determining reduction is as follows: a group of people is created who undergo preventive measures (for example, fluoridation of enamel) and a control group.

Then, after some time, the reduction rate is calculated. To determine it, the index of increase in the control group, where the subjects did not change their habits, is subtracted from the index of increase in the intensity of the disease in the group where preventive measures were regularly carried out.

Clinical examination according to the degree of caries activity

Patients under dispensary observation are divided into 4 categories according to the degree of caries activity in order to increase efficiency:

almost healthy;
with a compensated form of caries;
with subcompensated caries;
with decompensated caries.

1 subgroup undergoes a scheduled preventive examination once a year. Subgroup 2 is observed once every six months. Subgroup 3 – once every 3-4 months, 4 – once a month.

With the help of medical examination and dividing patients into groups, the number of molars removed and cases of complications are reduced. This clinical examination technique helps reduce the need for treatment of acute caries by 43.5 percent. Also, with the division according to the degree of disease activity, the number of fillings installed and the amount of work of the dentist decreases.

The decompensated form of caries is, in fact, an intensively developing caries, a pathological process that occurs very actively in the hard tissues of the tooth and leads to their rapid destruction. Often in this form the diseases are multiple and occur in many teeth at once.

In dentistry, there are several classifications of caries. When classified according to the severity of the process, the following forms of the disease are distinguished:

compensated;
subcompensated;
decompensated.

Decompensated (acute, blooming) caries is the most dangerous form, since it develops much faster than in compensated and subcompensated forms.

Acute caries can lead to tooth loss in just a few weeks. In this case, enamel and dentin are destroyed very quickly, and the transition from the initial stage to the deep stage occurs many times faster than in the chronic course of the disease.

On a note

The reasons for the development of pathology in the decompensated form are reduced bactericidal properties of saliva, lack of oral hygiene, unfavorable diet and hereditary factors, and unhealthy lifestyle. Sometimes acute caries develops due to weakened immunity.

Diagnosis of decompensated form of caries

Acute caries is most dangerous when the tooth is not treated. But unlike other forms, it is easily detected. The main symptoms that signal the development of a serious problem are the following:

multiple noticeable external manifestations of caries on the surface of tooth enamel;
acute prolonged pain in the teeth;
strong reaction to cold, chemical, mechanical irritants.

If such sensations occur in the oral cavity, you should immediately contact your dentist.

If the carious lesion on the surface is very small, but the described symptoms are present, you should not postpone a visit to the doctor. Under a small entrance there may be a large carious cavity. An additional clue will be the loss of shine of the enamel, its grayish or chalky tint.

A dentist can easily diagnose a decompensated form of caries based on the following signs:

wide base of carious form;
narrow entrance;
a large amount of softened dentin;
sharp pain during probing.

A probe and a dental mirror are usually sufficient for diagnosis. But if a carious cavity in a separate tooth is hidden from view, an X-ray is taken or transillumination is used (a method of “exposing” it to a bright light flux of lamps). Also, in the decompensated form, fissurotomy is often used (this is a method of diagnostic search for hidden caries using prophylactic excision of “darkened” pits and enamel depressions on the chewing teeth).

Who is at risk

The decompensated form of caries develops the faster, the lower the body's resistance. Therefore, the acute form is most often observed in people with weakened immune systems.

There are several groups of patients who are most at risk of developing this pathology:

children with baby teeth;
people who have recently had infectious diseases;
people with metabolic disorders;
elderly people with weakened immune systems.

To avoid the development of acute caries, it is recommended to undergo routine sanitation of the oral cavity 1-3 times a year.

The danger of decompensated form

Acute caries is dangerous for many reasons. The advanced form of the disease often leads to the following problems:

development of pulpitis and periodontitis;
development of periodontitis;
tooth splitting;
tooth loss.

In addition, the decompensated form is a signal of a disruption in the functioning of the entire organism. is often a consequence of a decrease in saliva production and a decrease in its bactericidal properties, which affects the general condition of the oral cavity as a whole. In pregnant women, this can affect the general physical condition of the expectant mother and the health of the fetus.

Types of disease

Acute caries has two forms:

medium spicy;
deep spicy.

The difference between medium and deep acute forms lies in the size of the carious cavity. With moderate acute caries, there is no need to remove the nerve, and the tooth can be treated and restored. In case of deep acute caries, depulpation is usually required, and in case of severe tooth decay it is necessary to remove it.

Since in the acute form of the pathology the destruction of tooth tissue occurs very quickly, and children are most susceptible to the disease, in pediatric dentistry the following grouping is accepted:

Compensated form (I group);
Subcompensated (group II);
Decompensated (group III).

Groups have been created to carry out clinical observation.

Pediatric dentist T. F. Vinogradova identified several dispensary groups:

practically healthy teeth;
compensated form;
subcompensated form;
decompensated form.

Children with a compensated form are examined once a year, with a subcompensated form - 2 times, with a decompensated form - 3 times. Planned sanitation reduces the risk of complications in the development of caries, the number of fillings and extracted teeth decreases. The need for treatment is also reduced by almost half, and the number of annual scheduled examinations is reduced.

Monitoring risk groups allows you to keep records based on a number of criteria:

general prevalence of caries;
anamnesis of life;
health status;
severity of the disease.

Planned and timely sanitation in adults and children makes it possible not only to cure it in the initial stages, but also to prevent the development of blooming caries.

How is blooming caries treated?

Treatment of decompensated forms of caries can be divided into three stages:

removal of all tooth tissue affected by caries;
removal of the nerve (if necessary);
tooth restoration.

Since blooming caries causes severe pain, all stages of treatment are carried out under local anesthesia or general anesthesia (less frequently). This means that the procedures are painless for the patient. Modern anesthetics are absolutely safe and hypoallergenic, so this treatment is available even for pregnant women.

Removal of affected tissue is mainly carried out using a drill. But this is not the only possibility. There are also more modern methods: washing out with dental sandblasting, evaporation with a dental laser. Unfortunately, these modern methods do not yet have a good evidence base for their effectiveness for the treatment of serious carious lesions, and are not widely used in our country.

At the next stage of treatment (if necessary), the dental nerve is removed using special equipment. Then the dental canals are cleaned and filled.

Restoration is the last stage of treatment. Using filling materials, the dentist restores the original shape of the tooth.

Treatment of acute caries is a complex and lengthy process. Most often it takes place in two visits. During the first, the affected tissue is removed and medicinal treatment is carried out. During the second visit, the tooth is restored.

Prevention of decompensated form of the disease

Everyone can prevent the development of acute caries. Even with a hereditary predisposition, dental problems arise due to poor oral hygiene and poor nutrition.

Prevention of the decompensated form of the disease is quite simple. To carry it out you need:

brush your teeth morning and evening;
use toothpaste with fluoride;
clean interdental spaces with dental floss;
do not consume too cold or hot food or drinks;
limit the amount of soft and sweet foods, since after eating them, plaque forms on the teeth, which contributes to the demineralization of the enamel;
Visit the dentist 1-3 times a year.

Planned sanitation of the oral cavity makes it possible to identify caries at the earliest stages and prevent it from developing into an acute form. Regular visits to the doctor allow you to timely detect weaknesses in the care of your teeth and gums, make adjustments and stop their diseases. Therefore, visiting a dental clinic to check the condition of your teeth should become a rule for everyone who cares about their health.

Section 7Dental caries

Dental caries is a disease expressed in the destruction and demineralization of hard dental tissues and occurs with the participation of microorganisms.

Caries affects almost the entire population of the planet, which determines not only its clinical, but also social significance. In Russia, the prevalence of carious lesions at the age of 17 years is, depending on the region, from 80 to 100%. According to an epidemiological survey from 1985, low prevalence is noted in Tambov and Tver, average in Moscow, St. Petersburg and Yekaterinburg, high in Khabarovsk and Arkhangelsk. Other epidemiological studies have found significant declines in the prevalence of dental caries in industrialized countries.

The International Classification of Diseases identifies several forms of caries: K. 02. Dental caries:

K. 02.0. Enamel caries. Stage of "chalk spot" (initial caries);

K. 02.1. Dentin caries;

K. 02.2. Cement caries;

K. 02.3. Suspended caries;

K. 02.4. Odontoclasia: childhood melanodentia, melanodontoclasia;

K. 02.8. Other dental caries;

K. 02.9. Dental caries, unspecified.

The following classification of caries has been adopted in Russia:

by depth of lesion: caries in the spot stage (chalky, pigmented), superficial, medium, deep;

with the flow: fast-flowing, chronic, stable.

The classification of dental caries in children is widely known. by degree of activity process proposed by T.F. Vinogradova (1972):

I - compensated form;

II - subcompensated form;

III - decompensated form.

The leading etiological factor is the microflora of the oral cavity, in particular Streptococus mutans (Keyers D.; Fitzgerder). Currently, several species of Streptococus mutans are recognized (Coykehdall, 1989). This group of bacteria has a variety of phenotypic characteristics, in particular acid tolerance and the ability to produce acid (Jason M., 1995).

It must be remembered that in acute and subacute forms of caries the cavity is dominated by streptococcal and staphylococcal flora, in chronic forms it is often mixed, with the possible presence of anaerobes. Depending on the depth of the carious cavity, the species composition of the microflora may change. At the initial and middle stages of the carious process, microorganisms are found that have acid-forming (streptococci, lactobacilli actinomycetes) and proteolytic (peptostreptococci, bacteroides) properties. As the process progresses, the flora becomes more diverse. Streptococci are found in deep carious cavities in association with fusobacteria and spirochetes.

In addition, dental plaque contains Streptococus sanguis and Streptococus salivarius, which are characterized by anaerobic fermentation. In this process, the substrate for bacteria is mainly carbohydrates, and for certain strains of bacteria - amino acids. The leading role in the occurrence of caries is played by sucrose. It is this that causes the fastest decrease in pH (pH) from 6 to 4 in a few minutes. The process of glycolysis occurs especially intensively during hyposalivation, xerostomia and during sleep. The activity of the fermentation process depends on the amount of carbohydrates involved. Thus, taking 10 grams of sugar leads to an increase in lactic acid in saliva by 10-16 times (Leontyev V.K., 1978). Studies have shown that at a pH of less than 6.2, saliva goes from being oversaturated with hydroxyapatite to undersaturated, hence changing from a mineralizing to a demineralizing fluid. A local change in pH under dental plaque is possible to a critical level of 4.5. It is this level of pH that leads to the dissolution of the hydroxyapatite crystal in the least stable areas of the enamel; acids penetrate into the subsurface layer of enamel and cause its demineralization. The microspaces between the crystals increase, which leads to an increase and increased permeability of the tooth enamel. As a result, ideal conditions are created for the penetration of microorganisms into the interprismatic spaces, that is, a cone-shaped lesion is formed inside the enamel.

The process of demineralization of enamel does not always end with the formation of superficial caries, since parallel to demineralization there is a process of remineralization or restoration of tooth enamel due to the constant supply of mineral components from oral fluid. When the processes of de- and remineralization are in balance, caries does not occur in the tooth enamel. If the balance is disturbed, when demineralization processes predominate, caries occurs in the white spot stage; the process may not stop there, but serve as the starting point for the formation of carious cavities of varying depths.

It should be noted that the action of general factors is carried out, as a rule, through the action of local ones, that is, diet, the state of organs and systems, extreme situations can change the composition and properties of oral fluid, and influence the microflora of dental plaque.

It is necessary to highlight the etiopathogenetic factors that determine the occurrence of a cariogenic situation:

- are common:

hereditary inferiority that determines the usefulness of the structure and chemical composition of tooth tissues; somatic diseases;

malnutrition (deficiency of proteins, vitamins); mineral composition of water (lack of macro- and microelements);

low social level; extreme exposures (radiation pollution, emotional stress); low level of dental prevention;

- local:

activity of oral microflora;

low level of oral hygiene;

excess carbohydrates in food;

the number of organic structures in the enamel (lamellae,

spindles);

complex shape of fissures;

properties of oral fluid:

Decreased remineralizing potential;

Buffer capacity;

Nonspecific and specific protective factors. Scheme of the occurrence of carious lesions: low level of oral hygiene + frequent consumption of carbohydrates → increase in dental plaque → increase in the number of bacteria Streptococus mutans, Streptococus sanguis, synthesis of lactobacilli + conversion of carbohydrates into polysaccharides → formation of dental plaque → formation of organic acids → change in pH under dental plaque to 5.0-4 .5 + decrease in the buffer capacity of the oral fluid → dissolution of the tooth pellicle → demineralization of the enamel along the lines of Retzius → penetration of acids into the subsurface layer of enamel → increase in microspaces between the crystals of enamel prisms → the source of acid formation (microorganisms) is transferred inside the enamel itself → formation of a carious cavity.

In children, the rapid development of the pathological process is due to the structure of the hard tissues of the tooth and the reactivity of the child’s body. The enamel of the tooth immediately after its eruption is not sufficiently mineralized. It initially matures in the area of the cutting edges and tubercles of all teeth, so the carious process occurs precisely in the immature enamel of the fissures and cervical region, which are risk areas.

Rapid maturation of tooth enamel occurs in the area of the cutting edges and tubercles within 4-6 months after their eruption. Its intensity is especially high in the first days and weeks after tooth eruption. The enamel of the cutting edges of incisors and fangs matures 2 times faster than in the cervical area. The rate of maturation of the enamel of the fissures of teeth is slower and largely depends on the degree of washing the teeth with saliva and covering the fissures with plaque. In all cases, the complete maturation of fissures of premolars and molars varies up to 2 years.

Of the various groups of teeth, molars are the most susceptible to caries, apparently due to their deep fissures and dorsal position in the oral cavity, where favorable conditions are created for retaining food debris. Particularly susceptible to caries are the first permanent molars and the cervical part of the primary incisors, the mineralization of which begins from the first days of a child’s life. The newborn adapts to new living conditions; its metabolic processes are very labile and easily disrupted. In the first months, the child loses passive immunity and often gets sick. All this probably reduces the resistance of tooth enamel to caries. The anterior teeth of the lower jaw are relatively immune to caries due to their constant washing with saliva.

Caries of baby teeth begins in children from 1.5-2 years of age, and permanent teeth - from 6-7 years, that is, soon after eruption. Caries in primary occlusion mostly affects symmetrical teeth on the right and left. The same trend, but to a lesser extent, is observed in the permanent dentition.

In children, the cervical area is affected by circular caries of milk and, less commonly, permanent teeth. Chalk stains in this area also appear on permanent teeth. The contact surface is a favorite for caries of primary teeth in children over four years of age; this surface is especially often affected in the first temporary molars. The chewing surface is most often affected in second primary and all permanent molars. Damage to the vestibular surface of primary teeth is observed in children under two years of age with intense caries. The lingual surface of the teeth is affected very rarely, with an atypical course of caries (for example, in children with diseases of the central nervous system).

The number of teeth affected by caries and the number of carious cavities, their localization revealed during the examination, the increase in the intensity of caries are considered as symptoms of caries, which make it possible to determine on their basis the degree of activity of the pathological process.

Compensated form of caries characterized by a small number of teeth affected by caries; the number of carious cavities practically does not exceed the number of affected teeth. Carious cavities in children with the first degree of caries activity are located in the “typical” areas of the tooth, have a small entrance hole, are pigmented, their edges are smoothed, the pathological dentin is dry and dense when probing. After mechanical treatment of the cavity, the bottom and walls, although pigmented, are dense. The pigmented fissure often cannot even be opened. There are no chalk spots. On the radiograph, destructive processes in untreated teeth have pronounced signs of limiting the pathological process. The hygiene index is low even in children who do not regularly take care of their oral cavity. Teeth are clean and shiny.

Decompensated form characterized by high activity of the pathological process: along with damage to a large number of teeth, severe destruction of each tooth is observed, and the rate of increase in the intensity of caries is high.

A carious cavity in children with the third degree of activity will have sharp edges, an abundance of soft and light dentin, the walls of the cavity will remain pliable even after mechanical treatment, and after opening the pigmented fissures, carious cavities are found. When examining old fillings, one can often detect their defects and relapses of caries.

Subcompensated form caries occupies a middle position in terms of the main clinical indicators characterizing the pathology under consideration.

According to the flow, caries is classified into slow-moving, fast-moving and stabilized caries. The slow progression of caries in children is observed relatively rarely: carious dentin is brown, dry, and difficult to remove with an excavator. The dense dentin at the bottom of the carious cavity is also pigmented. In preschoolers and schoolchildren, there is an intermediate course, when both decalcification and pigmentation of carious tissues are moderately expressed.

Features of the clinical course of caries in children are its circular and planar forms. Circular caries characterized by localization of the pathological process in the area of the tooth neck. This form of caries most often affects baby teeth, but also occurs in children on permanent teeth.

The circular form of caries occurs in infants and young children predisposed to caries in the cervical region of the incisors (usually the upper ones), less often - the canines. Soon after eruption, carious cavities form, spreading circularly along the neck of the tooth, which by the age of 2-3 years of a child’s life can lead to the breaking off of the crowns. The occurrence of circular caries is explained by the fact that areas of enamel formed in the antenatal period are more resistant to demineralization compared to the enamel of the cervical area of milk teeth, which is formed after birth even in full-term children.

Circular caries is characterized by rapid spread of the process towards the pulp, but acute pulpitis is rare. Cases of pulp exposure during crown fracture have been observed. More often, children present with symptoms of exacerbation of chronic periodontitis. The death of the pulp and the development of chronic periodontitis are asymptomatic.

T.F. Vinogradova (1978) explains the absence of a protective inflammatory reaction by reduced body resistance. She also describes cases when, in case of circular caries, the root pulp is isolated from the coronal pulp due to replacement dentin. The root pulp continues to exist, keeping the periodontium intact, while the crown of the tooth is missing.

The entrance to the root canal is walled with dense pigmented dentin. Such roots with living pulp continue to serve the child for a long time. Taking this into account, T.F. believes Vinogradov, during examination of the oral cavity, care should be taken when probing teeth affected by circular caries.

Another feature of the clinical course of caries in children is its flat shape, when tissue demineralization spreads faster along the surface of the tooth than in depth. In this case, the bottom of the components of the carious cavity is pronounced, and its walls are either absent or very small. This form of caries affects the chewing surfaces of primary molars and the vestibular and contact surfaces of incisors and canines.

As stated above, caries is divided depending on from the depth of the lesion and in my own way flow.

Caries in the spot stage. The patient complains of an aesthetic defect and increased sensitivity from chemical and thermal irritants. With this form of caries, there is a chalky stain on the surface of the tooth enamel. In this case, there is no defect in the hard tissues of the tooth. Pigmented brown spots characterize the stage of stabilization of the carious process. Pigmented spots are asymptomatic. Apart from an aesthetic defect, patients do not present any complaints.

The data of R.G. is of interest. Sinitsina (1970), explaining the cause of pigmentation of the carious cavity. He established the possibility of accumulation of tyrosine in enamel and dentin and its transformation into the pigment - melanin. This process occurs with the outer layer of enamel apparently intact, although it is noted that in the center of the spot there is a decrease in microhardness and an increase in permeability, in particular, for radioactive calcium.

Caries in the spot stage is observed in children of any age. In young children, the upper incisors are first affected, later - the first molars, canines and other teeth. In permanent teeth, chalk spots are detected mainly in the cervical region of the incisors, first permanent molars, and in children 12-15 years old - in the area of the necks of the canines, premolars, and less often - second molars.

Pigmented carious spots are observed in children much less often than chalk spots and are typical only for the anterior surfaces of the first permanent molars. This surface becomes accessible for inspection after the removal or loss of second primary molars. It is necessary to use the time before the eruption of the second premolars to identify the initial caries of this localization and carry out the necessary therapeutic measures.

Superficial caries. It is characterized by the occurrence of short-term pain from chemical irritants (sweet, salty, sour). It is also possible that short-term pain may appear from exposure to temperature stimuli, more often when the defect is localized at the neck of the tooth, in the area with the thinnest layer of enamel, as well as when brushing the teeth with a hard brush.

When examining a tooth at the affected area, a shallow defect within the enamel is discovered. It is determined by probing the tooth surface by the presence of enamel roughness. Often, roughness is detected in the center of a large white or pigmented spot. When a carious cavity is localized on the contact surface of a tooth, food gets stuck and inflammation of the interdental papilla occurs - swelling, hyperemia, bleeding when touched.

Significant difficulties arise when diagnosing superficial caries in the area of natural fissures. In such cases, dynamic observation is allowed - repeated examinations after 3-6 months. Transillumination always reveals an enamel defect, even a “hidden” one. Against the background of the bright glow of intact tooth tissues, a shadow corresponding to the enamel defect is clearly visible. Electrical odontometry does not reveal any deviations from the norm (normal value is 2-6 µA). A defect localized on the contact surface of the tooth is determined radiographically.

Average caries. With it, patients may not complain, but sometimes pain occurs from exposure to mechanical, chemical, temperature irritants, which quickly disappear after the irritating agent is eliminated.

With this form of carious process, the integrity of the enamel-dentin junction is disrupted, but a fairly thick layer of unchanged dentin remains above the tooth cavity. Upon examination tooth They discover a carious cavity of medium depth, filled with pigmented softened dentin, which is determined by probing. If there is softened dentin in the fissure, the probe lingers and gets stuck in it. In case of chronic caries, probing reveals a dense bottom and walls of the cavity, a wide entrance hole. In the acute form of medium caries, there is an abundance of softened dentin on the walls and bottom of the cavity, undermined, sharp and fragile edges.

Probing is painful at the enamel-dentin junction. The tooth pulp reacts to a current strength of 2-6 µA.

Medium caries is the most commonly clinically observed form of caries in children. It should be differentiated from deep, as well as complicated forms of caries (chronic forms of pulpitis and periodontitis). If, during probing and preparation, sensitivity is determined along the enamel-dentin border, and the bottom of the carious cavity is dense and painless, then the diagnosis of “moderate caries” can be confidently made.

Deep caries. Patients complain of short-term pain from mechanical, chemical and temperature stimuli, which quickly passes after the stimulus is eliminated.

When examining the tooth, a deep carious cavity is discovered with overhanging edges of the enamel, filled with softened and pigmented dentin. Probing the bottom of the cavity is painful. The dental pulp responds to a normal current strength of 2-6 μA, but there may be a decrease in excitability to 10-12 μA.

Pain occurs from chemical and temperature irritants, but, as a rule, quickly calms down after the cessation of the irritants. If the carious cavity is located in such a way that it is difficult to remove and wash out food debris, the tooth may hurt for a longer time until these irritants are removed. Percussion of the tooth is painless.

The carious process can be divided into chronic And fast-flowing. When diagnosing fast-flowing caries, we are guided by the following clinical criteria: there are 5-6 carious cavities at the same stage of development; cervical cavities, crater-shaped, affecting immune zones; fragility and chalky color of the enamel edges are noted; pain associated with the absence of zones of transparent and replacement dentin. And yet, as a rule, the course of caries is chronic.

Clinical diagnosis "deep caries" as practice shows, it is justified for permanent teeth. In relation to primary teeth, this diagnosis should be made with caution, mainly in older preschool children and with a slow development of the process. During the active course of caries in children aged from one to three years, replacement dentin is practically not formed. The dentin of the bottom of the carious cavity is deeply infected, there are changes in the pulp, characteristic of developing forms of chronic pulpitis or pulp necrosis, even in the complete absence of complaints from the child on the day of visiting the doctor or in the anamnesis.

In addition to the above-mentioned clinical diagnostic methods, the clinic widely uses such instrumental methods as X-ray, determination of the electrical conductivity of solid tissues and the study of the optical properties of tissues with laser radiation, etc. (see section 2).

Caries in the chalk spot stage is differentiated from enamel hypoplasia by vital staining of the affected areas with methylene blue or other dyes. Areas affected by the carious process are stained, but in the case of hypoplasia, staining does not occur.

Superficial caries is differentiated from initial caries. Unlike the initial one, in which a stain is visible, but the integrity of the enamel surface is not compromised, the formation of an enamel defect is typical for superficial caries.

It is also necessary to carry out differential diagnosis with enamel erosion. Unlike superficial caries, enamel erosion has an oval shape, the long diameter of which is located transversely, on the most convex part of the vestibular surface of the crown. The bottom of the erosion is smooth, shiny, dense. The boundaries of the defect are whitish and tend to spread in breadth rather than in depth, as with caries. Erosion is more common in middle-aged people, affecting several teeth at the same time, usually immune to caries. Often the process also affects symmetrical teeth. The history reveals excessive consumption of citrus fruits, juices and fruits, and sour foods.

Superficial caries is differentiated from enamel hypoplasia, in which the tooth surface is smooth, dense, defects are localized at different levels of symmetrical teeth, and not on the surfaces of tooth crowns characteristic of caries.

Erosive form endemic fluorosis, like superficial caries, it is characterized by a defect within the enamel. The differences in defects are obvious. With fluorosis, they are localized, as a rule, on the vestibular surfaces of the front teeth, immune to caries. Erosion, located chaotically against the background of unchanged (spotted) enamel, is distinguished by the strict symmetry of the lesion, which is not combined with caries. Hyperesthesia is not typical for such teeth. Since the erosive form of endemic fluorosis is formed when drinking water with a high fluorine content (more than 3 mg/l), signs of fluorosis are observed in the majority of residents of the region (Ovrutsky G.D., 1986).

Medium caries is differentiated from wedge-shaped defect, localized at the neck of the tooth, having dense smooth walls and a characteristic wedge shape, asymptomatic; With chronic apical periodontitis, which can be as asymptomatic as average caries. In this case, there is no pain when probing along the enamel-dentin border and no reaction to temperature and chemical stimuli. Preparation of a carious cavity with average caries is painful, but with periodontitis it is not, since the pulp is necrotic. The dental pulp with average caries reacts to a current of 2-6 μA, and with periodontitis - only to a current of more than 100 μA. X-ray examination of chronic apical periodontitis reveals a uniform expansion of the periodontal fissure and destructive changes in bone tissue in the area of the projection of the root apex.

Differential diagnosis in case of deep caries is carried out with average caries, which is characterized by a less deep carious cavity located within the dentin itself. The bottom and walls of the cavity are dense, probing is painful along the enamel-dentin junction, while with deep caries the cavity extends into the peripulpal dentin, probing the bottom is painful, temperature stimuli cause quickly passing pain.

Deep caries must be distinguished from acute focal pulpitis, which is characterized by acute spontaneous paroxysmal pain, intensifying in the evening and at night. Probing the bottom of the carious cavity is painful at one point, often in the area of projection of the source of pulp inflammation. With deep caries, probing the bottom of the carious cavity is evenly painful over the entire surface of the peripulpar dentin; there are no spontaneous or paroxysmal pains.

Differential diagnosis should also be carried out with chronic fibrous pulpitis, which is characterized by the presence of a deep carious cavity filled with softened dentin. When probing the bottom of a carious cavity, a connection with the tooth cavity can be detected; probing this area causes severe pain, the pulp bleeds, and there is a decrease in the excitability of the pulp, which begins to respond to a current strength of 25 to 40 μA. With deep caries, probing is painful along the entire bottom; the tooth pulp reacts to a current of 2-12 μA.

For the purpose of differential diagnosis of deep caries with chronic forms of pulpitis and periodontitis in baby teeth softened dentin should be completely removed with an excavator. If the tooth cavity is opened, then it is easy to clarify the diagnosis: the presence of a sensitive or painful red dot on probing at the bottom of the carious cavity indicates asymptomatic chronic fibrous pulpitis.

Necrotic coronal pulp (the connection between the carious cavity and the tooth cavity will be gray and painless upon probing) is a sign of chronic gangrenous pulpitis or chronic periodontitis. If, after removing softened dentin, the bottom is dense, light or slightly pigmented, a diagnosis of “deep caries” can be made. With good contact with the child, it is possible to establish the short-term pain from cold, typical for this form of caries, and pain during probing and preparation in the area of the bottom of the carious cavity.

In small crying children with a deep cavity, sometimes in order to clarify the diagnosis, it is useful to use a therapeutic and diagnostic bandage made from a thickly mixed zinc oxide eugenol paste.

During caries, changes occur in the dental pulp, the severity of which depends on the depth of damage to the hard tissues of the tooth. With caries in the spot stage and superficial caries, no noticeable changes in the pulp are detected. With average caries, reactive and dystrophic changes in the dental pulp take place, which intensify with deep caries.

Caries is a disease known in all corners of the globe, and it is difficult to find a person who would not encounter this problem at least once in his life. The disease affects hard, thinning enamel and penetrates into the deep layers of dentin, creating a carious cavity in them. Most often, damage is visually noticeable, except in cases where only deep layers of tissue are damaged.

Causes of the disease

Dentists identify a lot of theories about the occurrence of carious lesions, but the main ones remain unchanged:

Abuse of excessively salty or sweet foods.
Lack of carbohydrates and vitamins in the diet.
Low content of strengthening fluoride in tooth enamel.
Neglect of oral hygiene.
Infectious diseases.
Genetic predisposition.
Features of the tooth structure, the presence of natural grooves on the enamel surface in which microorganisms that are prone to subsequent decay accumulate.

All of the above factors to some extent affect the acid-base balance of the oral cavity, creating a favorable environment under the tooth enamel for the development of pathogenic bacteria. As a result of the gradual leaching of calcium from dental tissue, the enamel is destroyed and a carious cavity is formed. There are many criteria by which the classification of caries is based, and this is quite justified. An expanded classification based on several parameters allows us to make the most reliable diagnosis, determine the degree of neglect of the process and treatment options for the disease.

Black classification

The most used by dentists is the Black classification of caries. It reflects not only the location of the carious destruction on the surface, but also the depth of the lesion being studied. The designation of the variety of the latter occurs through classes - the higher the class, the more advanced the disease:

WHO/ICD 10 classification

The WHO (World Health Organization) classification of caries is based on identifying a specific affected area and identifies the following points with codes:

The classification of caries is considered the most popular in the practice of modern dentists. It is convenient in that it has clarifications in the form of points dedicated to suspended illness and its other types.

Classification according to the primacy of the disease

Dental practice divides caries according to the frequency of occurrence:

Primary - caries forms on a tooth that has not previously been exposed to disease, the etiology of which is classified through analysis and relationship to one or another category.
Secondary, or relapse, appears on the surface of an organ that has previously been filled. It occurs due to a violation of the seal’s adherence to the tooth tissue, resulting in the formation of a gap in which a favorable environment is created for the development of pathogenic bacteria.

Topographic classification

This is a gradation that distinguishes types of caries according to the degree of damage to the canals. It is as common in determining the diagnosis as the classification of caries according to ICD 10. The following stages of damage are determined:

Classification by intensity

Based on the intensity of infection of the oral cavity, there are 2 types of the disease:

Among patients with multiple caries, there are often people with diseases of the cardiovascular system. If the disease affects a child’s teeth, most likely he has had scarlet fever or tonsillitis. A gentle prevention of multiple caries for a child under three years of age is the silvering of baby teeth.

Classification according to the formation of complications

Untimely visits to the dentist by patients due to dental diseases are quite common. It is not difficult to guess what the consequences of ignoring the problem are. Of course, today there is also a classification of caries according to complications. According to her, it happens:

Complicated. The disease is accompanied by inflammatory processes in the oral cavity. A variety is flux.
Uncomplicated. The classification of caries makes it possible to understand that this is a type of disease that occurs in generally accepted stages, including superficial, medium and deep.

The rate of development of the carious process

The development of the disease occurs in each person with varying intensity depending on external factors and individual characteristics of the body. There are several categories of caries:

Spicy. Signs of the disease appear very quickly - within one to two weeks.
Chronic. The disease develops over a longer period of time and is characterized by the appearance of yellowish or brown spots on the affected enamel surface.
Flowering. Progressive type, in which multiple damage to the enamel is observed in a relatively short time.

Features of the course of the disease in children

Classification of caries in children is carried out according to the same criteria as in adults. In pediatric dentistry, there is also a gradation based on intensity, primaryity of the disease, the presence of complications, etc. The only distinguishing feature is the division into caries of primary and permanent teeth.

Carious lesions of the mammary organs cause no less discomfort than diseases of the permanent ones. In children, caries occurs much more often than in adults, so it is necessary to accustom the child to proper oral hygiene as early as possible and limit the consumption of sweets. Considering that baby teeth are still temporary, treatment tactics may differ slightly from the treatment of a permanent tooth.

Silvering of baby teeth in children

Modern parents, during a preventive visit to the dentist, are faced with the concept of silvering of the child’s teeth. This procedure is carried out to prevent and treat the initial stages of caries. In fact, the process is a “freezing” of the course of the disease.

The procedure is painless, during which the dentist applies a special composition containing silver to the tooth enamel using a cotton swab. A protective film is formed on the teeth, which prevents the settling and development of pathogenic bacteria on the surface of the enamel.

* Up to 9 years of age, the classification of children into groups with different caries activity is influenced by carious primary teeth (CP + CP). With regular treatment of temporary teeth, which prevents the occurrence of complicated forms of caries that affect the formation of the rudiments of permanent teeth, the condition of temporary teeth is not related to the condition of permanent teeth. The formation of primary teeth depends on the antenatal and postnatal development of the child; the formation of permanent teeth is influenced mainly by infancy and beyond.

If children at the age of 9 did not have caries, then by the age of 17, 8.95% of them have healthy teeth, and 76.12% have caries in a compensated form. If 3^4 carious teeth were present at the age of 9, the compensated form of caries persisted in 43% of schoolchildren. If children by the age of 9 already had 5 carious teeth or more (i.e., in addition to the first permanent molars, carious teeth were found cavities in the incisors), then by the age of 17, in 88.89% of children, caries passed into a decompensated form.

As a result of many years of research devoted to the study of the clinical development of dental caries in children, depending on the degree of activity of the pathological process, the team of the Department of Pediatric Dentistry TsOLIUV and the staff of the basic 26th children's dental clinic in Moscow obtained convincing data that allows us to recommend the following classification of caries for practical use:

CLASSIFICATION OF DENTAL CARIES IN CHILDREN

1. Classification of dental caries according to the degree of activity diseases:

Compensated form (groups I and I A),

Subcompensated form, I

Decompensated form, III

II. Classification of carious tooth lesions

1. By localization:

Fissure,

Approximal,

Cervical (caries of the buccal, labial, lingual surface, caries of combined localization).

2. According to the depth of damage to tooth tissue:

Elementary,

Surface,

Average,

Deep.

3. By sequence of occurrence:

Primary,

Secondary or recurrent.

4. According to pathomorphological changes [Panikorovsky V.V., 1966]:

Caries in the spot stage (white spot, gray spot, light brown spot, brown spot, black and brown spot),

Enamel caries (superficial caries),

Average caries,

Medium deep caries (corresponds to the clinic of deep caries),

Deep perforated caries (corresponds to pulpitis and periodontitis).

The practical use of this classification provides for the following: during the initial visit to the child, the doctor, knowing the average intensity of caries in children of the region in which he works, begins to study the condition of the dental tissues and records the number of carious (not treated and those subject to removal) temporary and permanent teeth, the number of teeth filled (regardless of the diagnosis), the number of permanent teeth removed and, summing up these indications, determines the CP, CP + CP, or CP for this child. Each tooth, regardless of the number of fillings or the number of carious cavities, is registered once in the KPU index. The number of fillings and cavities is recorded separately. Then the surface of the teeth is lubricated with Lugol’s solution and the hygienic index is calculated (Fig. 62). After thoroughly removing stained plaque from all surfaces of the tooth using silk thread or schlossers, each tooth is dried and inspected, visually determining the presence of chalky, pigmented spots and hidden carious cavities. Detected chalk spots are recorded and counted. Then the surface of the chalk stains is stained with a 2% solution of methylene blue and, after rinsing the mouth, the stains that have fixed the dye are determined (Fig. 63).

Based on the totality of the research results: KPU; KPU + kp; kp; Based on the hygienic index, the presence or absence of chalk stains, especially stains that actively absorb aniline dye, a diagnosis of dental caries and the degree of its activity or compensation for a given period of a child’s life are established.

63. Focal demineralization.

This diagnosis is placed on the title page of the medical history or treatment card.

When starting to sanitize the oral cavity, the doctor, bearing in mind the degree of caries activity, examines in detail each carious cavity, tooth fissure, chalk stain, etc. It is important to remember that a carious cavity in children with the third degree of activity will have sharp edges , an abundance of soft and light dentin, the walls of the cavity, even after treatment, will remain pliable, dry poorly, and the pigmented fissures will be very treacherous - after their opening, a carious cavity is revealed, the chalk spots will be rough, and when treated with a bur, they will simply crumble (Fig. 64) . When examining previously placed fillings, it is often possible to detect their defects and relapses of caries. Pulpitis and periodontitis often develop as primarily chronic processes with slightly painful symptoms. On an x-ray of previously treated teeth, you can see a progressive pathological process in the periodontium, spreading to the rudiments of permanent teeth, etc.

At the same time, in a child with degree I of caries activity, the carious cavities are pigmented, their edges are smoothed, the pathological dentin is dry and dense when probing. After treatment of the cavity, the bottom and walls, although pigmented, are dense and painful when probed. The pigmented fissure often cannot even be opened. There are no chalk spots. The hygiene index is low, even in children who do not regularly take care of their oral cavity. Teeth are clean and shiny. But pulpitis in children with stage I caries activity is almost always acute, painful with all the classic symptoms. On the radiograph, previously treated teeth have foci of hypercalcification around the root apices, destructive processes in untreated teeth have pronounced signs of limiting the pathological process, etc. (Fig. 65, 66).

Using the proposed classification of caries to write a diagnosis on the title page of a medical history or health card confirms the presence of caries and the degree of its compensation, reveals the features of the manifestation of all clinical symptoms of the disease and determines differentiated treatment tactics.