RU2395247C1 - Complex conservative-surgigal method of treating chronic granulomatous forms of periodontitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to dentistry, and can be used for treatment of chronic granulomatous forms of periodontitis. For this purpose tooth canal treatment is performed. Before each treatment carried out is ultreasonic sanitisation of oral cavity with 0.9% physiological solution with ozone concentration 1500 mcg/l during 30-90 s with fluctuation frequency 26.5 kHz and amplitude 50-80 mcm. After each stage of treatment tooth canal irrigation with the said solution is performed. After that ultrasonic sanitisation of periodontal recesses through the same solution is carried out during 20-30 s. Turundas with the said solution are introduced into canal, after which carried out is phonophoresis of periapical area tissues through technological pad with the said solution with fluctuation frequency 26.5 kHz, amplitude 20-50 mcm, during 20-30 s daily with course of 5-8 procedures. If granuloma dimension is 5 mm and more resection of tooth root apex is performed with carrying out sanitisation at each stage of operation with the said solution. After that formed cavity is filled with osteostimulating preparation, place of trepanation being covered with automembrane, prepared from patient's blood. Mucous-subperiosteal flap is put into its place and sewn above membrane with 3-4 interrupted sutures. Phonophoresis of periapical area tissues through technological pad is repeated.

EFFECT: invention allows to increase treatment efficiency due to synergistic impact of ozonised physiological solution and ultrasonic treatment.

2 cl, 2 tbl, 1 ex

Description

The invention relates to medicine, namely to dentistry, and can be used to treat chronic forms of periodontitis, namely granulomatous forms of periodontitis.

Currently used methods of treatment of periodontitis cannot be called perfect (V.A. Kozlov, 1979; A.I. Rybakov, 1981). The completeness of filling the tooth canals is 65-68% (B.C. Ivanov et al, 1979). Chronic foci of inflammation in the therapeutic treatment of periodontitis do not disappear immediately after treatment, even if the treatment was complete. In 22% of patients, foci of chronic odontogenic inflammation disappear after 4-6 months, and in 68% only after 1-2 years or more (M.I. Groshikov, 1966). According to the data of V.V. Mironov (1969), B.C. Ivanov and co-authors (1969) in 51.5% of patients with dental treatment, it is possible to eliminate the foci of chronic inflammation. Violation of certain methods for the treatment of patients with chronic periodontitis leads to the fact that open infection foci turn into closed, non-draining ones and become one of the main sources that cause the body to sensitize to bacteria, toxins and decay products. According to statistical reports, attendance for pulpitis and periodontitis accounted for 35% of all visits for dental treatment. In absolute terms, in 1993, 23.9 million visits were made for endodontic treatment. There are basically two reasons for tooth extraction: periodontal disease (52.4%) and caries complications (46%). If we take into account that for every resident aged 35-44 years there are 6-7 extracted teeth and 3-5 of them regarding periodontitis, then all the relevance and importance of this problem becomes clear.

NN Bazhanov et al. (1995) indicate that in 98-99% of cases, periodontitis of the teeth is the cause of phlegmon of the maxillofacial region, which is a great danger to the health and life of the patient.

Such a high prevalence of chronic odontogenic processes is directly related to the quality of endodontic treatment. The success of the treatment depends on how you managed to make the root canals passable. If the canals can be expanded with the help of endodontic instruments, and then their quality obturation can be performed with the removal of filling material beyond the apical hole, then we can hope for restoration of bone tissue. Such treatment can be considered radical. However, the processing and expansion of all canals of the tooth takes a lot of time at the doctor's office and is not always successful due to the complexity of their anatomical structure (root curvature, sclerotization). Despite the fact that a large number of teeth with poorly sealed root canals may not bother patients for a long time, x-ray control rarely indicates an improvement in the condition of the bone tissue of the periapical region, less often stabilization of the process, and more often there is an increase in the focus of rarefaction of bone tissue.

The success of the treatment depends on how you managed to make the root canals passable. If the canals can be expanded with the help of endodontic instruments, and then their quality obturation can be performed with the removal of filling material beyond the apical hole, then we can hope for restoration of bone tissue. Such treatment can be considered radical. However, the processing and expansion of all canals of the tooth takes a lot of time from the doctor and is not always successful because of the complexity of their anatomical structure (curvature of the root, sclerosis). Despite the fact that a large number of teeth with poorly filled root canals may not bother patients for a long time, x-ray control rarely indicates an improvement in the condition of the bone tissue of the periapical region, less often stabilization of the process, and more often there is an increase in the focus of rarefaction of bone tissue.

Currently, there are possibilities of using modern integrated technologies for the prevention and treatment of chronic destructive forms of periodontitis. The development of new technological approaches to the treatment of this category of patients with chronic apical processes at the apex of the root is devoted to the current search of many scientists - these are methods to reduce the risk of complications, not to use expensive medications, including antibiotics, and to shorten the treatment time. There are reports of the use of a laser for the prophylactic and therapeutic effects of high-intensity light, ultrasound, and hyperbaric oxygenation.

The choice of treatment method and material for filling the channel are directly related to the clinical manifestations of the disease.

Complex treatment in the traditional way boils down to the following actions:

- removal of pulp decay;

- impact on the microflora of the root canal with various medications;

- conducting mechanical expansion of the canal and apical foramen;

- effects on the peritoneal tissue with drugs;

- application of physical factors;

- thorough drying of the root canal;

- thorough obstruction of the root canal;

- restoration of the defect.

High-quality preparation of the tooth cavity for endodontic measures is carried out in accordance with all the rules of traditional treatment using thorough mechanical and instrumental treatment, removal of decay and with the preliminary introduction of an antiseptic into the canal - 2-3% hydrogen peroxide solution. After the canal has been expanded (EDTA can be used), a cotton wool with antiseptic is left in the root canal and the tooth is hermetically closed (M.I. Groshikov, V.K. Patrikeev. Teaching aid for therapeutic dentistry. M., "Medicine", 1975, p. 230).

At the second visit, the bandage is removed, the canal is reprocessed, the apical opening and filling are expanded. If the channel is difficult to pass, then a turunda with an antiseptic is left in the canal under a bandage up to 3 days before a clean turunda.

The bandage is removed, in the presence of clean turunda, drug treatment is performed and sealed according to the generally accepted technique. To accelerate the reparative processes, a biologically active paste can be removed beyond the apex and then fill the tooth canal.

The absolute indication for treatment in one visit is the presence of a fistulous course. Through it there is an outflow of exudate, therefore filling the canal and removing the material beyond the apical opening of the tooth root is not accompanied by an exacerbation of the inflammatory process.

This method is simple to implement and is applicable with low requirements for the result of treatment. However, a 3% hydrogen peroxide solution is not very effective for use as an independent means for washing the root canals. Hydrogen peroxide is unable to dissolve necrotic tissues and other organic residues and causes irreversible changes in cellular elements. Hydrogen peroxide does not have lytic properties and its antimicrobial effect is very limited. It is not very effective for use as an independent means for washing the root canal, does not have bacteriostatic properties. Conservative treatment may be unsuccessful with incomplete passage and filling of the root canal, if the apical focus of chronic inflammation in the periodontium has a message with the gingival pocket, with an increased load on the tooth, while reducing the overall immunological reactivity of the body. In this regard, as an additional treatment, a tooth-saving operation is performed - resection of the root apex. This operation aims to eliminate the pathological lesion in the bone, preserving the tooth (Solntsev A.M., Timofeev A.A. Odontogenic inflammatory diseases. - K .: Health, 1989. - p. 67).

Conservative treatment may be unsuccessful with incomplete passage and filling of the root canal, if the apical focus of chronic inflammation in the periodontium has a message with the gingival pocket, with an increased load on the tooth, while reducing the overall immunological reactivity of the body. In this regard, as an additional treatment, a tooth-saving operation is performed - resection of the apex of the root. This operation aims to eliminate the pathological lesion in the bone, preserving the tooth (Solntsev A.M., Timofeev A.A. Odontogenic inflammatory diseases. - K .: Health, 1989, p. 67).

Used conservative surgical methods of treatment (resection of the apex of the root of the tooth, coronoradicular separation, hemisection and amputation of the root, implantation) can save the entire tooth or part of it, create conditions for the functioning of the tooth with subsequent rational prosthetics.

The reason for failures after resection of the apex of the tooth root is most often not the error of the operation, but the errors in determining the indications and contraindications for this technique. Indications for the operation are: a fracture of the upper third of the root, a curvature of the apex of the root, a fracture of the instrument in the root canal, a lack of success from periapical therapy, excessive administration of filling material and its distribution under the periosteum, subperiosteal granulomas, periosteal cysts in the cavity of which the apexes of the roots are located.

The closest is the "Method of treating patients with chronic forms of periodontitis and periodontitis in the acute stage" (patent No. 23224452, IPC A61C 5/00, A61K 33/08, A61K 33/14, A61P 1/02, publ. 05.20.2008, Bull No. 14), in which before the tooth is treated, the oral cavity is irrigated with an ozonized 0.9% saline solution at an ozone concentration of 1500-2000 μg / l, the tooth cavity is opened and the putrid masses are evacuated with a pulp extractor, the canal and apical opening are expanded, after each stage treatment of the tooth channel carry out irrigation of 0.9% physiological about a solution with an ozone concentration of 1500-2000 μg / l, an ozonized 0.9% saline solution with an ozone concentration of 4000-6000 μg / l on turundum is introduced into the root canal, a temporary filling is placed. A temporary seal is removed and in the presence of clean turunda after treatment with the proposed solution, a permanent seal is placed. After treatment, patients conduct oral baths during the day after each meal with a solution with an ozone concentration of 1000-1500 μg / L.

The disadvantage of this method is that in chronic destructive forms of periodontitis with foci of destruction in the region of the apex of the root, this process may be exacerbated by suppuration of a granuloma or cyst during manipulations in the oral cavity.

The objective of the invention is to increase the effectiveness of treatment, reduce the risk of complications by improving the antimicrobial treatment of the oral cavity and the causative tooth and the rapid relief of the inflammatory process in the gum tissue due to tooth-saving technology - resection of the root apex, as well as due to the rapid saturation of the gum tissue with oxygen and increasing local factors protection.

The problem is solved by a comprehensive conservative-surgical method for the treatment of chronic granulomatous forms of periodontitis. The method includes the steps: irrigation of the oral cavity with 0.9% saline at an ozone concentration of 1500-2000 μg / l, treating the tooth with irrigation with this agent after each stage of processing the tooth canal, introducing this agent into the root canal on the turund with an ozone concentration of 4000-6000 μg / l, filling the channel with filling material.

As a solution for irrigation during manipulations in the oral cavity, 0.9% saline solution is used at an ozone concentration of 1,500 μg / L, which is poured into the tank for distilled water of the dental unit and fed using pomper.

In addition, before each tooth treatment, ultrasonic sanitation of the oral cavity is carried out with an agent at an ozone concentration of 1500 μg / l for 30-90 seconds, at a frequency of ultrasonic vibrations of 26.5 kHz, and an amplitude of oscillations of 50-80 microns.

Then carry out ultrasonic sanitation of periodontal pockets through the same solution for 20-30 seconds.

After introducing turunda with the drug into the root canal, phonophoresis of the tissues of the periapical region is carried out through a technological pad with this tool at an ozone concentration of 1500 μg / l at an ultrasonic frequency of 26.5 kHz, the amplitude of oscillations of the emitting end of the waveguide of the instrument is 20-50 μm, 20-30 sec daily course of 5-8 procedures.

With a granuloma size of 5 mm or more, the root of the tooth root is resected, for which a linear incision is made at the level of the tip of the resected tooth to the bone, the mucosal-periosteal flap is separated, the vestibular jaw plate trepan and the infected root tip is removed, granulations and softened bone areas are scraped out.

The resulting cavity is filled with an osteostimulating agent.

The trepanation site is closed with an automembrane prepared from the patient’s blood.

Lay the mucoperiosteal flap in place and suture it over the membrane with 3-4 interrupted sutures.

At each stage of the resection operation, irrigation of 0.9% saline with an ozone concentration of 1500 μg / L is performed.

Repeatedly conduct phonophoresis of tissues of the periapical region through the technological pad.

As an osteostimulating agent, material selected from the range: “Kolapol-KPZ”, “Osteopan”, “Osteo OSS”, “Osteo Gray” is used.

The novelty of the method lies in the fact that:

- As a solution for irrigation during manipulations in the oral cavity, 0.9% saline solution is used at an ozone concentration of 1,500 μg / l, which is poured into the tank for distilled water of the dental unit and served with the help of a blanker for sanitation of the oral cavity during various manipulations. This oxygen-containing agent has a stronger bactericidal and bacteriostatic effect and accelerates reparative processes. The tool allows for the supply of oxygen to the tissues of the oral cavity, which leads to improved trophism of the mucous membrane of the entire oral cavity and reduces bacterial contamination.

- Additionally, before each tooth treatment, ultrasonic sanitation of the oral cavity is carried out with an agent at an ozone concentration of 1500 μg / l for 30-90 seconds, at a frequency of ultrasonic vibrations of 26.5 kHz, and an amplitude of oscillations of 50-80 microns. This allows you to effectively affect the microbial landscape and significantly reduce the microflora of the oral cavity due to the double effect of ozone and ultrasound. Permeability and tissue respiration in the inflamed oral mucosa are normalized, leukocyte migration and desquamation of the oral epithelium increase.

- Then carry out ultrasonic sanitation of periodontal pockets through the same solution for 20-30 seconds. This local application of ultrasound allows you to influence the inflammatory process in the gingival mucosa of the causative tooth, the microbial landscape is reduced and a deeper diffusion of oxygen in the tissue is achieved. The intermediate solution is also used to prevent thermal burns of tissues in the sonication area.

- After introducing turunda with the drug into the root canal, phonophoresis of the tissues of the periapical region is carried out through the technological pad with this tool at an ozone concentration of 1500 μg / L at a frequency of ultrasonic vibrations of 26.5 kHz, the oscillation amplitude of the emitting end of the waveguide of the instrument is 20-50 μm, 20 30 sec daily course of 5-8 procedures. First of all, the inflammatory process in the gum is quickly stopped due to the impact on the processes in the deep layers of the tissues of the maxillofacial region, a deeper diffusion of oxygen in the tissue is achieved both from the side of the gum surface and the turunda installed in the root canal. This effect allows you to enhance reparative processes in the bone tissue. Under the influence of ultrasound, the pathological contents are extracted from the voiced tissues of the focus of infection and the rapid rejection of necrotic tissues.

- With a granulation size of 5 mm or more, the root of the tooth root is resected, for which a linear incision is made at the level of the tip of the resected tooth to the bone, the mucosal-periosteal flap is separated, the vestibular jaw plate trepan and the infected root tip is removed, the granulation and softened bone areas are scraped out . Each stage of the operation is accompanied by treatment with a means of ozone concentration of 1500 μg / L. This allows you to eliminate the pathological focus in the jaw bone, preserving the tooth, and create conditions for the functioning of the tooth with subsequent rational prosthetics.

- The resulting cavity is filled with osteostimulating material, which improves reparative processes.

- The place of trepanation is closed with an automembrane prepared from the patient’s blood. This allows you to accelerate tissue regeneration and osseointegration.

- Put in place the mucoperiosteal flap and suture it over the membrane with 3-4 interrupted sutures.

- At each stage of the resection operation, irrigation of 0.9% saline with an ozone concentration of 1500 μg / L is performed. This allows you to effectively affect the microbial landscape in the area of the pathological focus.

- Repeatedly conduct phonophoresis of tissues of the periapical region through the technological pad. Microcirculation and reparative activity of the bone are improved, a deeper diffusion of oxygen in the gum tissue is achieved, the inflammatory process is quickly stopped after the surgery.

- As an osteostimulating agent use material selected from the range: “Kolapol-KPZ”, “Osteopan”, “Osteo OSS”, “Osteo Gray”. The material stimulates reparative processes, it includes antibiotics that prevent secondary infection.

The proposed method allows you to effectively influence the microbial landscape in the area of the pathological focus, permeability and tissue respiration in the gingival mucosa are normalized, hypoxia is eliminated, microcirculation and reparative activity of the bone are improved. First of all, the inflammatory process in the gum is quickly stopped due to the impact on the processes in the deep layers of the tissues of the maxillofacial region, a deeper diffusion of oxygen in the tissue is achieved. Under the influence of ultrasound during irrigation, stimulation of rejection of necrotic tissues occurs. The wound heals by first intention. Sutures are removed for 5-7 days, depending on the degree of tension of the edges of the wound.

The combined effect of two factors in synergism enhances the effect of each, increasing the therapeutic effectiveness of both ozonized physiological saline and ultrasonic treatment. The release of oxygen from the used ozone-oxygen mixture is enhanced, and the tissues are subjected to mechanical vibrations of vibration and hydromassage at the cellular and subcellular levels.

Thus, the set of essential features of the invention also allows to obtain a new positive result, namely that when washing the root canal and during ultrasound exposure, necrotic tissues are more completely removed, necrotic tissues are radically removed from the cyst after resection of the root apex with simultaneous treatment with ozone oxygen mixture, and after phonophoresis, reparative processes are intensified, which contribute to the speedy restoration of bone tissue s, which significantly improves the outcome of treatment.

The achievement of a positive effect when using ultrasound in the treatment of diseases of the oral cavity and teeth is associated with its pronounced effect on microcirculation and metabolism in tissues, enzymatic activity, tissue trophism, reflex stimulation of neuro-trophic function, reparative and regenerative processes.

Ultrasound therapy is considered one of the most common and highly effective methods of modern physiotherapy and active therapy used in the complex treatment of a wide range of diseases in orthopedics and traumatology, surgery and gynecology, dentistry, dermatology. At the same time, a significant place is given to low-frequency ultrasound surgery and conservative therapy, which over the past three decades have been enriched by a number of physiological and experimental studies, on the basis of which the most effective methods of treatment using low-frequency ultrasound have been developed (G.A. Nikolayev, V.I. Loshchilov, 1980) [Ultrasonic technology in medicine. / Ed. V.I.Loshchilova. - M., 1980].

The basis of the biological action of ultrasound is its ability to be absorbed by the tissues of a living organism and can be due to both direct action of ultrasound (cavitation, acoustic flows, variable sound pressure) and indirect action, that is, secondary effects (biochemical, thermal, electrophysical, etc.) . The energy of absorbed ultrasound is transformed into other types of energy, causing a number of physical, physico-chemical processes and biological reactions. They, in turn, lead to a change in the homeostasis of tissue cells and the body as a whole.

Under the action of ultrasound, the tissues alternately compress and stretch the particles, which causes them to oscillate. Mechanical vibrations of tissue particles lead to cell massage, a shift in physicochemical processes and the formation of heat. With a high intensity of ultrasound in the stretching phase, intermolecular adhesion forces can break, attraction and the emergence of microcavities - cavitation. The vapor-gas bubbles formed during cavitation instantly disappear in the compression phase, and the shock waves, electric charges, and high local temperature peaks that arise during this process initiate specific sound-chemical reactions in the voiced medium. In a heterogeneous medium, in addition to the existing general acoustic pressure, small- and medium-scale flows and turbulations arise. They significantly accelerate the processes of dissolution and dispersion of substances. The influence of ultrasound changes the pH of the medium towards alkalosis, while the level of tissue absorption increases, and the accumulation of carbon dioxide decreases. Ultrasound has a pronounced bacteriostatic effect; it does not cause the death of microorganisms, but causes their morphological and functional rearrangements. They lead to a change in their properties. In general, the action of ultrasound on a biological object occurs through an acoustic medium: solutions of antiseptics, antibiotics, enzymes.

The effect of ultrasound through intermediate solutions of drugs helps to ensure complete or partial suppression of the action and development of microbial flora, extraction of pathological contents from the pathological focus. This achieves a deeper penetration of drugs. This increases the coverage of the drug, and therefore the rapid development of regenerative processes. We have proposed the use of ozonized physiological solution as an intermediate solution. This solution in itself already has a pronounced bactericidal, fungicidal, viralolytic, anti-stress, desensitizing and immunomodulating effect. Ozone has a bactericidal effect on microorganisms located in the root canal and oral cavity.

In our method, the joint multiple use of an ozonized agent is introduced, which is introduced into the oral cavity and root canal on the turunda, and ultrasound treatment, which intensifies the release of the therapeutic substance in the desired phase of treatment, is as close as possible to the focus of inflammation due to diffusion into the underlying layers of the gums, which allows significantly improve the result. All this in total affects the patient’s body as a whole and, taking into account the stimulation of the processes occurring in it, contributes to the healing of the pathological focus.

The proposed method is as follows.

In our work, we used a 0.9% solution of sodium chloride for local ozone therapy of patients with chronic periodontitis and periodontitis in the acute stage, the ozonation of which was carried out using a commercially available apparatus for gas ozone therapy "Ozotron" GKTE. 941714. 001 Substation, LLC Research and Production Company METROMED, Omsk, under the supervision of Academician RAMTN V.V. Pedders This device is equipped with special tube nozzles of various lengths and configurations for ease of use. The operating modes of the apparatus: the calculated oxygen concentration at the apparatus outlet is 1 l / min, the maximum supply of ozone-oxygen gas mixture at the apparatus outlet is 10,000 μg / l.

An ozonized 0.9% saline solution was prepared by barbation with an ozone-air mixture for 15-20 minutes at 250 ml of solution and 20-25 minutes at 400 ml. In this case, a concentration of 100 ml of physiological saline equal to 5000-7000 μg / L was obtained. To calculate the time of barbation in order to achieve the concentrations of ozone in physiological saline necessary for our study, the data were used (Durnovo EA, Justification for the use of ozone in the complex treatment of phlegmon of the face and neck: Dis .... Candidate of Medical Science. Nizhny Novgorod, 1998). The time of barbation was chosen taking into account the necessary concentration of ozone in the solution.

As a solution for irrigation during manipulations in the oral cavity, an ozonized 0.9% saline solution is used at an ozone concentration of 1500 μg / L. This product is poured into a tank for distilled water in a dental unit and, with the help of a water blanker, the oral cavity is sanitized and various manipulations are performed when working in the oral cavity.

Before tooth treatment, ozone-ultrasonic sanitation is additionally carried out with an jet-aerosol plume of the oral cavity with an ozonized 0.9% saline solution at an ozone concentration of 1500 μg / L.

Parameters and modes of ultrasonic processing:

- frequency of ultrasonic vibrations 26.5 kHz;

- the amplitude of the oscillations is 50-80 microns;

- the distance from the radiating end of the waveguide tool is at least 3-5 mm;

- exposure 30-90 seconds.

Ultrasonic processing is carried out using specialized ultrasound equipment - the STOMATON-1 apparatus, which includes a URSK-18 low-frequency ultrasonic oscillation generator, with a set of waveguides-instruments made of a titanium alloy manufactured by METROMED Research and Production Company, Omsk

Periodontal pockets are rehabilitated by sounding through an ozonized physiological solution with an ozone concentration of 1,500 μg / l, a waveguide tool in the form of a cylindrical rod with a working end, beveled at an angle of 45 °.

A tooth cavity is opened and putrid masses are evacuated from the root canal with a pulp extractor. Necrotic tissue and predentin are removed with augers and rasps, with an irrigation of 0.9% ozonated solution (endodontic syringe) with a concentration of 1500-2000 μg / l after each stage of processing of the tooth canal. Extend the apical third of the root canal and give it a conical shape with files and rimers, with the irrigation of 0.9% ozonated solution with a concentration of 1500-2000 μg / l. The root canal is thoroughly washed with turundas moistened with an ozonated 0.9% saline solution with an ozone concentration of 1500-2000 μg / l until they are clean. Set turunda dipped in a tool with an ozone concentration of 4000-6000 μg / l, establish a temporary seal.

Phonophoresis of the tissues of the periapical region of the causative tooth is carried out through the technological pad in the form of 2-4 layers of gauze soaked in an agent with an ozone concentration of 1500 μg / L. The frequency of ultrasonic vibrations is 26.5 kHz, the amplitude of oscillations is 20-50 microns, for 20-30 seconds daily with a course of 5-8 procedures.

Remove the temporary seal. At the same time, a means for irrigation and washing of the oral cavity with an ozone concentration of 1500 μg / L is supplied from the empty material for all manipulations in the oral cavity that require washing with water. In the presence of pure turundum, a tooth canal is treated with 0.9% ozonized physiological saline with a concentration of 1500-2000 μg / l.

The treatment of periodontitis is completed by root canal filling with calcium-containing filling materials of the KALASEPT type, thereby stopping the passage of microorganisms, microbial toxins and pulp decay products from the root canal to the periodontium.

With a granuloma size of 5 mm or more, an operation is performed on the root apex resection with restoration of the destruction site by an osteostimulating preparation as follows:

- local infiltration anesthesia;

- a linear section at the top of the resected tooth to the bone is carried out by the waveguide - the scalpel tool with the parameters and modes of ultrasonic processing: the frequency of ultrasonic vibrations is 26.5 kHz, the amplitude of oscillations of the working end of the waveguide tool is 30-100 μm, the speed of movement of the working end of the waveguide is instrument with a separation of 1-5 cm / sec, exposure of ultrasonic exposure by the working end of the waveguide-tool to the tissue - continuous or intermittent;

- separation of the mucoperiosteal flap;

- trepanation of the vestibular plate of the jaw with spherical boron;

- resection of the infected apex of the tooth root with fissure boron;

- removal of the separated tip of the tooth root with a spoon or tweezers;

- curettage of granulations and areas of softened bone;

- irrigation of a bone wound with 0.9% saline at an ozone concentration of 1500 μg / l;

- the cavity is filled with osteotropic bone material such as “Kolapol-KPZ”, “Osteopan”, “Osteo OSS”, “Osteo Gray”;

- the place of trepanation is closed with an automembrane prepared from the patient’s blood;

- put in place the mucoperiosteal flap and sutured it above the membrane along the cut line, applying 3-4 nodal sutures;

- each stage of the operation is irrigated with 0.9% saline with an ozone concentration of 1500 μg / l.

Automembranes are made using a FRP centrifuge, which allows you to get platelet gel rich in fibrins. The patient is sampled in special FRP tubes. The tubes are placed in a centrifuge and processed according to a specific program. At the end of the treatment, three layers of blood components are visible in the test tube: the central layer is a viscous creamy gel-like liquid - platelet-rich FRP gel, rich in fibrin. Using scissors, the FRP layer is separated, placed between two gauze and transferred to the installation site.

The study involved patients with the following symptoms: the presence of teeth with periapical damage. A total of 31 people of the middle age group from 20-55 years old participated, without concomitant chronic diseases. 18 people were treated for exacerbation of chronic apical destructive periodontitis. 13 patients received treatment with chronic apical destructive periodontitis, but the teeth were not previously treated. Of these, in 5 patients the lesion focus was 3-4 mm, in 11 patients granulomas of 5-6 mm were observed on the radiograph, and in 9 patients, destruction lesions with clear contours with a diameter of 7-10 mm. In 2 patients, the destruction site corresponded to 15 mm. The size of the cyst over 16 mm belonged to 4 patients, the age of one of them exceeded the age of the study group. The control group consisted of 12 healthy people (table 1).

Table 1 Distribution of patients by nosological form The diameter of the destruction center (mm) Chronic destructive periodontitis Exacerbation of chronic destructive periodontitis Control group 3-4 2 3 12 healthy donors 5-6 6 7-10 four 5 fifteen one one 17 one 3 13 eighteen

After collecting an anamnesis, clinical and radiological studies, a diagnosis was established and a treatment plan was selected. The necessary treatment consists in the complete destruction of pathogenic factors, the removal of the inflammatory reaction and the regulation of bone tissue regeneration processes. If with therapeutic intervention it is impossible to solve these problems, then there is a need for operational.

All patients were divided into two groups (Table 2).

table 2 Distribution of patients by treatment method The diameter of the destruction center in (mm) Treatment according to the prototype method Proposed Ozone Ultrasound Conservative Surgical Treatment Chronic forms Exacerbation of chronic forms Chronic forms Exacerbation of chronic forms 3-4 one one one 2 5-6 2 3 3 3 7-10 2 2 2 3 fifteen one - - one 17 one one - 2

The first of five patients, the group received treatment in accordance with the prototype method.

The second, which included all other patients, was a comprehensive ozone-ultrasound conservative surgical treatment of patients.

The control group consisted of 12 people without foci of odontogenic infection and associated chronic diseases.

Dynamic monitoring of the effectiveness of the regeneration processes after the application of various treatment methods was carried out by clinical, laboratory and radiological methods before and after the events.

When evaluating the effectiveness of changes, the most informative for us were: bacteriological analysis of the contents of the focus of infection, blood biochemistry: total protein, ratio of protein fractions.

To assess the amount of microflora, samples of the contents of the root canal were taken before and after treatment from all the studied groups and the material was inoculated with “lawn” on blood agar.

On average, during bacteriological examination, in the material before treatment, we found up to five species of various microorganisms, mainly representatives of the coccal flora: green streptococcus, mainly in 75% of cases, hemolytic enterococcus, epidermal staphylococcus, mainly in 100% of cases, Escherichia coli was isolated in 3 % of cases, bacteroids. After treatment using the prototype method, the presence of epidermal staphylococcus was detected in 43% of cases, green streptococcus in 20% of cases, E. coli in 2% of cases, and microflora growth was not detected after ozone-ultrasonic treatment.

The study of the level of protein fractions in dynamics in patients with chronic destructive periodontitis is one of the most informative methods for assessing the severity of the clinical course of the disease and protein synthesizing liver function. The total amount of serum protein does not go beyond the average values before and after treatment. A decrease in the level of albumin to 52.1 + -1.93 (p <0.05), and the content of globulin fractions increased in the acute period. On average, before the events immediately after them, the content of globulin fractions was:

- a1-globulins 5.5 + -0.7 - a2-globulins 13.2 + -1.3 - b-globulins 15.1 + -0.62 - y-globulins 19.4 + -1.8 (Y1 and Y2 globulin fractions unchanged)

The next day, these indicators were maintained, and a month after the therapeutic measures, the level of albumin rose to normal values, and the globulin fractions were approaching normal.

The decrease in the albumin-globulin coefficient occurs mainly due to the relative increase in the level of b-globulins. An increase in Y-globulin fractions in patients of an older age group is regarded as a favorable prognostic indicator. In addition, in individuals of the older age group, an increase in the level of C-reactive protein was noted.

In group No. 1, where treatment was carried out according to the prototype method, in 5 patients with chronic destructive forms of periodontitis after 4-6 months, 30% of the cases revealed a complete restoration of the destruction focus, especially in patients with a destruction focus from 3 to 4 mm in diameter. Size reduction was noted in 45.7% of patients. No change was observed in 24.3%. In two patients with a lesion focus of more than 15 mm, no changes were observed at these times. In three patients with an exacerbation of this disease, after conservative measures were taken within a period of 4-6 months, the destruction focus decreased by 1/3.

In group No. 2, where a comprehensive ozone-ultrasonic conservative surgical method of treatment was performed in 6 patients with chronic forms of periodontitis, a decrease in the lesion focus, especially with a small diameter, occurred after 2-3 months, by almost 1/2. In 3 patients with an exacerbation of this disease with a lesion diameter of 3-4 mm, a complete restoration of the destruction lesion occurred within 3-4 months, the rest underwent surgery with resection of the root apex, after which 3-4 months were noted complete disappearance of the focus of destruction.

Analysis of the results of treatment of chronic destructive periodontitis in group No. 2, using the proposed method, indicates the high therapeutic effectiveness of this method. In the period from 3 to 6 months, in patients with granulomas there was an almost complete disappearance of the destruction site, a decrease in the destruction site was determined in 95% of cases, it was observed without changes in 0.5% of patients. Immediate and long-term results: no cysts were detected radiologically and clinically in any patient.

After 18 months, we considered an excellent result of the treatment of this pathology an increase in favorable results in the absence of complaints and clinical manifestations: pain, swelling, the presence of fistulous passage, preservation of function, lack of growth. In all cases, suppuration of the cyst did not occur. Radiologically determined significant reduction in the destruction of the lesion or the complete absence of a cyst.

Example

Patient A., 29 years old, was admitted with complaints of pain, discomfort in 42 tooth. The disease does not connect with anything. An objective examination of the mucous membrane in the region of the 42 tooth is hyperemic, swollen, painful on palpation, painful swelling is determined, the crown of the 42 tooth is intact, not changed in color. Radiologically determined destruction site of a clear, rounded shape with a diameter of 15 mm. The diagnosis was made on the basis of complaints and objective research methods. As an additional research method, the x-ray method was carried out: intraoral and according to the indications of orthopantomograms. 7 mm granuloma.

The general condition of the patient did not suffer, elevated body temperature was not observed.

On treatment, a diagnosis was made: Chronic granulomatous periodontitis, a cyst from 42 teeth. Treatment was carried out, including ozone-ultrasound treatment followed by filling of the canals with osteostimulating paste “Kalasept”, a gutta-perforated pin was used as an additional obturator, resection and removal of the apex of the tooth root was performed.

The treatment was as follows:

- Spent irrigation of the oral cavity with 0.9% saline at an ozone concentration of 2000 μg / l;

- before tooth treatment, at the preparatory stage, an ozone-ultrasonic jet-aerosol torch was used to rehabilitate the oral cavity with this agent at a concentration of 1,500 μg / l of the ozone-oxygen mixture for 30 seconds, at a frequency of ultrasonic vibrations of 26.5 kHz, and an amplitude of 50-80 microns;

- tooth treatment with irrigation with a concentration of 1,500 μg / l after each stage of tooth canal treatment, evacuation of putrid masses from the root canal with a pulp extractor;

- removal of necrotic tissue and predentin with augers and rasps, with the irrigation of 0.9% ozonized solution with an endodontic syringe with a concentration of 1500 μg / l;

- ultrasound - sanitation of periodontal pockets by voicing through an intermediate solution a concentration of 1,500 μg / l of ozone-oxygen mixture for 20 seconds;

- expansion of the apical third of the root canal and giving it a conical shape with files and rimers, with the irrigation of 0.9% ozonized solution with a concentration of 1500 μg / l;

- thorough washing of the root canal with turundas moistened with ozonated 0.9% physiological saline to their purity with a solution concentration of 1500 μg / l;

- installation of turunda moistened in a solution with a concentration of 4000 μg / l, installation of a temporary seal;

- removal of a temporary filling, in the presence of clean turundum, we carry out drug treatment with 0.9% ozonized physiological saline with a concentration of 1500 μg / l;

- root canal filling in order to stop the entry of microorganisms, microbial toxins and pulp decay products from the root canal into the periodontium. "CALASEPT" is a sterile application system of calcium hydroxide for temporary and permanent filling of canals. Its advantage is coagulation and complete dissolution of necrotic tissues, which prevents the creation of a favorable nutrient medium for microorganisms and their further growth. When filling with this drug, the apex of the tooth root is completely closed due to the stimulation of cementoblasts. This process is completed in 8-12 months. For successful treatment, it is necessary to strictly observe the rules of antiseptics;

- phonophoresis of the periapical region through a technological pad with a concentration solution of 1500 μg / l at a frequency of ultrasonic vibrations of 26.5 kHz, an amplitude of oscillations of the emitting end of the instrument waveguide of 20-50 microns, 20 seconds daily with a course of 5 procedures;

- the operation of resection of the apex of the root with a granuloma size of 7 mm, in which at each stage the bone wound is irrigated with 0.9% saline solution with an ozone concentration of 1500 μg / l;

- a linear incision at the level of the 42 tooth being resected to the bone, separation of the mucoperiosteal flap, trepanation of the jaw and removal of the infected apex of the root of the tooth, curettage of the granulation and areas of softened bone, filling of the cavity formed with Osteopan material, closing the trepanation site with an automembrane made from the blood of this the patient, laying the mucoperiosteal flap in place and suturing with four interrupted sutures;

- phonophoresis of the tissues of the periapical region with a solution of a concentration of 1,500 μg / l of the ozone-oxygen mixture through the technological pad with ultrasound in the same parameters as before, 20 seconds, daily with 5 treatments.

After the measures taken, the patient did not complain, the tooth actively takes part in the chewing act, the mucous membrane is pale pink, without visible changes, the wound was healed by primary intention.

When evaluating the effectiveness of changes in the tissues of the periapical region, studying the immediate and long-term results, we came to the conclusion that the use of the proposed method for the treatment of chronic granulomatous forms of periodontitis suggests its undoubted advantage over traditional treatment methods. The combined action of ultrasound and ozone revealed advantages compared with traditional methods of treatment and the prototype, namely, reduction of treatment time, lengthening remission, reduction of drug load on the body, the possibility of using inexpensive drugs, the absence of contraindications and complications, which allows the use of these methods in therapeutic dentistry with a comprehensive conservative surgical method for the treatment of granulomatous forms of periodontitis.

Improving the effectiveness of treatment of destructive forms of periodontitis remains at the moment the most important task. In this regard, we proposed a method that meets all the parameters necessary for economic and quality treatment, we can recommend for clinical practice.

Claims (2)

1. A comprehensive conservative surgical method for the treatment of chronic granulomatous forms of periodontitis, which includes the steps: irrigation of the oral cavity with 0.9% physiological saline at an ozone concentration of 1500-2000 μg / l, treating the tooth with irrigation with this agent after each stage of processing the tooth canal, introducing this agent into the root canal on turund with an ozone concentration of 4000-6000 μg / l, filling the canal with filling material, characterized in that 0.9% physio is used as a solution for irrigation during manipulations in the oral cavity logical solution at an ozone concentration of 1500 μg / l, in addition, before each tooth treatment, ultrasonic sanitation of the oral cavity is carried out with an agent at an ozone concentration of 1500 μg / l for 30-90 s, at an ultrasonic vibration frequency of 26.5 kHz, an oscillation amplitude of 50-80 μm then ultrasonic sanitation of periodontal pockets through the same solution is carried out for 20-30 s, after the introduction of turunda with the drug into the root canal, phonophoresis of the tissues of the periapical region is carried out through the technological pad with this tool ozone concentration of 1,500 μg / l with an ultrasonic vibration frequency of 26.5 kHz, an amplitude of oscillations of the emitting end of the tool waveguide of 20-50 μm, 20-30 with a daily course of 5-8 procedures, with a granuloma size of 5 mm or more, the root tip is resected, why a linear incision is performed at the level of the apex of the resected tooth to the bone, the mucosal-periosteal flap is separated, the vestibular plate of the jaw is trepanded and the infected apex of the root of the tooth is removed, the granulations and areas of softened bone scraped out the cavity is filled with an osteostimulating agent, the trepanation site is closed with an automembrane prepared from the patient’s blood, a mucoperiosteal flap is placed in place and 3-4 nodal sutures are sutured over the membrane, at each stage of the resection operation, they are irrigated with a 0.9% saline solution with a concentration ozone 1500 μg / l, phonophoresis of the tissues of the periapical region is repeated through the technological pad. 2. A comprehensive conservative surgical method for the treatment of chronic granulomatous forms of periodontitis according to claim 1, characterized in that as an osteostimulating agent, a material selected from the range of “Kolapol-KPZ”, “Osteopan”, Osteo OSS, “Osteo Gray” is used.