RU2798307C1 - Way to treat dental fluorosis - Google Patents

Abstract

FIELD: medicine; therapeutic dentistry.

SUBSTANCE: invention is intended for use in the treatment of dental fluorosis. Opalustre gel is applied to the vestibular surface of the tooth for 1 minute and the drug is rubbed in for 30 seconds, washed with water for 30 seconds and Opalustre is reapplied up to five times, depending on the visual removal of the pigment. Three times on a dry tooth surface, Icon-Etch 15% hydrochloric acid is evenly distributed for 3 minutes using a nozzle for vestibular surfaces and rubbed during the entire exposure time, Icon-Dry ethanol-containing conditioner is applied for 30 seconds, dried with air. Icon-Infiltrant is applied to the lesion for 3 minutes and cured with an LED curing lamp for 40 seconds. Icon-Infiltrant is applied for 1 minute and polymerized for 40 seconds, low-modulus Constic composite is applied in the area of enamel defects with a layer of no more than 2 mm. If the volume of tissues is not replenished in one portion of application, the composite is applied again with a layer of not more than 2 mm, polymerizing each layer separately for 20 seconds.

EFFECT: method makes it possible to increase the effectiveness of treatment of discoloration of teeth with minimal impact on the hard tissues of the teeth and to reduce the treatment time.

1 cl, 17 dwg, 1 tbl, 1 ex

Description

The invention relates to medicine, namely to therapeutic dentistry, and can be used to treat dental fluorosis.

Dental fluorosis is a chronic disease that develops before teething with prolonged ingestion of water or foods with a high content of fluorine compounds. The disease is endemic. Treatment of patients with this pathology remains one of the urgent problems of modern aesthetic dentistry.

According to the International Classification of Dental Diseases based on ICD-10, fluorosis is designated by the code K00.30 (K00.3 - mottled teeth).

With dental fluorosis, there is a matte shade and discoloration of the enamel from white to yellow or dark brown stripes and spots, enamel defects, abrasion and destruction of the crown. The severity of the changes depends on the concentration of fluoride in the water.

Dental fluorosis is characterized by a change in the composition and properties of the hard tissues of the tooth. Conducted by N.V. Eremina (2002), a histological examination of tooth enamel with fluorosis showed that under a layer of well-mineralized enamel there is a subsurface zone of hypomineralized enamel.

Violation of the enamel mineralization process in fluorosis necessitates remineralizing therapy. Of the modern methods of remotherapy, applications in mouthguards of the R.O.C.S. gel are used. medical minerals, Biorepair gel, Tooth mousse gel, President Profi Rem Minerals gel.

However, this treatment option does not give immediate aesthetic results, it requires the patient to comply with the application application regimen. In addition, remineralization occurs only superficially, and the body of the lesion remains porous, which explains the unpredictability of the results of remotherapy and the persistence of the color of the white spot (Zawaideh F. et al., 2014).

To eliminate discoloration limited to the surface layer of enamel, Croll T.P. in 1993 proposed the method of microabrasion, which consists in applying an acid and an abrasive agent to the surface of the affected tooth. The thickness of the removed enamel layer during microabrasion reaches up to 200 microns, depending on the concentration of the acid and the duration of application (Croll T.P., 2009).

For microabrasion, Opalustre gel (Ultradent, USA) is used, which contains 6.6% hydrochloric acid and silicon carbide microparticles. Processing is carried out after isolation of soft tissues using rubber cups Opal Cups at low speed contra-angle for 10-20 seconds on each tooth. The number of applications of Opalustre gel varies depending on the degree of staining of the enamel (Nahsan F.P. et al., 2011). Celik et al. (2013) recommend treating the enamel 5 times for light staining, and up to 10 applications for moderate to severe staining. A.V. Akulovich recommends up to 5 applications of Opalustre Gel per microabrasion session. After a course of microabrasion, it is necessary to conduct a course of remineralizing therapy in individual mouthguards for 1 month (Akulovich A.V., Yalyshev R.K., 2015; Krikheli N.I. et al., 2017; Deshpande A.N. et al., 2017).

The location of the subsurface zone of hypomineralized enamel under a layer of well-mineralized enamel in fluorosis substantiates the possibility of conducting an infiltration technique for this pathology using the ICON system (abbreviation for Infiltration CONception). This system has previously been used to treat chalky spots in caries in the stain stage, when the spots are localized in the surface layer of the enamel. The ICON system (DMG) includes the following components:

- ICON-Etch: 15% hydrochloric acid, pyrogenic silicic acid, surfactants;

- ICON-Dry: 99% ethanol (rectified ethyl alcohol - contains 95.57%, absolute ethyl alcohol - alcohol content 99.9%);

- ICON-Infiltrant: methyl methacrylate, initiators, additives.

The method is based on the removal of the surface layer of enamel with 15% hydrochloric acid, followed by filling the hypomineralized focus with a mixture of synthetic resins that have certain rheological properties (low viscosity) and, accordingly, a higher penetrating ability (high penetration coefficient). As a result of impregnation with the infiltrant and its polymerization, the porous demineralized enamel is filled with polymer resin, which changes the refraction of light and ensures the achievement of an aesthetic result after infiltration.

But unlike a carious spot, the zone of hypomineralization during fluorosis is located deeper, which increases resistance to the infiltration process (Shahroom N. S. B. et al., 2019). Therefore, to provide access to the hypomineralized zone and the subsequent deeper penetration of the infiltrant, the treatment of the tooth surface with hydrochloric acid is repeated several times until a visual change in color occurs (Bharath K. et al., 2014). In addition, Gugnani N. et al. (2014) recommend increasing the time of exposure to hydrochloric acid in fluorosis.

Also, a number of authors recommend a combination of microabrasion and subsequent infiltration in the treatment of deep white spots (Giannetti L. et al., 2018; Hasmun N. et al., 2018; Sammarco G., 2019).

With a significant damage to the hard tissues of the tooth, orthopedic treatment is performed using veneers and crowns.

For the prototype of the proposed method of treatment, a well-known method of treatment proposed by Attal J.P. et al. (2014) (White spots on enamel: treatment protocol by superficial or deep infiltration (part 2) / J.P. Attal, A. Atlan, M. Denis, E. Vennat [et al.] // Int. Orthod. – 2014. – No. 12. - P. 1-31). The method consists in the fact that in case of surface localization of spots with dental fluorosis, the authors apply surface infiltration with the treatment of ICON Etch, ICON Dry and ICON Infiltrant according to the following algorithm: ICON Etch treatment 3 times for 2 minutes, then applying ICON Dry for 30 seconds and applying ICON Infiltrant for 3 minutes and 1 minute respectively with LED curing after each application for 40 seconds and then polishing the surface. In the absence of a result, as well as a deep location of the spots, the authors carry out deep infiltration, when the surface of the spot is treated with aluminum oxide-based powder, then infiltration is carried out according to the above algorithm, and after polymerization of the second layer of ICON Infiltrant, the surface is covered with a composite filling material.

The disadvantage of this method is the uncontrolled removal of enamel tissue when treated with powder based on aluminum oxide. In addition, there are no clear treatment algorithms and features of the choice of composite material when used in combination with ICON Infiltrant.

The goal is to ensure good treatment results while reducing the impact on the hard tissues of the tooth and reducing the treatment time.

EFFECT: expanding the arsenal of technical means for the treatment of dental fluorosis, increasing the efficiency of treating discoloration of teeth with minimal impact on the hard tissues of the tooth, and reducing the treatment time.

The technical result is achieved by the fact that in the method of treating fluorosis, including infiltration using the ICON system, Opalustre gel is applied to the vestibular surface of the tooth for 1 minute and the preparation is rubbed for 30 seconds, washed with water for 30 seconds and Opalustre is applied repeatedly up to five times. depending on the visual removal of the pigment, 15% hydrochloric acid Icon-Etch is evenly distributed three times on the dry surface of the tooth for 3 minutes using a nozzle for the vestibular surfaces and rubbing is carried out during the entire exposure time, ethanol-containing Icon-Dry conditioner is applied for 30 seconds , dry with air, Icon-Infiltrant is applied to the lesion for 3 minutes and polymerized with an LED polymerization lamp for 40 seconds, Icon-Infiltrant is applied for 1 minute and polymerized for 40 seconds, low-modulus Constic composite is applied in the area of enamel defects with a layer of no more than 2 mm and polymerize for 20 seconds.

The proposed method is carried out as follows.

Perform professional oral hygiene and isolation of gum tissue using liquid rubber dam. Then Opalustre gel (Ultradent, USA) is applied to the vestibular surface of the tooth for 1 minute and the preparation is rubbed with Opal Cups at a speed of 1500 rpm for 30 seconds. Rinse with water for 30 seconds and reapply Opalustre up to five times depending on visual pigment removal. Then the gel is washed off and the work area is dried with dry air. On a dry tooth surface, Icon-Etch 15% hydrochloric acid is evenly distributed for 3 minutes using a nozzle for the vestibular surfaces and rubbed in during the entire exposure time. Then wash Icon-Etch with water for 30 seconds, reapply Icon-Etch twice for three minutes, rinse, air dry and apply Icon-Dry ethanol conditioner for 30 seconds and air dry again, after which Icon-Etch is applied to the lesion. -Infiltrant with a slight excess. Leave the material to act for 3 minutes and cure with an LED curing lamp for 40 seconds. To reduce polymerization shrinkage and increase microhardness, the material is applied a second time for 1 minute and polymerized for 40 seconds. To compensate for the lack of tissues in the area of enamel defects, a low-modulus composite Constic (DMG) is applied, which has the property of self-adhesion with a layer of no more than 2 mm. Constic contains a binding agent - an adhesive monomer MDP, its phosphate functional group provides etching of tooth tissues and chemical bonding with calcium ions of dentin and enamel. The methacrylate functional group provides chemical bonding to cements and methacrylate-based materials or cross-links with other functional and structural monomers. If the volume of tissues is not replenished in one portion of application, the material is applied again with a layer of no more than 2 mm. A layer of material is polymerized with an LED lamp. Grinding and polishing is carried out with discs, rubber bands and brushes.

The method was applied on 120 extracted teeth, where the adhesive peel strength was studied using various materials and in 45 patients with dental fluorosis.

To study the adhesive peel strength, 60 teeth with fluorosis and 60 intact teeth were examined. By random sampling, teeth with fluorosis were divided into 4 groups of 15 teeth each (1, 2, 3, 4 groups), and intact teeth were divided into 4 groups of 15 teeth in each group (5, 6, 7, 8 groups ). To form a defect in order to study the adhesive strength using a sandblasting machine (Rondoflex, CAVO, Germany), the center of the vestibular surface was treated with a powder based on aluminum oxide with a particle size of 27 microns at a distance of 1 cm for 3 seconds.

Then, in groups 1 and 5, the surface was treated with phosphoric acid (Travex gel, Omegadent, Russia), the 5th generation adhesive system Optibond solo plus (Kerr, Italy) was applied, polymerization was carried out for 20 seconds, after which the low-modulus composite material Estelite flow quick (Tokyama dental) was applied , Japan) in the form of a 4×3×3 mm bar and polymerized for 20 seconds. After the manufacture of the first bar, an impression was taken from it using the Spidex silicone mass, cut longitudinally so that subsequent samples were poured in the same shape.

In groups 2 and 6, the surface was treated with phosphoric acid (Travex gel, Omegadent, Russia), the All bond universal adhesive system (Bisco, USA) was applied, polymerization was carried out for 20 seconds, and the low-modulus composite material Estelite flow quick (Tokyama dental, Japan) was applied in the form bar size 4×3×3 mm and polymerized for 20 seconds.

In groups 3 and 7, the enamel surface was treated with ICON etch (DMG, Germany) three times for 3 minutes using a special nozzle ICON vectibular (DMG, Germany), washed off with water and dried after each application. Then ICON dry was applied for 30 seconds and ICON infiltrant for 3 minutes, excess material was removed and cured for 40 seconds. After that, ICON infiltrant was reapplied for 1 minute, excess material was removed and polymerized for 40 seconds. Further, without polishing the surface, a low-modulus composite material Estelite flow quick (Tokyama dental, Japan) was applied to the surface of the infiltrant in the form of a bar 4 × 3 × 3 mm in size and polymerized for 20 seconds.

In groups 4 and 8, the enamel surface was treated with ICON etch (DMG, Germany) three times for 3 minutes using a special nozzle ICON vectibular (DMG, Germany), washed off with water and dried after each application. Then ICON dry was applied for 30 seconds and ICON infiltrant for 3 minutes, excess material was removed and cured for 40 seconds. After that, ICON infiltrant was reapplied for 1 minute, excess material was removed and polymerized for 40 seconds. Further, without polishing the surface, a low-modulus composite material containing the MDP monomer, Constic (DMG, Germany), was applied to the surface of the infiltrant in the form of a bar 4 × 3 × 3 mm in size and polymerized for 20 seconds.

After fixing the composite bars, their length, width, and height were measured. Then the samples were placed in distilled water in a thermostat at a temperature of 37°C for 24 hours. After preparing the samples, the adhesive peel strength was studied.

The adhesive peel strength was determined on an Instron universal testing machine (USA) with a traverse movement speed of 0.8 mm/min, which makes it possible to determine the force applied to the peel specimen F, expressed in newtons (N). Data processing was carried out using Instron Bluehill 3 software. Peel adhesion strength Σ was calculated using the formula: Σ=3Fl/bh2, where F is the force in Newtons (N) applied to the composite bar at which the peel occurred; l is the length of the bar in m; b is the width of the bar in m; h is the height of the bar in m.

Peel adhesive strength Σ was expressed in N/m2 or in megapascals (MPa). Table 1 shows data on the adhesive peel strength in the studied groups.

Table 1

Comparison of the index of adhesive peel strength in the studied groups

Group Minimum Maximum Median 1st quartile 3rd quartile Average value Standard deviation 1 17 24 19.13 17.41 20.26 19.11 1.84 2 18 28 26.35 25.45 27.58 25.82 2.48 3 16 24 20.12 18.88 21.47 20.12 2.08 4 23 thirty 26.69 24.74 27.82 26.43 2.07 5 16 25 19.15 17.29 21.69 19.56 2.62 6 21 33 25.63 22.89 27.69 24.04 3.23 7 13 27 21.43 17.96 23.24 20.84 3.69 8 21 29 27.75 26.03 28.52 27.08 2.25

To compare the adhesive strength in the study groups, the Kruskal-Wallis test was used using the generally accepted significance level p<0.05. The value of the Kruskal-Wallis test was 76.401, and the corresponding significance level was p<0.0001. This showed that, overall, the differences between the groups were statistically significant. To determine which specific groups had significant differences, it was necessary to conduct a pairwise comparison of all groups, and therefore used the Mann-Whitney U-test, recalculating the significance level p as a correction for multiple comparisons ( p ' = 0.05/ 28=0.0018).

The results obtained allow us to conclude that the adhesive strength of the composite material to enamel when using the same method of adhesive fixation in intact teeth and teeth with fluorosis does not differ. The best indicators of adhesive peel strength were obtained with the use of a universal adhesive system and a low-modulus composite material, as well as with a combination of the use of an infiltrant and a low-modulus composite material Constic containing an MDP monomer.

The results of the experimental study made it possible to apply the combined use of the ICON infiltrant infiltrant and the low-modulus composite material Constic in the clinic.

An example of a specific implementation of the treatment method is presented in the form of an extract from the case histories.

Clinical example

Objectively: the patient lives in an endemic area with high levels of fluoride in drinking water. The source of water is centralized water supply. On examination, it was found that the lesions affected all groups of teeth. The enamel of all teeth has a matte tint, lacks luster, is covered with multiple spots of light brown color, there are areas of destruction in the form of stripes and rounded depressions located within the enamel. The patient presented increased aesthetic complaints to the appearance of the upper incisors and canines. Therefore, a decision was made to carry out treatment in the area of teeth 1.3, 1.2, 1.1, 2.1, 2.2, 2.3.

On the vestibular surfaces 1.3, 1.2, 1.1, 2.1, 2.2, 2.3, there are rounded foci of destruction that do not reach the enamel-dentin border, pigmentation varies from light yellow to dark brown. When probing, pain is not noted, the surface is rough, there is no reaction to temperature stimuli. Diagnosis: dental fluorosis. K00.30.

Stages of treatment: after professional oral hygiene, the gum tissue was isolated using a liquid rubber dam (Fig. 2).

Opalustre (Ultradent, USA) was applied to the vestibular surfaces of the teeth (Fig. 3) for 1 minute, and the drug was rubbed with Opal Cups at a speed of 1500 rpm (Fig. 4) for 30 seconds. in the area of each tooth.

Rinse with water for 30 seconds and reapply Opalustre five times with repeated rubbing for 30 seconds on each tooth.

In FIG. 5 shows the surface of the teeth after the first 30 second rubbing cycle of Opalustre, FIG. 6, 7, 8, 9 - view of the teeth after the second, third, fourth and fifth application of Opalustre. After washing off the gel, the work area was dried with dry air.

The next stage of treatment was the use of Icon. 15% Icon-Etch hydrochloric acid was evenly spread on the dry surface of the anterior teeth for 2 minutes (Fig. 10).

Using a nozzle for the vestibular surfaces, the agent was rubbed in during the entire exposure time (Fig. 11).

Icon-Etch was then washed off with water for 30 seconds, Icon-Etch was reapplied twice for two minutes, rinsed, air dried, and Icon-Dry ethanol conditioner was applied for 30 seconds (Figure 12). Then again dried with air (Fig. 13).

The next stage of treatment is the direct infiltration of the vestibular surfaces of the teeth. Icon-Infiltrant was applied with a slight excess to the lesions. Left the material to act for 3 minutes (Fig. 14). During this time, the material penetrates into the porous structure of the enamel by the capillary principle.

The Icon-Infiltrant was then polymerized for 40 seconds with an LED lamp. To reduce polymerization shrinkage and increase microhardness, the material was applied a second time for 1 minute and polymerized for 40 seconds.

If you carefully look at the surface of the teeth, then in areas where there were already enamel defects and where we actively applied mechanical and chemical effects, there is a slight lack of tissues (Fig. 15), which can be filled with a minimum layer of composite filling material.

After polymerization of the last Icon-Infiltrant layer, an oxygen-inhibited layer remains on its surface. Directly on it in the area of defects in the enamel of teeth 1.2, 1.1, 2.1, 2.2, a low-modulus composite Constic (DMG) was applied with a layer of 1 mm. To completely restore the vestibular surface in the area of tooth 1.1, a second layer of material was applied with a layer of 1 mm, so the total thickness of the coating in area 1.1 was 2 mm.

Photopolymerization of each layer was carried out for 20 seconds. Grinding and polishing was done with Sof-lex discs, Enhance rubbers, and Occlubrush brushes.

As a result of the treatment, a good aesthetic result was obtained without preparation, in one visit. At the same time, the hard tissues of the patient's teeth were preserved as much as possible, their shape was not changed. No ceramic or composite veneers were required (Fig. 17).

Claims (1)

A method for the treatment of dental fluorosis, including infiltration using the ICON system, followed by the application of a composite, characterized in that Opalustre gel is applied to the vestibular surface of the tooth for 1 minute and the preparation is rubbed in for 30 seconds, rinsed with water for 30 seconds and Opalustre is applied again until five times, depending on the visual removal of the pigment, 15% Icon-Etch hydrochloric acid is evenly distributed three times on the dry tooth surface for 3 minutes using a nozzle for the vestibular surfaces and rubbed during the entire exposure time, Icon-Dry ethanol-containing conditioner is applied for 30 seconds , dry with air, Icon-Infiltrant is applied to the lesion for 3 minutes and polymerized with an LED polymerization lamp for 40 seconds, Icon-Infiltrant is applied for 1 minute and polymerized for 40 seconds, low-modulus Constic composite is applied in the area of enamel defects with a layer of no more than 2 mm, if the tissue volume is not replenished in one portion of the application, the composite is reapplied with a layer of no more than 2 mm, polymerizing each layer separately for 20 seconds.

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