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Transcript
Caries of teeth Caries of teeth is a pathological process, which appears after eruption of teeth, characterized by demineralization and softening of hard tissues of teeth with subsequent formation of defect (cavitation). Caries of teeth is the key problem of dentistry, very interesting in theoretical and exceptionally important in a practical relation. In obedience to the nomenclature of WOHP for the estimation of staggered of teeth use three basic indexes a caries: 1. Prevalence of disease. It is an index, by the percent of persons, which have the carious, stopped and remote teeth in that or other settlement, district, city, area which is determined. 2. Intensity of defeat of teeth is determined a caries on the number of the teeth staggered a caries. For this purpose the committee of experts of WOHP for dentistry (1962) was offered for adults to use the index of CSR (C is a carious tooth, S - stopped, R – a tooth is remote); for children with a temporal or suckling bite - cs (c – carious, s – stopped); for children with a variable bite – CSR+cs. To facilitate the comparative estimation of morbidity a caries on the different contingents of the world, WOHP in 1980 year suggested to select 5 degrees of staggered depending on CSR for children 12 years: 1) very low – from 0 to 1,1; 2) low – 1,2 – 2,6; 3) moderate – 2,7-4,4; 4) high – 4,5-6,5; 5) ever-higher – 6,6 and higher. For the receipt of reliable information at determination of prevalence and intensity of decay of teeth the groups of population must look around taking into account age and floor, climatic geographical and socio-economic terms. Usually children inspect in age 5-6, 12 years, 15 years, adults 35-44 and 65 years. The groups of ages of most models of population is 12- and 15- of children of summers. 3. Increase of intensity or morbidity. Determined for the same person or contingent through a certain term (1, 3, 5, 10 years). Difference in the value of index between the first and second reviews and makes the increase of intensity of caries. By an epidemiology dental inspection it is possible to define prevalence and intensity of basic dental diseases, quality of sanation of cavity of mouth, efficiency of prophylaxis of caries of teeth and illnesses of paradontium, level of the hygienical state of cavity of mouth, and also find out the necessity of every caries of teeth, illnesses of paradontium and mucous cavity of mouth inspected in treatment. Such inspection allows to work out an individual plan of medical and prophylactic measures for every patient. Statistical indexes of caries Pursuant to the nomenclature of WOHP for the estimation of staggered of teeth by a caries use three basic indexes: prevalence, intensity and increase of intensity of caries. Prevalence of caries is correlation amounts of persons (in percents), which have the stopped and remote teeth carious, to the common amount of inspected. Prevalence of caries in different age-old periods is different. The carious defeats are diagnosed at children in age from 1-1,5 year. Under age 7-9 years prevalence of caries grows to 95-100%, at children 11-12 years goes down to 70-80% as a result of physiology change of teeth and forming of permanent bite. Beginning from 13-14, years prevalence of caries grows again. Intensity of caries (index of caries) is the amount of the carious stopped and remote teeth in one inspected. At children with a temporal bite the index of caries is marked as "cs" (carious, stopped), because remote temporal teeth are not subject to the account. At children with a variable bite the index of caries is marked as CSE + cs (the staggered is taken into account by caries the both temporal and second teeth). At children with a permanent bite the index of caries is reflected as CSE (carious, stopped, extracted). The indexes of intensity of caries at children vary in connection with influencing of far of both external and internal factors. That is why WOHP suggested take into account intensity of caries in 12-years-old children as basis for the estimation of the state of hard tissues of teeth. At these children intensities of caries select five levels: 1) very low (0-1,1); 2) low (1,2-2,6); 3) middle (2,7-4,4); 4) high (4,5-6,5); 5) ever – higher (6,6 and higher). As index of intensity of caries next to the index of caries which takes into account the staggered and remote teeth, an index which takes into account the amount of the surfaces of teeth staggered by a caries is used — CSs. For determination of this index the amount of staggered is counted up by a caries or the sealed surfaces of teeth. This index more precisely represents the dynamics of carious process, that it is especially important at determination of efficiency of prophylactic measures. For an estimation exactly of these processes (loud speakers of development of caries and efficiency of his prophylaxis) the index of increase of intensity – caries is used. For this purpose determine intensity of caries (after the index of teeth decay or after the index of caries of surfaces) at the same person or contingent through a certain period (1-3-5 years). A difference in the value of index between the second and first inspections makes the increase of intensity of caries. Theories of origin of caries of teeth 1. Miller’s chemically - parasite theory of caries (1884.). At one time this theory was progressive, had confession and wide enough distribution. In our time this theory of caries was fixed in basis of modern conception of pathogeny of caries. In obedience to this theory, carious destruction takes place two stages: a) demineralization of hard tissues of tooth. Suckling acid which appears in the cavity of mouth, as a result of milk sour fermentation of tailings of carbohydrates of meal dissolves the inorganic matters of enamel and dentine; b) there is destruction of organic matter of dentine by the proteolytic enzymes of microorganisms. Together with such factors, as microorganisms and acids, Miller acknowledged existence of factors of contributory infringements. He specified the role of amount and quality of saliva, factor of feed, drinkingwater, underlined the value of the inherited factor and terms of forming of enamel. 2. Entin’s physical and chemical theory of caries (1928). Entin pulled out the theory of caries on the basis of research of physical and chemical properties of saliva and tooth. He considered that tissues of tooth were semi penetrate membrane, which osmotic currents, conditioned the difference of osmotic pressure of two environments which contact with a tooth, pass through: blood from within and saliva outwardly. According to his opinion, at favourable terms osmotic currents have centrifugal direction and provides the normal terms of feed of dentine and enamel, and also hinder operating on the enamel of external unfavorable factors. In same queue centripetal motion of matters, that from the surface of tooth to pulp, considered pathological and little direct connection with the diseases of the nervous and endocrine systems, heredity, violation of mineral exchange, terms of feed, way of life, labor, physiology mutual relations which result in violation, in the system pulp – tooth – saliva. At unfavorable terms centrifugal direction of osmotic currents relaxes and acquires centripetal direction which violates the feed of enamel and facilitates operating on her of harmful external agents (microorganisms), causing a caries. Negative sides of Entin’s theory: did not know that at centripetal motion of matters in an enamel took place feed of enamel by mineral salts from saliva, and the method of exogenous prophylaxis of caries is thereon founded – on the surface of enamel with the purpose of to fill up stocked coverage of teeth by fluorine varnish , causing of remineralization matters (appliques) them in an enamel – remtherapy; and also method of treatment of caries in the stage of spot: appliques are on the staggered area of enamel of remineralization matters. 3. Lukomskij’s biological theory of caries (1948). The author of this theory considered that such endogenous factors, as a lack of vitamins D, B, and also failing and wrong correlation of salts of calcium, phosphorus, fluorine in a meal, absence or lack of ultraviolet rays violate mineral and albumen exchanges. Investigation of it is a disease ofodontoblast, which at first weaken and become inferior then. A size and amount of odontoblasts diminishes that results in a metabolic disturbance in an enamel and dentine. Demineralization comes at first then there is a change of composition of organic matters. Negative sides of this theory: there are not proofs, that odontoblasts is the trophic centers of tooth; a theory does not explain the role of sugar in development of caries, localization of carious defeats and prophylactic action of fluorine; it is not proved that odontoblasts inferior at a caries. Even in a healthy contact tooth it is possible to meet degeneration of odontoblasts as their atrophy. 4. Sharpenak’s theory (1949). Sharpenak explained reason of origin of caries of tooth local impoverishments of enamel by squirrel as a result of their speed-up disintegration and deceleration of resinthesis that certainly results in the origin of caries in the stage of white spot. Deceleration of resinthesis is conditioned absence or low maintenance of such amino acid and reason of strengthening of proteolysis is a high temperature of surrounding air, hyperthyreosis, nervous excitation, pregnancy, tuberculosis, pneumonia, accumulation of acids in tissues of organism (in particular, at the insufficient entering organism of vitamins of group B, plenty of acid accumulates in tissues) which results in strengthening of disintegration of albumen. Cariogenic action of carbohydrates of Sharpenak explains that at their large mastering the necessity of organism rises in the vitamin of B1, which can cause avitaminosis and strengthening of proteolysis in the hard substances of tooth. Negative sides of theory: it was not confirmed experimentally, that at caries in the stage of spot begins proteolysis albumens; an author underestimated the role of microorganisms, local cariogenic factors, and over-estimated the role of general factors. 5. Shatts’s and Martin’s proteolysis theory of caries (1956). Authors explained perception of enamel to the defeat a caries stability of calcium albumens complexes. An enamel of tooth is the not negative structure of organism, which through functional features mineralized more than other tissues. Thus mineral and organic components of enamel are in close biochemical connection. Firmness of the last can be broken at penetration in the enamel of different active chemical agents, in particular proteolysis. Development of carious process is examined in 2 stages: a) proteolysis, at which a break of connections is between squirrel and minerals of enamel as a result of operating of bacterial proteolysis enzymes on albuminous components; b) when destruction of mineral part of hard tissues of tooth is from formation of complex connections of ions of metals with acid ion of acids, salts of organic acids, amino acid, squirrel and intermediate products of disintegration. Negative sides of theory: presently there are not proofs of the first phase of carious process for Shatts - Martin. 6. Platonov’s trophic nervous theory The author of this theory examined the caries of teeth as trophic nervous process, which, according to his opinion, develops only then, when the feed of hard tissues of tooth is violated. By the basic Platonov’s pathogenic factor counted violation of the nervous adjusting of trophic of dental tissues. However today known it is that teeth with remote mash in time to 17 continue normally to function. Delete of mash however much one of methods of treatment the complicated forms of caries does not cause structural and functional changes in the enamel of tooth, last continues to function as a valuable organ. The permanent dynamic co-operating with a mouth liquid provides hard tissues of devitalized tooth high mineralization which is answered by large acid proofness and structural homogeneity. The confessedly mechanism of origin of caries is making progress demineralization of hard tissues of teeth under the action of organic acids formation of which is related to activity of microorganisms. In the origin of carious process take part great number of etiologic factors, that allows to consider caries a proteolysis disease. Basic etiologic factors is: 1) microflora of cavity of mouth; 2) character and diet, maintenance of fluorine in water; 3) amount and quality of saliva selection; 4) common state of organism; 5) the extreme operating is on an organism. All above-stated factors were adopted cariogenic and subdivided into general and local, such which act important part in the origin of caries. General factors: 1) Inferior diet and drinking-water; 2) Somatic diseases, change in the functional state of organs and systems, are in the period of forming and ripening of tissues of tooth. 3) The extreme operating is on an organism; 4) Heredity, stipulating the full value of structure and chemical composition of tissues of tooth. Unfavorable genetic code. Local factors: 1) Dental name-plate and dental deposit which is insulated microorganisms; 2) Violation of composition and properties of mouth liquid; 3) Hydrocarbons are sticky food tailings of cavity of mouth; 4) Resistance of dental tissues, conditioned a valuable structure and chemical composition of hard tissues of tooth; 5) Rejection in biochemical composition of hard tissues of tooth and inferior structure of tissues of tooth; 6) State of pulp of tooth; 7) The state of the tooth – jaw system is in the period of book-mark, development and eruption of the second teeth. At influence of cariogenic factors there are processes of demineralization in the enamel of teeth, as a result a carious defeat the first stage of which is a hearth of subsuperficialdemineralization develops is a «white spot» in an enamel. Pathogeny As a result of the frequent use of carbohydrates and insufficient care of cavity of mouth cariogenic microorganisms are densely fixed on pellicle, forming a dental deposit. At the use of sticky meal tailings of her harden in the retention points of teeth (fissures, pits, contact surfaces, stopping, prosthetic appliances) and added fermentation and rotting. On formation of dental deposit influence: 1) an anatomic structure of tooth and interrelation of him is with surrounding tissues; 2) structure of surface of tooth; 3) food ration and intensity of mastication; 4) saliva and gingival liquid; 5) hygiene of cavity of mouth; 6) a presence of stopping and prosthetic appliances is in the cavity of mouth; 7) tooth – jaw anomalies. A soft dental deposit has a porous structure which provides penetration inward of his saliva of liquid components of meal. This soft amorphous matter, densely adjoining to the surface of tooth. An accumulation in the deposit of the finished goods of vital functions of microorganisms and mineral salts slows this diffusion, as porosity disappears. And this already new matter is a dental name-plate, deleting which is possible only violent, but also that is not fully. Under a dental name-plate there is an accumulation of organic acids – milk, ant, oily and other. The last are the products of fermentation sugar most bacteria in the process of their growth. Exactly a basic role belongs to these acids in appearance on the limited area of enamel of demineralized area. Neutralization of these acids does not take place, as there is limitation of diffusion both in a dental deposit and from him. There are streptococci in a dental deposit in particular Str. mutans, Str. sanguis, Str. salivarius, which characteristic anaerobic fermentation is for. In this process substance for bacteria mainly are carbohydrates, and for the separate cultures of bacteria – amino acid. Leading role in the origin of caries taken a saccharose. Exactly she causes the most rapid decline of pH from 6 to 4 for a few minutes. Especially intensively there is a process of glycolysis at hypomyxia, xerostomia, during sleep. And activity of process of fermentation depends on the amount of carbohydrates which are attracted. It is set that in the period of consumption of surplus the sugars amount of deposit is considerably multiplied. Composition of meal, its consistency, influences on formation of name-plate. It is proved that a dental name-plate quick appears during sleep, than during a meal, as saliva selection and mechanical action is instrumental in deceleration of formation of dental name-plate. The microorganisms of dental deposit are able to be fixed, raise on hard tissues of tooth, metal, plastic, to product geteropolysugars, that contain different carbohydrates –glicans, levans, dextrans, which a no less important role is taken: 1) glicans provide adhesion of bacteria with each other and by the surface of tooth which conduces to growth and bulge of dental deposit. 2) Levans is energy and enormous amount of organic acids sources, high adhesion own. 3) Dextrans also are product of enormous amount of organic acids which have demineralization influence on the enamel of tooth due to good adhesion. Research in the polarized light of cuts of enamel allowed describe the areas of carious spot. Most deep area — transparent — appears because of hypermineralization of enamel. Silverstone (1973) described a carious defeat without formation of cavity, zoning him depending on the degree of mineralization as follows: semilucent area (front of spot); dark area, separating the body of defeat semilucent; superficial intact layer. The first area appears as a result of destruction of enamel as micropore or micro spaces in area of scopes of prisms of enamels. Both periphery and core of prisms dissolves in the body of defeat, pores are made by an from 5 to 25% volume of enamel. It can spread on a small depth and go parallel surfaces or to proceed in a depth fabric. External layer of enamel in depth to 30 mkm is here saved practically intact. On the surface of tooth the methods of optical and electronic microscopy are reveal the followings organic educations: pellicle, deposit, microorganisms, loose structures.Pellicle the subsuperficial layer of which penetrates on 0,1 mkm in the crystalline layer of enamel is most intimately related to the tooth. The presence of pelliclein 4 times reduces solubility of her on calcium. Moreover, the initial caries of the stabilized form develops at presence of outward shell of tooth, without her are carious defects on an erosive type. On the early stages of carious defeat a bulge or making light, thinning of pellicle, can be marked. There is opening of pores of enamel above a carious hearth. In a number of cases separate prisms dissolve on a surface. Modern knowledges about etiology of caries give the clear pictures of origin of porosity, namely: to acid demineralization of crystalline structures of tooth under influencing of organic acids, producted the microorganisms of dental nameplate. Conformities to the law of dissolution enamels, studied the methods of acid biopsy, showed the primaryprimary output of calcium (so-called decalcification), and then already phosphorus. Researchers explain it a presence in mineral composition of enamel of four phases of phosphate of calcium, characterized different solubility. For clarification of the stages of pathogeny the models of caries, allowing to get the artificial hearths of subsuperficial demineralization, were developed. So, Miller (1883) placed remote teeth in mixture of saliva, chewed bread and meat with addition of sugar and maintained them in a thermostat at the temperature of 370 C during 3 months. Thus chalky spots appeared on the surface of enamel. Presently researchers are use milk sour gel of pH 3,7—4,5. The most wide distribution was got by a model, offered Silverstone (1969). On his method a tooth is covered varnish, leaving a «window» on a surface, and immerse in solution of oxideethilcellulosa, acidified to pH 4,5. The design of caries is presently used also them on cuts of enamel in a 17% gelatinous gel, acidified suckling acid to pH 4,3; containing 0,5 g/l of synthetic gidroxideapatites. Structural likeness of caries of in vivo and in vitro is shown, that allows widely use a design in the study of caries. At the design of hearth of subsuperficialdemineralization on an own method as influencing substance attachment faction of saliva, acidified suckling acid to necessary pH, was used (4,3—5,0). The use exactly of saliva is conditioned that in her there are in an optimum concentration matters, providing in a norm the process of remineralization enamel, including calcium. Experimental a way it is set that for providing of the expected effect are receipts of chalky spot — the action of every separate portion of substance proceeds from 30 to 60 minutes. Thus the terms of development of hearth of demineralization hesitate from 18 to 40 hours. Mechanisms of hearth demineralization The general picture of forming of hearth of demineralization appears as follows: the first stage is a loss of calcium a tooth with further remineralization. Demineralization is again established then. These processes are alternated from a primary decalcification of enamel up to the visual discovery of morphological signs of initial caries — chalk similar of the changed areas, losers brilliance at drying of enamel. As a result of further influence they meet in one hearth, forming a «white spot» in the beginning with a smooth surface, and then and with rough. Research in the reflected light and by the method of scanning electronic microscopy of surface of enamel above a chalky spot, as a rule, did not expose considerable differences from an intact enamel: she was covered organic educations with scratches, furrows, unclear determined heads of prisms. Considerably the greater volume of information about the structure of hearths of carious defeat of enamel is got at research of cuts the method of interference contrast. In thesubsuperficial layers of enamel carious hearths were revealed in the form of cone, oval, wide and narrow bars. The body of defeat, surrounded a dark area, was expressly determined usually. On a border with an intact enamel there was a semilucent area of hypomineralization. A superficial layer was practically intact. Destruction of prisms was revealed in the body of defeat a different degree: from violation of clearness of their picture to fragmentation and complete disintegration. A semilucent area was characterized expansion of scopes of interprisms due to dissolution mainly of periphery of prisms that was observed on all studied standards. Thus on transversal motion of prisms cuts on scopes between prisms micropores was revealed, and on longitudinal cuts — micro cracks. The bodies of prisms collapsed rarer. For the «white spots» of minimum sizes formation of typical areas is not characteristic. The hearth of defeat is revealed strengthening of prism picture. In a number of cases the areas of carious enamel differed from intact the extended scopes of prisms in subsuperficial layers. The lines of Rettsius were sharply contrasting and were dark uneven bars, formed the chain of micropore, intervals in the partly blasted rows of prisms. Found out also micropores, opened on a surface. Typical areas of caries on these standards not determined. Increased lines of Rettsius in some approaching it is possible to examine as areas of chalky spot, namely is alternation of dark and semilucentareas. In other cases a superficial layer meets with the body of defeat under which a dark area is well expressed or absent. In those cases, when a hearth was designed at the low values of pH (<3,7), on standards destruction of superficial layer was marked in combination with the subsuperficial hearth of demineralization. Expansion of microspaces and formation of micropore in a subsuperficial layer characteristically for the chalky spots of small sizes, and also for the peripheral departments of all carious hearths. The typical areas of caries, expressed in a greater or less degree, meet most often — regardless of degree of maturity of enamel, intact superficial layer with separatemicropores, dark area, surrounding the body of defeat, semilucent area with the extended scopes of prisms and actually body of defeat with the expressed destruction of prisms and porosity of enamel. Combination of subsuperficial demineralization with partial destruction of superficial layer of enamel is incident to the teeth of any age group at the action of low index ofpH; this type is most unfavorable, as renewal of enamel becomes impossible. The pathoanatomical picture of superficial caries of enamel is presented two basic areas: external is destruction of prisms; internal is demineralization of periphery or core of prisms. An intact enamel is deeper disposed. The caries of dentine is characterized the area of destruction of mineral component, and also organic matter and by the layer of demineralization. In addition, the brightly expressed protective layer of hypermineralization can be formed in a dentine, and in mash is a reparative dentine. Caries of cement is making progress destruction of surface of root of tooth, developing as a result cariogenic operating of microorganisms on bare part of root. Researches showed that 40—50% microflora of deposit makes actinomycoma. On that ground a conclusion was done that along with streptococci surface of root mushrooms render the pathogenic affecting. The caries of root of tooth more frequent meets for seniors and old men, having expressed retraction of gums, characterized demineralization and destruction of cement and dentine. Carious hearths can take shape (as knots) rounded, oval or wrong, striking more frequent than all not one, but a few surfaces and roots of tooth. Depth they are rarely exceeded by 1 mm. An initial caries differs softening influence of cement, a defect is not revealed, however characterized a surface is discoloration: discolored or, vice versa, pigmented, acquiring the hazel, reddish tint of hard tissues, pliability at sounding. Appearance of carious cavity is accompanied destruction of dentine on a day and walls. As a result the tag of probe easily submerges in fabric of root. The caries of cement can spread on the circumference of tooth, circular, towards the apex of root or, vice versa, to enamel – dentine connection. Development on a proximalsurface can flow without symptom up to an origin pulpit. The delete of dental deposits is instrumental in the visual discovery of the hidden defeats of cement. The use of sharp probe allows define softening influence of dentine and level of warm sensitiveness. Sciagraphy research — to diagnose a proximal caries. ACTIVITY DEGREES OF CARIES. AGE 3–6 7 – 10 11 – 14 15 – 18 Тактика: cs CSE+cs CSE CSE 1-st DEGREE 2 –d DEGREE 3-d DEGREE Менее 3 Менее 5 Менее 4 Менее 7 Exanination once a year 3–6 6–8 5–8 7–9 Examination and rehabilitation twice a year Более 6 Более 6 Более 8 Более 9 Rehabilitation 3 times a year.