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Treatment of caries of primary teeth in infants
Caries of milk teeth at an early age is one of the most difficult problems of children's dentistry. At the age of 6 months to 3 years, it is characterized by a rapid course, a multiplicity of damage. Baby teeth may be damaged immediately after the appearance.
According to the results of the examination, 50 - 57% of children aged two years have caries. By three years, this figure increases dramatically to 80%. The main misconception of parents is the conviction that baby teeth "will change to permanent ones anyway." For this reason, a visit to the dentist often occurs with the complete destruction of the crown part of the tooth, when a deep inflammation of the internal tissues (pulpitis, periodontitis) develops, or in the case of acute pain.
To denote caries of milk teeth, different terms were used:
blooming caries,
multiple caries,
bottle caries,
feeding caries,
caries caries,
creeping caries.
Since 2002, the term "early caries" has been adopted to refer to severe caries of milk teeth and its complications in children from one to four years.
Causes of caries of dairy teeth
Milk teeth caries develops not only under the influence of cariogenic bacteria in a child’s mouth. The following factors contribute to susceptibility to the disease:
inadequate maturation of enamel;
food deficient in protein products, macro-and micronutrients, with an excess of carbohydrates;
water with an insufficient amount of fluorine is one of the leading factors;
the absence of pellicle - a film that occurs on the surface of the teeth after their eruption; it is a structural element of the surface layer of enamel, protects hard tooth tissues from the effects of acids;
saliva composition, its concentration, viscosity, quantity and rate of production;
the biochemical composition of the hard tissues of the tooth, which determines the course of caries (a dense structure with minimal spaces of the crystal lattice slows down the course of caries and vice versa);
the state of the neurovascular bundle of the tooth;
the state of the body during the formation and maturation of tooth tissues;
abnormal tooth development due to common bodily diseases.
The risk of developing an infectious process is also associated with the immaturity of local immunity: the secretory immunoglobulin A1 contained in saliva is destroyed by pathogenic bacteria. The concentration of this immunoglobulin in early childhood is significantly lower than that of an adult. Therefore, the child is more susceptible to the development of infectious inflammation, including diseases of the hard tissues of the tooth of an infectious nature - caries.
The development of caries at an early age (up to three years) is affected by:
violations of the structure of the teeth, which occur during fetal development, are associated with diseases of the mother (mineral metabolism), with toxicosis;
artificial feeding, night or long-term breastfeeding;
severe debilitating diseases of the child in the first months after birth;
prematurity of children;
antibiotic treatment in the first months of a child’s life.
After three years, other reasons are joining: a genetic predisposition (imperfect mineralization of the teeth), poor oral hygiene, which allows them to accumulate on the teeth.
Features of the development of caries in childhood
In childhood, caries is more intense. This is due to the structural features of enamel and dentin (solid tooth base):
hard tissues are poorly mineralized;
on the enamel surface there are micropores and microcracks;
the layer of enamel and dentin is relatively small;
dentinal tubules shorter and wider;
a significant volume of the cavity of the tooth, the horns of the pulp (loose fibrous connective tissue that fills the cavity of the tooth, containing a large number of nerve endings) are located close to the enamel-dentinal joint;
the immature pulp at the stage of formation of the temporary tooth is almost incapable of forming replacement dentin.
There is a rapid lesion of the dentin due to the low content of salts in it and the lack of protective reactions from the immature pulp.
Immaturity is expressed not only in the peculiarities of the structure of enamel. The roots of the tooth are formed within 2 to 3 years after eruption. Their structure is diverse. At the stage of root formation, pathology is acute.
The first caries affects the upper front incisors. Wet dentin is removed by layers. Characterized by a rapid transition of the disease in the complicated stage. This leads to the rapid destruction of a temporary tooth.
Single tooth decay caries in early childhood are rare. As a rule, 8 or more (up to 20) teeth are involved in the process. In one tooth there are several carious cavities. Such caries develops after acute infectious diseases (measles, scarlet fever, sore throat, and others), which have been severe. It is also called sharp, sharp, flowering. Sometimes a large number of new carious cavities form after an illness.
Multiple caries develops in some chronic diseases (tonsillitis, diseases of the bronchopulmonary system), rickets, Down's disease.
Forms of caries of dairy teeth
Caries in a child is classified the same as in adults:
elementary,
surface,
average,
deep.
Caries of milk teeth is often deep.
Special forms, characteristic only for milk teeth, are:
circular caries;
plane caries.
When circular caries lesions spread in the neck and surround the tooth in a circle. This is due to the later mineralization of the part of the tooth located in the cervical part.
Circular caries manifests itself after the eruption of the front incisors under adverse environmental conditions, when the mineralizing potential of the biological fluid in the oral cavity decreases. Most often, this form of pathology is found in a premature or weakened child. With late dentition, the circular form of pathology practically does not occur.
The reason for flat caries is enamel underdevelopment due to the violation of the mineral and protein metabolism of the tooth still in its infancy. This form of caries of milk teeth is localized on the chewing part of the posterior posterior teeth (molars), covering the entire surface. The peculiarity of the pathology is the rapid transition to medium and deep caries.
The classification of carious defects differs in their type and stage of the process. There are 6 stages of formation of carious defects from d0 to d4. They are presented in Table 1.
When making a diagnosis, most often a pediatric dentist applies a classification of the activity of the carious process (acute, acute, chronic) and the level of intensity of caries is low or high.
Symptoms of early caries
An early diagnostic sign of caries is a large amount of plaque. It is practically not removed from the surface of the tooth. In the future, appear chalky spots - the first carious lesions. Within 2 to 3 months, the spots become light yellow. Then, on the spot of spots, defects of hard tissues in the form of carious cavities are formed.
At the middle stage of caries, the child experiences pain when it enters the carious cavity of food with a sweet and sour taste. With medium and deep caries, due to the small thickness of the bottom of the carious cavity, which separates it from the space in the coronal part of the tooth, infection can be transmitted to the pulp, the development of the inflammatory process and its death.
The teeth of a child with early childhood decay are affected in the order in which they erupt. The first defects are usually found on the outer, labial surface of the upper front teeth in the cervical area. The lower incisors suffer much less frequently, since they have the best opportunities for self-cleaning due to the position of the tongue and abundant washing with saliva. If caries has captured lower baby teeth, we will talk about the most acute, extremely severe form of caries.
The initial stage of caries of milk teeth
After the consumption of carbohydrates, the mineralizing properties of saliva are disturbed, since the crystallization processes change, and this leads to an increase in the activity of the carious process. Caries begins with demineralization - reduction of mineral salts in the enamel. The process develops from the inner layers of enamel, spreading from the inside outwards.
A sign of the initial stage of the development of the disease is a chalky spot without a natural luster in the cervical area. Initially, it is small, and then spreads over the entire surface of the crown. In case of intensive flow, carious spots are bright, the borders are blurred. They are constantly progressing.
If the course of the pathology is intense, a carious cavity soon forms - superficial caries. The size of the process is determined by the spot size.
If demineralization proceeds at a slow pace, if it is prone to suspend the spread of infection, the stain may be pigmented. But such a phenomenon in children practically does not occur. More often, caries of primary teeth develops without any signs, especially in the early stages.
Caries in the staining stage can be detected in children from 6 to 8 months. In babies, upper anterior teeth often fall ill.
With an average form of caries, the child does not complain. The defect is detected on a routine examination by a dentist. Sometimes the tooth hurts from the sweet. After thorough rinsing the mouth stops hurting. On examination, it is clear that there is a shallow carious cavity filled with softened dentin.
When caries is deep, only a thin layer of dentin separates the carious cavity from the pulp. The bulk of the dentine within the cavity is completely destroyed. The child can not eat sour and sweet, refuses to brush his teeth with a toothbrush. If there are complaints of pain from thermal irritants (cold and hot), then the pulp is most likely already infected.
Caries on the front baby teeth
Circular caries usually develops on the upper front teeth. It occurs mainly in premature babies, with malnutrition, rickets, tuberculosis, and in children fed with artificial compounds.
Carious infection quickly spreads to the pulp. Often a complication of the circular caries of the front teeth in children can be a breakdown of the crown of the primary tooth. But sharp pulpitis in the front milk teeth are practically not found. This is possible for two reasons:
If the body's resistance is lowered, the child does not hurt anything when the pulp dies, a chronic inflammation of the tooth root gradually develops.
Due to the formation of replacement dentin, the cone-shaped stump of the tooth remains. If such caries has developed and the pulp is still alive, the tooth continues to “serve” the child for some time. This option in children is less common.
Complications of caries of milk teeth develop severe inflammatory processes in the jaw area. When they are removed early, dental anomalies are formed.
The child’s front teeth also have an atypical localization of the disease in the cervical part of the sky. This form of pathology develops in the "bottle" of caries.
What should parents do?
Initially, the pathology proceeds without the participation of cariogenic bacteria. Microorganisms, their toxins, organic acids from food residues join from the moment of damage to the enamel layers. With caries at the staining stage, the process is reversible. Treatment will be preventive (elimination by early measures).
Preventive treatment of caries in children
This type of treatment reduces the effect of acid-forming microflora and includes the following measures:
oral hygiene with the selection of individual funds;
correction of diet and diet;
administration of fluoride and calcium preparations;
antimicrobial treatment;
remineralizing therapy.
Parents are recommended to include in the ration fluorinated (iodinated-fluorinated) salt or bottled water with an optimal fluorine content every day. Consult a pediatrician and give your child calcium supplements, micronutrients, vitamin D.
Antimicrobial treatment
In order to reduce cariogenic microflora in the oral cavity, antimicrobial therapy is carried out. Schemes for the use of antimicrobial agents in the treatment of early childhood caries are presented in Table 2.
The application of a 0.05% chlorhexidine solution is carried out with a cotton swab or a well wrung cotton swab.
Cervitek lacquer contains 1% chlorhexidine and 1% thymol as antimicrobial substances. It is also effective in reducing bacterial flora in plaque and saliva. In parallel, daily rinses with a 0.1% chlorhexidine solution for 7 to 10 days are recommended.
One of the modern methods of controlling microflora is the use of ozone. Its high oxidative potential effectively destroys microbial cells and thus sterilizes tooth tissues before remineralization, sealing, and filling.
Remineralizing therapy
Enamel can be restored with the help of remineralizing solutions. Being introduced into the crystal lattice, they form a persistent compound that reduces the solubility of enamel and increases resistance to caries. Fluoride has a strong anti-caries effect. The solubility of enamel reduces calcium, phosphorus, molybdenum, zinc, aluminum.
Fluorine preparations. Of all the dosage forms of fluorine-containing drugs (solutions, gels, varnishes) in young children, from a practical point of view, the use of varnishes is most convenient. Varnish should be applied at least 2 times a year, and in the presence of a high risk of caries - every 3 months. To apply a varnish in the minimum quantity.
You can spend deep fluoridation using enamel-sealing liquid. The minimum rate is once a month for six months before the stabilization of the process.
The use of glass ionomer cements (JIC). The SIC is characterized by good adhesion to the enamel surface, good biological compatibility with hard tooth tissues, high fluoride content (about 20%), and their active release. Glass ionomer cements with preventive treatment are very effective.
Preparations of calcium and phosphorus. At home, the use of remineralizing gels is recommended:
Belagel - Ca / P (Vladmiva);
Recaldent (Recaldent Pty. Limited);
GC Tooth Mousse (GC);
ROCS Medical Minerals (DRC Group);
foam produced by Splat.
For many years, dentists have used silver nitrate or silver fluoride to stop the progression of the carious process on temporary teeth. These drugs are not used in any of the developed countries of the world, as the child's teeth are painted black.
The most effective technique to stop the development of initial carious lesions in the pits and on the chewing surfaces is sealing (siling). The procedure is performed by the JRC since the first molars appeared and during the first 2–2.5 years.
When carrying out all the recommendations listed above, usually the carious process is suspended:
there is a remineralization of the initial lesions, in the area of chalky spots the enamel begins to shine;
development of carious defects stops;
affected hard tissue compacted, delimited from healthy tissue.
Such treatment makes it possible to delay the technically complex and uncomfortable for the child methods of caries treatment for a later date.
Rehabilitation treatment of caries of milk teeth
Enamel is not capable of recovery, the cavity created in it will not disappear. Treatment of young children is a rather difficult task for the dentist. This is connected not only with the peculiarities of psycho-emotional development, but with the anatomical and physiological features of the maxillofacial region of the child, the impossibility of retaining a static posture.
Therefore, in some cases, young children can be shown treatment with the use of prior drug preparation, immersion in superficial sleep , under general anesthesia.
However, with uncomplicated caries, with the strong desire of parents and appropriate step-by-step technologies, it is possible to treat young children in normal conditions.
Modern dental technology involves not only the restoration of the shape and function of the tooth, but also the prevention of the progression of the carious process. These are methods that allow to process (dissect) tooth tissues with minimal damage:
mechanical or chemomechanical preparation;
air or water-abrasive preparation, laser preparation, polymeric burs;
excisional biopsy followed by the restoration of defects by materials with high biological compatibility to the cavity walls (SIC, compomers).
The properties of modern fillings make it possible not to form an extensive cavity during treatment, but only to remove infected tissue. Materials possess biological activity (first of all, JRC). By saturating hard tooth tissues with fluoride ions, they are able to restore their mineral composition and protect against further damage.
ART-technique (atraumatic restorative treatment). The treatment technique is maximally simplified. The defect is prepared with hand tools, dried with cotton balls and sealed with the JRC. If the filling is made at the early stages of the development of pathology, then it allows to stop the progression of the process of destruction of hard tooth tissues.
Chemical-mechanical dentin preparation. The principle of removal of carious dentin lies in its chemical softening and subsequent selective separation. For softening, a special gel is used, which gains access only to infected dentin, and the preparation does not act on the healthy part of the tooth. The gel is introduced into the carious cavity for a maximum of 30 seconds, after which it is scraped with a hand tool. The treatment procedure continues until the complete removal of necrotic tissue. The disadvantage of the method is its duration. This makes it difficult to use in young children.
In cases of significant destruction of the crown of the tooth (complicated caries) in conditions of general anesthesia, methods of endodontic and surgical treatment are used, followed by restoration or prosthetics with crowns.
Disease prevention
In dental clinical practice, there is such a thing as "bottle" caries (feeding caries). Unfortunately, the first type of complementary food in Russia is traditionally fruit juices and mashed potatoes. Complementary food is introduced at the age of 4 - 6 months. Mashed potatoes are often given with a spoon, but the mum continues to pour the juice by inertia into the bottle, especially before bedtime .
Clarified fruit juices, juices from citrus, bananas increase the cariogenic situation in the oral cavity of the child. Sweet night drink is unacceptable. In the study of drinks for baby food, it was established that all fruit drinks have a higher, than sucrose, index of cariogenic potential.
"Bottle" caries affects the upper front teeth. Fangs suffer less frequently due to later terms of eruption. The incisors on the lower jaw remain healthy, as they are protected by the tongue, while sucking tightly covering the nipple from below.
Caries of the upper front teeth of the “bottle” type develops also during breastfeeding of a child after a year. Breast milk contains β-lactose. This sugar has a low cariogenic potential. However, frequent and long-term stay of breast milk in the mouth, especially at night, also helps to reduce the pH of plaque and demineralization of hard dental tissues.
The formation of plaque begins with the attachment of aerobic bacteria Streptococcus mutans to the smooth surfaces of the teeth. It is important that the care of a child’s teeth starts from the moment the first tooth erupts. At the first stage (with the appearance of the first teeth), this may be wiping with a gauze cloth moistened with boiled water, special wipes with xylitol ("Spiffies"), cleaning with a silicone brush napalechnik or a traditional brush.
With the advent of the first temporary molars, brushing is carried out only with a toothbrush twice a day. It uses a small amount of toothpaste ("traces").
It is believed that the first paste should not contain fluoride compounds due to the possibility of its ingestion, and the excessive intake of fluoride ions during this period increases the risk of developing fluorosis of permanent teeth. Fluorosis is a chronic disease that occurs in areas with excessive fluoride in drinking water. It develops to teething.
To maintain the best balance between prevention of caries and the development of fluorosis, the use of pastes with a fluoride concentration of 500 ppm is recommended. The use of toothpastes with a lower concentration of fluoride or lack thereof is ineffective. In children with a high risk of developing caries, it is necessary to use a more concentrated fluoride-containing paste (900–1100 ppm). As a safety precaution, it is recommended not to leave the child unattended while brushing your teeth. At a younger age, use only “smear, traces” of toothpaste.
The recommendations of the European Academy of Pediatric Dentistry on the use of fluoride-containing paste for children are presented in Table 3.
When licking nipples, sampling food from a spoon, chewing food, kissing lips, the baby’s mouth is quickly contaminated with cariogenic microorganisms. “Salivary contacts” with the child are recommended to be avoided.
The high intensity of caries entails serious consequences for the child’s developing body:
intoxication and bacterial allergization from foci of chronic infection;
violation of the functions of biting and chewing food and resulting violation of the processes of digestion;
change of passability and disarticulation;
aesthetic defects;
perhaps psychological complexes.
Caries in young children is one of the factors for early tooth loss and malocclusion. The disease aggravates the course of many diseases and creates serious problems with the health of the child.
The period of physiological maturation (mineralization) of enamel can take from 2 to 5 years. Throughout the entire period of mineral maturation, especially during the first year after eruption, the child's teeth need careful and effective care. Compliance with the rules of oral hygiene will strengthen health, prevent the development of caries of milk teeth.
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