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20. Копецкий И.С., Еремин Д.А., Полунина Н.В. Разработка мероприятий по реабилитации пациентов с повреждением нижнего альвеолярного нерва // Вестник Российского государственного медицинского университета. 2018. № 1. С.
84-89. [Kopetskii I.S., Eremin D.A., Polunina N.V. Development of measures for the rehabilitation of patients with damage to the lower alveolar nerve. Vestnik Rossiiskogo gosudarstvennogo meditsinskogo universiteta. 2018;1:84-89. (In Russ.)]
УДК 616.314.18-002-08 DOI 10.24411/2220-7880-2021-10150
CONSERVATIVE TREATMENT OF PULPITIS
Gromova S.N., Pyshkina O.A., Agalakova T.B., Kaysina T.N., Kolevatykh E.P., Raskov A.A.
Kirov State Medical University, Kirov, Russia (610998, Kirov, K. Marx St., 112), e-mail: GromovaSN@yandex.ru
Treatment of complicated forms of caries in permanent teeth with an open apex in children is the most relevant today. Among patients who apply for pediatric dental help the percentage of asymptomatic pulpitis is about 1/3. Inefficient treatment of teeth trauma often leads to development of acute or chronic pulpitis. Sometimes it can lead to pulp necrosis and injure the growth plate of tooth roots. After applying calcium paste the pulp can also become infected and die.
Keywords: pulpitis, open apex in permanent teeth, chlorhexedine, metronidazole, chloramphenicol.
МЕТОД КОНСЕРВАТИВНОГО ЛЕЧЕНИЯ ПУЛЬПИТА
Громова С.Н., Пышкина О.А., Агалакова Т.Б., Кайсина Т.Н., Колеватых Е.П., Расков А.А.
ФГБОУ ВО Кировский государственный медицинский университет Минздрава России, Киров, Россия (610998, г. Киров, ул. К. Маркса, 112), e-mail: GromovaSN@yandex.ru
Лечение осложненных форм кариеса постоянных зубов с несформированными верхушками корней у детей представляется наиболее актуальным на сегодняшний день. Почти треть детей обращаются к детскому стоматологу с бессимптомным течением пульпитов. Часто нерациональное лечение травм приводит к развитию острого и хронического пульпитов, порой это может привести к гибели пульпы и ростковой зоны корней зуба. После наложения только кальцийсодержащих паст возможно инфицирование пульпы зуба, что также приведет к ее гибели.
Ключевые слова: пульпит, несформированные корни постоянных зубов, хлоргексидин, метронидазол, левомицетин.
Introduction
Treatment of pulpitis in teeth with open apex has a number of specific features. Its goal is to maintain pulp viability, which provides future formation of the tooth root. There's an increased risk of progression of infectious process and inflammation of the periapical tissue. Complete bacteria elimination from the inflamed pulp is necessary for osteoblast activation and dentin formation [1-3].
Topical antiseptic, anti-inflammatory, hypersensi-tizing and odontotropic medications have become widely accepted treatment for the inflamed pulp [2-9]. The medications can be used as a temporary or permanent application or introduced into the dental pulp with the help of electro- or phonophoresis.
Different biological treatments of pulpitis with antiseptics, such as ethacridine lactate, furatsilin, iodinol, enzymes, antibiotics, hormones, were tested by Russian scientists and accepted in dental practice in the late 20th century. (Ivanov V.S., Urbanovich L.I., Berezhnoi V.P., 1990). Indications to various dental treatment pastes containing eugenol, calcium hydroxide, collagen (Dmitrieva L.A., Nezhivenko L.N., Gerasina O.V, 1986), dimexide with crystalline lysozyme (Musharapova S.I., 1983) have been worked out. Bone meal and heparin (Chumakov A.A., Kolenova Z.D., Leontyev V.K., 1986) as well as algipor and heparin containing medications (Dmitrieva L.A., Ardabatskaya G.A., Ulyanova T.V., 1986) have shown a positive effect.
However, all these drugs have selective bacterio-static and bactericidal activity against microorganisms that live in the carious cavity. Many drugs don't have odontotropic effect, so they don't stimulate the formation of reparative dentin and dentin remineralization. Antibiotics and sulfanilamides can selectively decrease a microbial risk and often have a sensibilizing action. Some drugs reduce their activity with long-term keeping. Zinc oxide euvgenol paste has a specific odor. Dimexide is a highly toxic drug. Calcium hydroxide formulations should be used with great care as they can cause pulp necrosis due to strong alkaline reaction (pH 11-12). Some of the drugs are tooth stainable («MTA») [10, 11].
Treatment of pulpitis (tooth filling) using polymeth-acrylic acid is available (Japan, application N 3-22042, publication 90.05.17. M. cl. A 61 K 6/00). However, polymethacrylic acid being in a bound form because of hardening complicates its positive effect on dental pulp through dentinal tubules. This material composition does not have dentin formation and mineralization effect, and does not change pH. This filling material is capable of forming a chemical compound with tooth enamel and dentin through carboxylate groups and does not irritate dental pulp. Due to the presence of potassium nitrate, this cavity liner has odontotropic effect and stimulates reparative function of the pulp.
Biological method of treating pulpitis is the closest to the suggested method. It involves cavity preparation
followed by antiseptic treatment, placing curative cavity liner on the bottom and then isolating liner and then filling the cavity. The procedure requires sequential management of cavity with 1% solution of polymethacrylic acid with pH 8.5-9.0. Then, after mechanical pre-treatment of lesions 1-2% polymethacrylic acid solution with pH 9,0 is administered to the cavity bottom under the dressing for 3-5 days. Finally a paste consisting of a mixture of Remodent powder and 2% polymethacrylic acid solution with pH 8,0 (see patent RU №2070032; Cl. A61K 6/08, 1996) is applied under the permanent filling.
Despite a great number of studies and suggested methods, there is no generally accepted and approved management of pulpitis in permanent teeth with open apex [2-9].
Aim: To develop a method of treatment of pulpitis in permanent teeth with open apex that would provide an effective pulp and dentin tubules sanitation removing all types of microorganisms and preventing spread of inflammation, that would finally lead to the formation of dentin bridge at the border of a healthy tooth tissue and contribute to apexogenesis.
Objectives: To develop a composition of the paste administered into the cavity before applying calcium-containing paste, that would have antimicrobial and anti-inflammatory effect and could affect microorganisms in the carious cavity and dental pulp at different levels of the lesion in permanent teeth with open apex.
Materials and methods
25 patients aged 6 to 10 years with acute and chronic inflammation of the pulp of different groups of teeth with open apex were treated. In every case the pulp chamber was opened after necrotomy. In 14 cases the vital amputation was inevitable.
2% chlorhexidine solution was used for antiseptic treatment of the tooth cavity, then paste containing «Me-trogyl Denta» gel in combination with chloramphenicol powder was applied. During the second visit a calcium-containing paste («Trioksident», «MTA») was used to stimulate apexification and apexogenesis.
Microbiological examination was carried out in
Composition ol
all the patients. The obtained material was prepared by ten-fold dilution. Vitelline-salt agar (VSA) was used for isolation of staphylococci, which were incubated at 37 0C for 48 hours. Biochemical plates made by SPA «Nizhegorodsky kontur» were used for identification.
Streptococci were cultured on blood agar; entero-cocci - on enterococc agar; corynebacterium - on cory-nebac agar; Klebsiella, coli bacillus - on Endo medium; anaerobic organisms - on the elective medium for cultivation using gas-producing packages GasPac made by «HiMedia», India. Test sets Lachema made in the Czech Republic were used to identify microorganisms. Microorganism sensitivity to antibiotics was determined using disk-diffusion method and method of serial dilution.
Results and discussion
Pediatric patients with carious cavities in permanent molars and premolars and seeking dental treatment of traumas were involved in the study. Prior to the study, the children's parents were asked to complete and sign informed consent form. Immediate treatment for pulpits was carried out during two visits.
The preparation process showed uncovered tooth cavity. Anesthesia, preparation, drug management of the cavity, hemostasis (with sterile cotton swabs), application of dental treatment paste either to the cavity bottom or to the stump were carried out during the first visit. The paste, prepared ex tempore, consisting of a mixture of chloramphenicol powder and «Metrogyl Denta» gel was applied under a temporary bandage for 3-5 days.
During the second visit (if the patient didn't report inflammation or any other problems) the paste was removed. The cavity was treated with 2% chlorhexidine aqueous solution and calcium-containing paste («Triok-sident», «MTA») was applied to the cavity bottom. Then application of an insulating lining and tooth filling were provided.
This method provides management of pulp inflammation and pain, preserving its viability and functions, further development of permanent tooth root.
Bacteriological examination revealed the prevalence of gut microflora and yeasts (table 1).
Table 1
ioth microflora
Name of Microorganisms Number of Microorganisms
in the tooth cavity
Escherichia coli 104 KOE/ml
in the infected dentin layer
Enterococcus faecium 103 KOE/ml
Corynebacterium granulosum 103 KOE/ml
Candida albicans 103 KOE/ml
Fusobacterium spp. 103 KOE/ml
under the dentin, in the tooth pulp
Candida albicans 102 KOE/ml
Fusobacterium spp. 102 KOE/ml
after treatment
Candida albicans 102 KOE/ml
Klebsiella spp. 102 KOE/ml
Gram-positive and negative bacteria were found in the tooth cavity and infected dentin layer. Presence of Escherichia coli and Enterococcus faecium suggests imbalance in oral cavity microbiota. Hemolytic E. coli suggest contribution of intestinal flora to pulpitis pathogenesis. Corynebacterium granulosum affects the tis-
sue structure. Fungi of the genus Candida appear to be markers of tissue immunity imbalance. Gram-negative anaerobics, which produce pathogenic factors, such as hemolysin and lecithinase, vegetate in the opened tooth cavity under the dentin. As a result of the treatment fungi and Klebsiella bacteria remain [1, 10].
The described method of treatment shows the following advantages caused by drugs' pharmacology and dosage forms [11-13].
Chlorhexidine gluconate is a bactericidal agent which is active against wide range of Gram-positive and Gram-negative bacteria. No evidence for resistance to Chlorhexidine has been noted. The drug works in the blood or pulp debris (cellular elements are always present in pulpitis in children), though its activity is a little reduced. The efficiency of chlorhexidine gluconate solution in pulpitis treatment was shown in the works of Ruiz-Esparza CL et al., 2011, Rosenberg L. et al., 2013. [8, 11, 12].
Metronidazole is an antimicrobial agent, which is active against wide range of Gram-positive and Gramnegative microorganisms, as well as anaerobic forms. The use of metronidazole in combination with chlorhexi-dine enhances the bactericidal effect on Fusobacterium spp (Drugs and Medications Directory) [13].
Chloramphenicol is another antimicrobial agent, which is active against wide range of Gram-positive and Gram-negative microorganisms. It has a strong bacteriostatic action. If highly concentrated it exhibits bactericidal activity against certain strains. It is also active against Escherichia coli, Enterococcus faecium (Drugs and Medications Directory) [9].
Paste gel structure promotes good penetration of drugs through dentinal tubules. Chloramphenicol is active against microorganisms causing pulp inflammation. Thus, the composition of the paste we use provides a sufficient concentration of wide range antimicrobial drugs with prolonged effect in the pulp. This is also confirmed microbiologically: there are no pathogens, only background flora.
Elimination of infectious agents provides transition from the inflammatory to proliferative phase, which is accompanied by stimulation of connective tissue growth, increased osteoblast activity and osteoclast suppression. Use of calcium medications and alkaline environment also contribute to this positive result.
Stimulation of apexification with MTA provides faster dentinal bridge formation and fewer complications compared with calcium hydroxide apexification (Prad-han DP et al, 2006;. Kavitarani B Rudagi and BM Ru-dagi, 2012). «Trioksident», a Russian analogue of MTA, has shown good results in treatment of pulpitis and peri-odontitis in permanent teeth with open apex [5, 6, 10].
Twelve children with complicated crown fractures were given the suggested treatment during the period of two years. After sufficient anesthesia the crown pulp was removed and chloramphenicol paste was applied to the stump under a temporary bandage for 3-5 days. During the second visit, after removal of the bandage and drug management of the cavity, «Trioksident» («ProRoot MTA» or «Rootdent») [3,14] was applied.
The medical examination was repeated in 3 weeks' time, 3, 6 and 12 months' time and up to the root formation period. The patients had no complaints, clinical manifestations as well as radiologic abnormalities of the root apex were not revealed. During the whole period the process of dentin bridge formation in the pulp was observed.
All the patients showed sustained favorable long-term outcome. There were no complications such exacerbation of chronic pulpitis or development of chronic periodontitis.
Case 1.
An eight-year-old girl with a crown fracture of the anterior teeth caused by an accident in the playground was referred to the Paediatric Dentistry Department. After the first visit to the dentist the teeth were regularly treated with fluoride. Two days later sensitivity to temperature (reaction to cold that goes away without cold stimulus) occurred in tooth 4.1.
Clinical management: The face configuration is not changed, the regional lymph nodes are not enlarged and painless on palpation. On the cutting edge of tooth 4.1 the fracture line is within vasodentin, the pulp is not exposed. One site of the cavity is slightly painful on probing, but it does not bleed.
The color of the crown is not changed. During horizontal percussion pain is experienced. Periodontal membrane is pale pink. The tooth sensitivity to cold is acute, with lingering pain after cessation of cold stimulus.
The x-ray (fig. 1) shows that the tooth root is growing, the growth plate is contoured, indicating its viability.
Fig. 1. The x-ray of tooth 4.1 before starting treatment.
The diagnosis was made by medical history and instrumental examination following ICD: chronic pulpitis in the acute stage (K04.03). The following treatment was given:
The 1-st visit:
• hygienic dental treatment,
• infiltration anesthesia,
• cavity preparation,
• cavity drug treatment,
• opening of pulp cavity with a sterile bur,
• crown pulp amputation,
• hemostasis with sterile cotton wool tampons,
• applying therapeutic paste consisting of a mixture of «Metrogyl Denta» and chloramphenicol powder for 5 days,
• applying a temporary bandage. The 2-nd visit:
• hygienic dental treatment,
• bandage removing,
• cavity drug treatment with 2% chlorhexidine solution,
• application of calcium-containing paste («Trio-ksident» made by «VladMiva») to the stump,
• low modulus composite lining,
• dental compomer filling.
Check-up examination after 4 months:
The patient had no complaints; no ditching was observed. The x-ray (fig. 2) confirmed the formation of dentin bridge, the root continues growing.
Fig. 2. The x-ray of tooth 4.1 confirmed the formation of dentin bridge after 4 month.
Check-up examination after 7 months: The patient had no complaints; no ditching was observed. The girl slightly bites with the tooth. The x-ray (fig. 3) revealed dentin bridge formation, the growth plate is not contoured. Dense barrier of cement-like tissue is supposed to be forming. This method of treatment showed favourable outcome.
Fig. 3. The x-ray of tooth 4.1 revealed dentin bridge formation after 7 months.
Case 2.
A nine-year-old girl with tooth 3.1. fracture caused by a fall was referred to the Paediatric Dentistry Department. The tooth was sensitive to cold air. First the girl was referred to a dental clinic, where the fracture line was treated with fluoride. The patient was recommended to wait up until she was 14 years for restoration. After the first visit the teeth were regularly treated with fluoride.
Clinical management:
The face configuration is not changed, the regional lymph nodes are not enlarged and painless on palpation. On the cutting edge of tooth 3.1 the fracture line is within vasodentin, the pulp is not exposed. One site of the cavity is slightly painful on probing, but it does not bleed.
The color of the crown is not changed. During horizontal and vertical percussion pain is experienced. Peri-odontal membrane is pale pink. The tooth sensitivity to cold is acute, with lingering pain after cessation of cold stimulus.
The x-ray (fig. 4) shows that the tooth root is growing, the growth plate is contoured, indicating its viability.
Fig. 4. The x-ray of tooth 3.1 before starting treatment.
The diagnosis was made by medical history and instrumental examination following ICD: chronic pulpitis in the acute stage (K04.01).
The same treatment as in case 1 was provided. After that the girl wasn't reexamined.
A visit to the dental clinic in 1,5 years
Clinical management: The facial configuration is not changed, the regional lymph nodes are not enlarged and painless on palpation. The filling in tooth 3.1 remains.
The color of the crown is not changed. Horizontal and vertical tooth percussion is painless. Periodontal membrane is pale pink. There's no reaction to cold.
The x-ray (fig. 5) revealed dentin bridge formation, the growth plate is not contoured. Dense barrier of cement-like tissue is supposed to be forming. This method of treatment showed favourable outcome.
Fig. 5. The x-ray of tooth 3.1 revealed dentin bridge formation after 1,5 years.
Case 3.
A seven-year-old boy was referred to the Paediatric Dentistry Department. Odontolysis of tooth 4.6 began immediately after the tooth eruption.
Clinical management: The facial configuration is not changed, the regional lymph nodes are not enlarged
and painless on palpation. On the chewing surface of tooth 4.6 within vasodentin there is a deep carious cavity of softened dentin and food debris. On probing One site of the cavity is slightly painful, but it does not bleed.
The tooth crown is not changed in color. Horizontal tooth percussion is painful. Periodontal membrane is pale pink. The tooth sensitivity to cold is acute, with lingering pain after cessation of cold stimulus.
The x-ray (fig. 6) revealed that carious cavity of tooth 4.6 is linked with the tooth cavity, the roots are in the growth stage, the growth plate is contoured, indicating its viability.
Fig. 6. The x-ray of tooth 4.6 before starting treatment.
The diagnosis was made by medical history and instrumental examination following ICD: chronic pulpitis (K04.03). The following treatment was provided: The 1-st visit:
• hygienic dental treatment,
• infiltration anesthesia,
• carious cavity preparation,
• drug treatment of the carious cavity,
• opening of pulp cavity with a sterile bur,
• crown pulp amputation,
• hemostasis with sterile cotton wood tampons,
• applying therapeutic paste consisting of a mixture of «Metrogyl Denta» and chloramphenicol powder for 5 days,
• applying a temporary bandage.
The 2-nd visit:
• hygienic dental treatment,
• bandage removing,
• cavity drug treatment with of 2% chlorhexidine solution,
• application of calcium-containing paste (MTA made by «Dentsply») to the stump,
• low modulus composite lining,
• compomer filling.
A visit in 2,5 years
Clinical management: The facial configuration is not changed, the regional lymph nodes are not enlarged and painless on palpation. The filling in tooth 4.6 remains, but gingival attachment is loose.
The tooth crown is not changed in color. Horizontal and vertical tooth percussion is painless. Periodontal membrane is pale pink. There's no tooth sensitivity to cold.
The x-ray (fig. 7) revealed dentin bridge formation, near the apex growth plate is not contoured. Tooth roots are mature but there is obliteration in the root channels.
Fig. 7. The x-ray of tooth 4.6 revealed dentin bridge formation after 2,5 years.
This outcome is considered to be favorable, though in many cases endodontic treatment is indicated. The boy's parents refused the suggested treatment.
Conclusions
1. This method of treatment of pulpitis in permanent teeth with open apex can be recommended for treatment of acute and chronic pulpitis of different etiology in different groups of permanent teeth (incisors and molars) with immature root.
2. It is better to perform dental procedures taking into consideration microbiological and radiological findings.
3. According to the clinical and microbiological data this method shows that it is possible to increase the number of cases when pulp is preserved. It is especially important in the period of root growth.
4. As a result of the study patent RF № 2542437, patent application № 2013147561 and invention priority October 24, 2013 (co-authors: V.A. Rumyantsev, V.Yu. Nicholsky) have been received.
References
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8. Chutima Traira Tvorakul, Areerat Koothira Trakarn. Calcium hydroxide partial pulpotomy is an alternative to
formocresol pulpotomy based on a 3-year randomized trial. International Journal ofPaediatric Dentistry. 2012;22: 382-389.
9. Chutima Traira Tvorakul, Treesa Sastararuji. Indirect pulp treatment VS antibiotic sterilization of deep caries in mandibular primary molars. International Journal ofPaediatric Dentistry. 2014;24: 23-31.
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УДК 616.314-007-036.22:614.1 DOI 10.24411/2220-7880-2021-10151
ЧАСТОТА И ХАРАКТЕРИСТИКА СВЕРХКОМПЛЕКТНЫХ ЗУБОВ У ПАЦИЕНТОВ СТОМАТОЛОГИЧЕСКИХ КЛИНИК Г. СИМФЕРОПОЛЯ (РЕТРОСПЕКТИВНЫЙ АНАЛИЗ)
Колесник К.А., Каблова О.В.
ФГАОУ ВО «КФУ имени В.И. Вернадского», Медицинская академия имени С.И. Георгиевского (структурное подразделение) Министерства образования и науки России, Симферополь, Россия (295051, Республика Крым, г. Симферополь, бульвар Ленина, 5/7), e-mail: nalivkina2009@mail.ru
Цель: определение частоты встречаемости гипердонтии по обращаемости ортодонтических пациентов и изучение морфологической характеристики сверхкомплектных зубов. Для определения частоты и характеристики сверхкомплектных зубов, сопутствующих осложнений было проведено ретроспективное исследование 3112 медицинских карт пациентов, обратившихся за ортодонтической помощью с 2014 по 2019 год в ГАУЗРК «Крымский республиканский стоматологический центр», частные клиники г. Симферополя. При проведении исследования определено, что у пациентов, обратившихся за ортодонтической помощью, частота встречаемости сверхкомплектных зубов составляет 4,48%. Выявлено, что у 139 (4,48%) ортодонтических пациентов было диагностировано 203 сверхкомплектных зуба (СКЗ). Гипердонтия чаще выявлялась в 10-12 лет, 6,1% случаев из общего количества пациентов этой возрастной группы. В периоде сменного прикуса СКЗ определялись в 56,83%, в постоянном прикусе - в 39,56% и во временном прикусе - только в 3,61% случаев. При невысоком проценте задокументированных случаев гипердонтии отмечается значительное количество осложнений - 94,24%, связанных с этой аномалией. Наибольший удельный вес при этом имеют задержка прорезывания постоянных зубов или их ретенция (30,22% случаев), аномалии положения комплектных зубов (42,45%) и аномалии корней соседних зубов (36,69%).
Ключевые слова: сверхкомплектные зубы, распространенность, морфология.
THE FREQUENCY AND PERFORMANCE OF SUPERCOMPLETE TEETH IN PATIENTS. RETROSPECTIVE ANALYSIS OF DATA OBTAINED FROM DENTAL CLINICS IN SIMFEROPOL
Kolesnik K.A., Kablova O.V.
Medical Academy named after S.I. Georgievsky of Vernadsky CFU, Simferopol, Russia (295051, Republic of Crimea, Simferopol, Lenin Boulevard, 5/7), e-mail: nalivkina2009@mail.ru
To determine the incidence of hyperdontia based on the appealability of orthodontic patients and the morphological characteristics of supernumerary teeth. To determine the frequency and characteristics of supernumerary teeth, associated complications, a retrospective study of 3112 medical records of patients who applied for orthodontic care from 2014 to 2019 at the Crimean Republican Dental Center, private clinics in Simferopol, was carried out. During the study, it was determined that in patients who applied for orthodontic care, the frequency of occurrence of supernumerary teeth is 4.48%. It was found that 139 (4.48%) orthodontic patients were diagnosed with 203 supernumerary teeth (SNT). Hyperdontia was more often detected at 10-12 years of age, 6.1% of the total number of patients were recorded in this age group. In the period of mixed bite, SNT were determined in 56.83% cases, in permanent bite - in 39.56% and in temporary bite - only in 3.61% of cases. In spite of the low percentage of documented cases of hyperdontia, there is a significant number of complications - 94.24% cases associated with this anomaly. The most common complications are the delay in eruption of permanent teeth or their retention (30.22% of cases), anomalies in the position of complete teeth (42.45%) and anomalies in the roots of adjacent teeth (36.69%).
Keywords: supernumerary teeth, prevalence, morphology.
