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Techniques of treatment of patients with dentine caries

dentine Caries remains to the most widespread in the world the form of a lesion of a teeth (Edvina A.M., 2003, Borovskij E.V., 2004). The problem of treatment of patients with caries of a dentine till the present moment is not decided owing to that the success of treatment is in many respects defined by the chosen technique (Mamedova L.A., 2002., Maksimova O.

P, 2004). Huge influence on a treatment outcome is rendered by age of patients, hygiene level, nonspecific and specific factors of protection of an oral cavity (Redinova T.L., 2007). Results of successful treatment of caries of a dentine, in the form of formation reparativnogo a dentine, are in many respects defined by features of a structure of tissues of a tooth.

the Dentine forms a functional unit together with a subject pulp of a tooth (Huang G.T., 2010).na to border with a pulp it is located gipomineralizovannyj the predentin, follows further okolopulparnyj and a cover dentine. On border with a pulp the fibrilloblasts which processes can reach up to emalevo - dentinal and dentinno-cement border settle down. Thick enough (0,35-0,6 and #956; m) processes of fibrilloblasts give the branches in peritubuljarnoe space, and can frame anastomoses with processes of the next fibrilloblasts (Schroeder U., 2000). Processes of fibrilloblasts in dentinal canaliculuses are surrounded by a dentinal liquid. The quantity of canaliculuses and their diameter at young age prevails in comparison with more mature age. The size and quantity of canaliculuses decreases in a direction to emalevo-dentinnoj to border. Peritubuljarnyj the dentine has dense, homogeneous and more mineralizirovannuju structure in comparison with other structures of a dentine. The thickness peritubuljarnogo a dentine depends on localisation of a canaliculus and from age of the individual (Mjor I.A., 2001). All areas of a dentine are formed by crystals gidroksiapatita. Peritubuljarnyj the dentine is formed as initial structure in the basic part okolopulparnogo a dentine (Goldberg M., et al., 2011). On a chemical compound the dentine in 50 % of volume makes a liquid. The calcium and Natrii phosphas parity to other mineral components makes 1:2. Crystals
gidroksiapatita have the size at width about 3-4 nanometers, at length of 60-70 nanometers, diameter of 20-35 nanometers (Schroeder U., 2000).

the Irregular or tertiary dentine formed in reply to external influence - result of protective reaction from a pulp (Bjorndal L., Mjor I.A., 2001). It can accept atypical structure which is expressed, including, in a wrong locating of the channel, "gofrirovannosti" the channel. The tertiary dentine can be formed only in very limited areas on border with a pulp. These areas correspond in most cases to those zones of a dentine which erosions have undergone, to caries or preparing (Schemel W., et al., 1984). Despite differences on structure, structure, the dentine and a tooth pulp are an integral part each other as the physiological and pathological reactions arising in one of tissues, concern also another (Mjor I.A. et al., 2001).

the tooth Pulp is the isolated connecting tissue consisting of cells, intercellular basic substance, reticular, collagenic fibers, nervous fibers, arterioles, venules and lymphatic vessels (Waddington R.J., 2009).

Fibroblasts represent the most significant cell population of a pulp (Hellwig E.J., et al., 2007).

In a pulp it is possible to designate 3 peripheric zones: odontoblastichesky a layer, subodontoblastichesky a layer and a bipolar zone. The bipolar zone is rich with mesenchymal cells and fibroblasts. The basic function of a pulp - a dentification (Sakai V.T., 2010).

Ability of neogenesis of a dentine depends on many factors. The individual structure, physiology and gistopatologija a corresponding tooth influences ability of a pulp to form okolopulparnyj a dentine (Teti G., et al., 2013).

As the tooth pulp settles down in immediate proximity with a carious cavity, is frequent after treatment of patients with dentine caries there are complications (Britova A.A., 2004).

the Outcome of treatment of patients with dentine caries not always yields desirable result owing to bacteriemic kontaminatsii a dentine (Mjor I.A., 2002).

search of a method of treatment of patients with deep caries (Chen F Till now is spent., 2010; Peters M.C., 2010).

After treatment of caries of a dentine of a teeth with application of various materials, by estimations of some authors, in 32 % of cases secondary caries (Orehova L.J. 2003) is observed.

A.I. Nikolaev and L.M.Tsepov is cited by data, on which; in a year after treatment of primary carious process secondary caries is diagnosed in 50 %, and in two years - in 70 % of cases (Nikolaev A.I., 2008).

At treatment of caries of a teeth long time germicides (Tsarev V. N, 1994) were widely applied. These preparations render

bacteriostatic action, but do not possess residual bactericidal activity.

As a result of poor-quality preparing of a carious cavity, polimerizatsionnoj usadki plombirovochnogo a material quite often there is recurrent caries (Hidirbegishvili O. E, 2006). Nevertheless, the dentine of a carious cavity of a teeth even after the most careful preparing remains infected (Britova A.A., 2004), therefore success of therapeutic action of antibiotics is defined by sensitivity to them of microbes. The microflora of a carious dentine is presented by streptococcuses, laktobakterijami, vejlonellami, staphilococcuses and others Gr + and Gr - microorganisms, which are most sensitive to Monomycinum (to Denisov L.A., 1987), hloralfenikolu and to streptomycin. It is steadier against Penicillinum, hlortetratsiklinu and to Tetracyclinum (Ivanov V. S, 1984). Use of an admixture of antibiotics (Burduli M. A, 1985, Liu M is supposed., Pertl C. 1992), that raises activity of medical action of preparations even in the presence of a microflora, refractory to one of antibiotics. The remote results of application of medical Pastas on the basis of antibiotics a number of authors have shown, that the inflammation in a pulp is not liquidated, and passes in a chronic asymptomatic current (Mamedova L.A., 2000). Earlier antibiotics used only at the first stage of treatment of deep caries as their bacteriostatic action remains
within only several hours, replacement of given Pasta on odontotropnuju (Maksimovskij J.M., 1994) therefore was required.

Now at treatment of caries of a dentine antibiotics do not apply, as they lead to occurrence aktibiotikoustojchivyh strains of bacteria, besides they suppress phagocytic activity of cells of a pulp and oppress activity of fibrilloblasts (Alliot-Licht B., et al., 2001; Caufield P.W., et al., 2001).

At treatment of caries of a teeth besides antibiotics Pastas on the basis of enzymes (Kuzmina E.M., 1996) were used also.

As antiinflammatory preparations till the present moment detergents, such as etony and hlorgeksidin (Frentzen M are used., et al., 2001). Etony bacteriostatic and bactericidal an effect (Makeeva I.M., 2009) has. The preparation is effective concerning streptococcuses, staphilococcuses and other microorganisms, possesses weak anaesthetising action. Etony it is used in the form of 0,5 % of a solution for processing of a carious cavity and is a part some medical Pastas. Hlorgeksidin renders bacteria - tsidnoe and antiseptic action (Bermudez O., et al., 1994). It is used for processing of a carious cavity in the form of 0,05-0,2 % of solutions (Zagorodnova V. P, 1992). It used for cupping of inflammatory process in a tooth pulp, leaving on a wad under a time seal within a week. It caused formation granuljatsionnoj tissues with plentiful reproduction of fibroblasts. For 21-s' days there were no signs of an inflammation, and by 90th days the layer of a replaceable dentine was formed. Complications have made 3,3 % (Zagorodnova V. P, 1988).

the Expressed antimicrobic effect at use of these preparations, is not the desirably at treatment of caries of a dentine as besides disinfection of a carious cavity the aim of stimulation of a mineralization of a dentine and circulation improvement in a tooth pulp (A is pursued. Sharma et al., 2009).

Deep studying by scientists of all world of properties hitozana has defined possibility of its use in various areas of medicine as it is an antiinflammatory, antimicrobial, antitoxic and antioxidatic preparation (Aral K, et al., 1968, Amiji M.M., 1996). The water-soluble form hitozana finds out high activity on linkage of animal cells and microorganisms that frames high bacteriostatic effect (Solntsev A.S., Ali-Riza A.E., Mihajlova O. V, Bolshakov I.N., 2004). Some authors assert, that hitozan corresponds to the basic demands shown to preparations for treatment of deep caries, stated above (Viha G. V, Maksimov V. I, from co-workers., 1995).

K.Y. Lee, W.S. Ha, W.H. Park investigated reaction of vessels on hitozansoderzhashchuju Pasta. As a result of research at usual techniques of treatment of caries of a dentine reaction became perceptible makrofagalnaja and the fragmentation of nervous fibers less expressed at application hitozana was observed. The plethora of fine vessels, number of hemorrhages and inflammatory reactions have been also more weakly expressed at application hitozana. Authors did not observe thus a vacuolation of fibrilloblasts. Stimulation of metabolic processes of fibrilloblasts in the form of adjournment of a replaceable dentine, augmentation of the maintenance of cellular elements of type of fibroblasts in subodontoblasticheskom a layer has been shown. In researches K.Y. Lee it is shown, that application as an isolating lining hitozansoderzhashchej Pastas prevented the expressed edema of a pulp, interfered with inflammatory reaction and appreciable vascular disorders, reduced number of hemorrhages (Lee K.Y., et al., 1995).

Widely used zinc-evgenolovuju Pasta as a lining at a stage of applying of a seal at treatment of caries of the dentine, possessing antiseptic, anaesthetising, odontotropnym action. (Ehrenreich D.W., 1968). Pasta on a basis okisi zinc promotes rising of a proliferation of fibrilloblasts and augmentation of the maintenance of the basic substance of a dentine in a boundary zone with a pulp. Even at a partial necretomy under a lining from
zinc-evgenolovogo of cement the dentine becomes rather free from microorganisms (Slops of K, 1988). Sterility of a dentine under a lining is found out in 82 % of observations, a disadvantage is bad adhesion with composites light otverzhdenija, and as consequence - recurrent caries. Therefore the given technique demands the delayed applying of a constant seal, as well as all previous, that is economically not favourable ways of treatment.

In N.N.Fajzullaeva's research (2009) has shown, that modern self-pickling (Hepo ²²², I Bond) and unicomponent (Single Bond) adhesive systems are biocompatible materials that allows to use them for conservation of viability of a pulp of a teeth at its casual opening and treatment of a deep carious lesion of a dentine.

Some authors assert, that clinical application samoprotrav - livajushchej adhesive system for a direct and indirect covering of a pulp of a teeth, in case of its treatment at a deep carious lesion of a dentine or casual opening of a pulp cavity, allows to normalise level of perfusion of blood in short terms: in pulp microvessels - in 1 month, a sensitive innervation - in 10 days - 1 month (Accorinte L., et al., 2005).

In work E Koliniotou-Koumpia (2005) it is described, that clinical application of self-pickling adhesive system with a view of conservation of viability of a pulp of a teeth at an indirect way of its covering allows to receive a treatment positive take in 100 % of cases, and at a direct method - in 94,1 % of cases (Koliniotou-Koumpia E., Tziafas D., 2005).

Y. Kitasako with co-authors (2000) in the work data cite, that at a direct covering of casually opened pulp adhesive system the threshold of electroexcitability of a pulp increases next day to 22 mka, by 3 day decreases on 7 mka, by 10 day - for 6 mka, reaching normal value in an intact symmetric teeth to term 1 months; at an indirect covering of a pulp the threshold it elekrovozbudimosti starts to decrease and is normalised by 10 day (Kitasako Y., et al., 2000)

For today practising stomatologists prefer the preparations possessing not only odontotropnym, but also remineralizujushchim action (Subramaniam P., 2006). First of all, it is preparations on the basis of a calcium hydroxide. Domestic preparations concern them: kaltsin, kalmetsin, kalsept. Foreign preparations: kalksil, septokaltsin, dajkal, lajf, kaltsipulpa, dzhen lajn (Kolips A., 1983; Auschill T.M., 2003), etc. These preparations possess the expressed causeticity and thanks to it cause neutralisation of acidic medium in an inflammation zone (Klaiber B., 1984). High concentration gidroksidnyh ions provides bactericidal action of a preparation (Lu Y., et al., 2008). Preparations on the basis of a calcium hydroxide possess odontotropnym action, cause a remineralization of a dentine at the expense of passive adjournment of salts of calcium (as a calcification of tissues, but not biological formation of crystals gidroksiapatita) (Nakajima M., 1995). Use as a lining of preparations on the basis of a calcium hydroxide leads to appreciable enough regressive changes in a pulp in the form of a vacuolar dystrophia, a sclerosis of a tissue and its petrification, all it testifies to depression of functional ability of a pulp that has been shown at histological research (Ersin N.K, Eronat N., 2005).

Kalmetsin does not lead to normalisation of a structure of capillaries and nervous elements of a pulp, even in the remote terms, therefore it combine from 20 % a solution of a dimethylsulfoxide (Dimexidum) (Kalihman S.P., 1990). Dimexidum has the expressed antiseptic an effect, it leads to fast normalisation of a condition of a vascular bed of a pulp. Good results are received at sharing kalmetsina about 5 % by a solution of Sodium nitritum of a potassium (Afanaseva N.I., 1990)

T. Schiff with co-authors (2009), investigated influence of processing of a dentine ^edinenijami calcium on morphology of a pulp of a teeth. On a surface processed by a hydroxide of calcium, the acid-resistant layer which does not have crystalline structure, localised in lumens dentinal
tubules, but because of the small size (about 0,3 microns) not filling them completely (Schiff T was formed., et al., 2009).

Under the statement of some researchers, total protravlivanie after processing of a cavity by a calcium hydroxide as does not cause dissolution of the framed precipitate, but on the sites blank by this precipitate, «the greased layer» is dissolved (Koliniotou-Koumpia E., 2002).

Applying kaltsijsoderzhashchih preparations at treatment of caries of a dentine or on casually opened horn of a pulp very often causes a local necrosis of a pulp and unessentially leads full reminiralizatsii a dentine (Hellwig I.J., 2007). As Pasta disadvantage on a basis gidroksida the calcium, used at treatment of deep caries, is its mechanical instability (Schuurs A.H., et al., 2000). As a result of high ability of Pasta to diffuse, in dentinal canaliculuses «tunnel defects» which can serve as a place of penetration of microorganisms (Cox C.F are formed so-called. et al., 1985).

Modern medical linings on the basis of a calcium hydroxide have in structure additional antiinflammatory preparations (Noetzel J., Kielbassa

A. M., 2005).

So, for example, A.A. Hafez (2002) and J.S. Rees (2003) into structure entered ftorsoderzhashchy gel to parity Ca:P = 2:1 and hlorgeksidin. It has helped to get rid of complications which at use of a pure hydroxide of calcium made 3,6 % (Hafez A.A., 2002; Rees JS., 2003).

However, use of the medical Pastas containing a hydroxide of calcium, does not eliminate to the full pathological pulpifactions that conducts to change of its trophicity at dentine caries (Brannstom M., 1981; Shroeder H.E., 1985). It is proved, that gidroksid calcium causes a sclerosis of dentinal canaliculuses and formation of a replaceable dentine (Horsted-Bindslev P., et al., 2003).

High alkaline reaction of a hydroxide of calcium provides ­ insignificant antiseptic activity, will neutralise the acids released from cements, but, at the same time, high pH (to 12,0) can lead
to a contact necrosis of a pulp, a vacuolar dystrophia, a hyalinosis, and also to formation of denticles and petrifikatov, that leads to a pulp cavity obliteration (Subramaniam P., et al., 2006).

gidroksid calcium considerably accelerates processes of a regenerative dentinogenesis, but, at the same time, its antiinflammatory action it is expressed insufficiently (Lu Y., et al., 2008). It is established, that terms of full normalisation of a structural condition of a pulp at application of Pastas containing a hydroxide of calcium, exceed 1 month (Falster C.A, et al., 2002).

gidroksiapatit and trikaltsy Natrii phosphas normalisation of a functional condition of a pulp of a tooth lead and cause a remineralization of a dentine of a bottom of a carious cavity (Maksimovskij J.M., 1994). Preparations on a basis calcium - phosphatic ceramics (gidroksiapatit, trikaltsy Natrii phosphas) are similar on the physical and chemical properties to osteal tissues (Dickens S.H, et al., 2004). They bioinertny, are capable rezorbirovatsja and to allocate calcium and fluorine ions. Possessing absorbtsionnoj the ability, the given preparations in interaction with tooth liquor, with osteal tissues which are rich with fibers, enzymes and salts, promote rekaltsinatsii nadpulparnogo a dentine (Yoshiyama M., 2000).

Cements on the basis of calcium Natrii phosphas differ high biocompatibility,­ osteoinductive ability, and as fast achievement of a firm condition (Sugawara A., et al., 1996). Fast formation gidroksiapatita in this case is induced, in particular, by neutral size rn cements.

One more advantage of cements on the basis of calcium Natrii phosphas is their hydrophylic nature and as consequence - vysokoja fastness to dissolution in a stomatic liquid, blood, a saliva (Yasuda Y., et al., 2008). However vital activity products kislotoobrazujushchih microorganisms are capable to reduce rn the mediums, framed cements on the basis of calcium Natrii phosphas (Chow L.C., 2001). In experiments with animals the effect of a dentinogenesis has been confirmed at
immediate applying of various linings on the basis of calcium Natrii phosphas on okolopulparnyj a dentine (Schroeder U., et al., 1982; Zhang W.X., 2008).

Y. Yoshimine (1995) with co-authors estimated reaction of a pulp after an immediate covering tetrakaltsijfosfattsementom on 10-15 week rats in control terms: 1, 3, 7 and 10 weeks. In 10 days after experience process reminiralizatsii without inflammation signs in a pulp in all 27 assays was accurately observed. Completely restored «dentinal ponticuluses» were in immediate contact with tetrakaltsijfosfattsementom (Yoshimine Y., Maeda K., 1995).

caries Complications occur as a result of penetration into a pulp of a tooth of an infection through system of dentinal tubules that does expedient application desensibilizatorov a dentine, used for treatment of the hyperesthesia, dentinal tubules causing blockade (Markowitz K., 2008), Thus there is a spontaneous settling out of highly dispersive fluoric calcium to average size of particles 50À, and also the fluoric magnesium possessing still larger solubility, than fluoric calcium. Admixture ÑàF2 formed as a result of reaction and MgF2 gives concentration of fluorine in a solution in 100 times more, than concentration of saturation of natural fluoric calcium or received is artificial (Imai M., 1993; Jin C., 2000). As a result of observations M. Sena (2004) it has been shown, that unitary processing of a teeth by preparations on the basis of fluoric magnesium led to hypersensitivity elimination in 75 % of cases (Sena M., 2004).

V.G.Bokaja (2000) carried out researches in which result it has been established that on the basis of fluoric magnesium with an interval of 5-7 days two-multiple processing of a teeth by preparations is on occasion necessary for depression of hypersensitivity of a dentine (for Bokaja V. G, 2000.).

At use of a solution of Sodium nitritum of potassium A.H. Schuurs (2000) observed formation large plazmoticheskih crystals. " greased ñëîé" lost the uniformity at the expense of formation of conglomerates of dentinal sawdust. Crystals covered less than 10 % of a surface. Under the influence of acid occurred
reduction of the sizes of crystals. Microbic permeability decreased to 23 %. Potassium Sodium oxalatum caused formation of an acid-resistant crystalline layer. Thus microbic permeability decreased to 6,5 % (Schuurs A.H., 2000.).

Preparations for deep fluorination also reliably prevent hypersensitivity after preparing of a teeth under orthopedic designs (Johnston D. W., 1995; Weintraub J.A., 2001).

the calcium Hydroxide causes formation of the amorphous precipitate closing about 50 % of apertures of dentinal tubules (Knappwost A, 2000). Use dentin-germetizirujushchego likvida leads to change of permeability of a dentine that is caused by chemical interaction of components likvida and mineral components of a dentine with obrazova-niem the insoluble deposits causing full, or partial, an occlusion of dentinal tubules.

JU.M.Maksimovsky and T.V.Ulyanov (2009) recommend to use deep fluorination at treatment of caries of a dentine. Deep fluorination of a dentine at treatment of caries of a teeth on A.S.Platonovoj's A.SH observations. (2005) reduces frequency of development of secondary and recurrent caries in three-year term of observation almost in 2 times.

Insolubility of the given products in weak solutions of acids is the factor providing protective action of linings concerning penetration of chemical components plombirovochnyh of materials and metabolites of microorganisms in a pulp of a tooth (Schiff T., 2009; Hamlin D., 2009).

the Method of deep fluorination of a dentine with use dentin - germetizirujushchej the liquids, including simultaneous application of liquids different in structure (Knappwost A, Grothe F., 2001): fluoric silicate of magnesium, a hydroxide of copper-calcium and fluoric sodium as the stabilizer for today is the most widespread. The a part hydroxide of copper-calcium possesses in 100 times more powerful disinfectant force, than the hydroxide of calcium which is a part of medical linings (Sadovsky V.V., 2006).

At the deep fluorination, dropping out in a deposit, containing copper the substance (alkaline fluoride of copper), has permanent bactericidal an effect, and put for a bottom and walls of a cavity the preparation is capable to prevent decades secondary caries (Butvilovskij A.V., 2010).

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Scientific source KOVALEVA MARIA SERGEEVNA. Clinico-morphological research of a condition of tissues of a tooth at treatment of caries of a dentine with application of deep fluorination and nizkointensivnogo laser radiation. The dissertation on competition of a scientific degree of the candidate of medical sciences. Great Novgorod - & 2014. 2014

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