classification of caries. Classifications of caries General approaches to the diagnosis and treatment of dental caries

The protocol for managing patients with dental caries was developed by the Moscow State University of Medicine and Dentistry (Kuzmina E.M., Maksimovsky Yu.M., Maly A.Yu., Zheludeva I.V., Smirnova T.A., Bychkova N.V. , Titkina N.A.), Dental Association of Russia (Leontiev V.K., Borovsky E.V., Vagner V.D.), Moscow Medical Academy. THEM. Sechenov Roszdrav (Vorobiev P.A., Avksentieva M.V., Lukyantseva D.V.), dental clinic No. 2 in Moscow (Chepovskaya S.G., Kocherov A.M., Bagdasaryan M.I., Kocherova M.A.).

I. SCOPE

The dental caries management protocol is intended for use in the healthcare system Russian Federation.

II. NORMATIVE REFERENCES

- Decree of the Government of the Russian Federation dated 05.11.97 No. 1387 "On measures to stabilize and develop health care and medical science in the Russian Federation" (Collected Legislation of the Russian Federation, 1997, No. 46, Art. 5312).
- Decree of the Government of the Russian Federation of October 26, 1999 No. 1194 "On approval of the Program of state guarantees for providing citizens of the Russian Federation with free medical care" (Collected Legislation of the Russian Federation, 1997, No. 46, Art. 5322).
- Nomenclature of works and services in health care. Approved by the Ministry of Health and Social Development of Russia on July 12, 2004 - M., 2004. - 211 p.

III. GENERAL PROVISIONS

The protocol for managing patients with dental caries has been developed to solve the following problems:

- establishment of uniform requirements for the procedure for diagnosing and treating patients with dental caries;
- unification of the development of basic programs of compulsory health insurance and optimization of medical care for patients with dental caries;
- ensuring optimal volumes, availability and quality of medical care provided to the patient in a medical institution.

The scope of this protocol is medical and preventive institutions of all levels and organizational and legal forms that provide medical dental care, including specialized departments and offices of any form of ownership.

This paper uses the data evidence strength scale:

A) The evidence is compelling: there is strong evidence for the proposed assertion.
B) Relative Strength of Evidence: there is sufficient evidence to recommend this proposal.
C) There is not enough evidence: The available evidence is insufficient to make a recommendation, but recommendations may be made in other circumstances.
D) Sufficient negative evidence: there is enough evidence to recommend that the use of this drug, material, method, technology be abandoned under certain conditions.
E) Strong negative evidence: there is sufficient evidence to exclude the drug, method, technique from the recommendations.

IV. RECORD KEEPING

Maintaining the Protocol "Dental caries" is carried out by the Moscow State Medical and Dental University of Roszdrav. The reference system provides for the interaction of the Moscow State University of Medicine and Dentistry with all interested organizations.

V. GENERAL QUESTIONS

Dental caries(K02 according to ICD-10) is an infectious pathological process that manifests itself after teething, in which demineralization and softening of the hard tissues of the tooth occur, followed by the formation of a defect in the form of a cavity.

Currently, dental caries is the most common disease of the dentoalveolar system. The prevalence of caries in our country in the adult population aged 35 years and older is 98-99%. AT overall structure providing medical care to patients in medical and preventive institutions of the dental profile, this disease occurs in all age groups of patients. Dental caries with untimely or improper treatment can cause the development inflammatory diseases pulp and periodontal disease, loss of teeth, development of pyoinflammatory diseases maxillofacial area. Dental caries are potential foci of intoxication and infectious sensitization of the body.

The development rates of complications of dental caries are significant: in the age group of 35-44 years, the need for filling and prosthetics is 48% and tooth extraction - 24%.

Untimely treatment of dental caries, as well as the extraction of teeth as a result of its complications, in turn, lead to the appearance of secondary deformation of the dentition and the occurrence of pathology of the temporomandibular joint. Dental caries directly affects the health and quality of life of the patient, causing violations of the chewing process up to the final loss of this function of the body, which affects the digestion process.

In addition, dental caries is often the cause of the development of diseases of the gastrointestinal tract.

ETIOLOGY AND PATHOGENESIS

The direct cause of enamel demineralization and the formation of a carious focus are organic acids (mainly lactic), which are formed during the fermentation of carbohydrates by plaque microorganisms. Caries is a multifactorial process. Microorganisms in the oral cavity, the nature and diet, enamel resistance, the quantity and quality of mixed saliva, the general condition of the body, exogenous effects on the body, the fluorine content in drinking water affect the occurrence of an enamel demineralization focus, the course of the process and the possibility of its stabilization. Initially, a carious lesion occurs due to the frequent use of carbohydrates and insufficient oral care. As a result, adhesion and reproduction of cariogenic microorganisms occur on the tooth surface and dental plaque. Further intake of carbohydrates leads to a local change in pH to the acid side, demineralization and the formation of microdefects in the subsurface layers of enamel. However, if the organic matrix of enamel is preserved, then the carious process at the stage of its demineralization can be reversible. Long-term existence of the focus of demineralization leads to the dissolution of the surface, more stable layer of enamel. Stabilization of this process can be clinically manifested by the formation of a pigmented spot that has existed for years.

CLINICAL PICTURE OF DENTAL CARIES

The clinical picture is characterized by diversity and depends on the depth and topography of the carious cavity. A sign of initial caries is a change in the color of the tooth enamel in a limited area and the appearance of a spot, subsequently a defect develops in the form of a cavity, and the main manifestation of the developed caries is the destruction of the hard tissues of the tooth.

With an increase in the depth of the carious cavity, patients feel increased sensitivity to chemical, thermal and mechanical stimuli. Pain from irritants is short-lived, after elimination of the irritant quickly passes. There may be no pain response. carious lesion chewing teeth causes dysfunction of chewing, patients complain of pain when eating and violations of aesthetics.

CLASSIFICATION OF DENTAL CARIES

In the International Statistical Classification of Diseases and Related Health Problems of the World Health Organization of the Tenth Revision (ICD-10), caries is singled out as a separate heading.

K02.0 Enamel caries. "White (chalky) spot" stage [initial caries]
K02.I Dentinal caries
K02.2 Cement caries
K02.3 Suspended dental caries
K02.4 Odontoclasia
K02.8 Other dental caries
K02.9 Dental caries, unspecified

Modified classification of carious lesions by localization (according to Black)

Class I - cavities located in the area of ​​fissures and natural recesses of incisors, canines, molars and premolars.
Class II - cavities located on the contact surface of molars and premolars.
Class III - cavities located on the contact surface of the incisors and canines without disturbing the cutting edge.
Class IV - cavities located on the contact surface of the incisors and canines with a violation of the angle of the crown part of the tooth and its cutting edge.
Class V - cavities located in the cervical region of all groups of teeth.
Class VI - cavities located on the tubercles of molars and premolars and the cutting edges of incisors and canines.

The stain stage corresponds to the ICD-C code K02.0 - "Enamel caries. The stage of the "white (matte) spot" [initial caries]". Caries in the stain stage is characterized by changes in the color (matte surface) resulting from demineralization, and then the texture (roughness) of the enamel in the absence of a carious cavity, which did not spread beyond the enamel-dentin border.

The stage of dentine caries corresponds to the ICD-C code K02.1 and is characterized by destructive changes in enamel and dentin with the transition of the enamel-dentin border, however, the pulp is covered with a larger or smaller layer of preserved dentin and without signs of hyperemia.

The cement caries stage corresponds to the ICD-C code K02.2 and is characterized by damage to the exposed surface of the tooth root in the cervical region.

The stage of suspended caries corresponds to the ICD-C code K02.3 and is characterized by the presence of a dark pigmented spot within the enamel (focal enamel demineralization).

1 ICD-C - International classification of dental diseases based on ICD-10.

GENERAL APPROACHES TO THE DIAGNOSIS OF DENTAL CARIES

Diagnosis of dental caries is made by taking anamnesis, clinical examination and additional methods examinations. The main task in the diagnosis is to determine the stage of development of the carious process and the choice of the appropriate method of treatment. When diagnosing, the localization of caries and the degree of destruction of the crown part of the tooth are established. Depending on the diagnosis, the method of treatment is chosen.

Diagnosis is carried out for each tooth and is aimed at identifying factors that prevent the immediate start of treatment. These factors can be:

- the presence of intolerance medicines and materials used at this stage of treatment;
- comorbidities that aggravate treatment;
- inadequate psycho-emotional state of the patient before treatment;
- acute lesions of the oral mucosa and the red border of the lips;
- acute inflammatory diseases of the organs and tissues of the oral cavity;
- life threatening acute condition / illness or exacerbation of a chronic disease (including myocardial infarction, acute disorder cerebral circulation) that developed less than 6 months before applying for this dental care;
- diseases of periodontal tissues in the acute stage;
- unsatisfactory hygienic condition of the oral cavity;
- refusal of treatment.

GENERAL APPROACHES TO THE TREATMENT OF DENTAL CARIES

The principles of treatment of patients with dental caries provide for the simultaneous solution of several problems:

- elimination of factors causing the process of demineralization;
- prevention of further development of the pathological carious process;
- preservation and restoration of the anatomical shape of the tooth affected by caries and the functional ability of the entire dental system;
- prevention of development of pathological processes and complications;
- Improving the quality of life of patients.

Caries treatment may include:

- elimination of microorganisms from the surface of the teeth;
- remineralizing therapy at the stage of "white (chalky) spot";
- fluoridation of hard tissues of teeth with suspended caries;
- preservation, as far as possible, of healthy hard tissues of the tooth, if necessary, excision of pathologically altered tissues, followed by restoration of the tooth crown;
- Issuance of recommendations on the timing of re-applying.

Treatment is carried out for each tooth affected by caries, regardless of the degree of damage and the treatment of other teeth.

In the treatment of dental caries, only those dental materials and medicines are used that are approved for use on the territory of the Russian Federation in the prescribed manner.

ORGANIZATION OF MEDICAL CARE FOR PATIENTS WITH DENTAL CARIES

Treatment of patients with dental caries is carried out in medical and preventive institutions of the dental profile, as well as in departments and offices of therapeutic dentistry of multidisciplinary medical and preventive institutions. As a rule, treatment is carried out on an outpatient basis.

The list of dental materials and tools necessary for the work of a doctor is presented in Appendix 1.

Assistance to patients with dental caries is carried out mainly by dentists, general dentists, orthopedic dentists, and dentists. Nursing staff and dental hygienists are involved in the process of providing assistance.

VI. CHARACTERISTICS OF REQUIREMENTS

6.1. Patient Model

6.1.1 Criteria and features that define the patient model

6.1.2 How to include a patient in the Protocol

6.1.3. Requirements for the diagnosis of outpatient

6.1.4. Characteristics of algorithms and features of the implementation of diagnostic measures

For this purpose, all patients must take an anamnesis, examine the oral cavity and teeth, as well as other necessary studies, the results of which are entered in the medical record of the dental patient (form 043 / y).

Collection of anamnesis

All teeth are subject to examination, starting with the right upper molars and ending with the lower right molars. All surfaces of each tooth are examined in detail, paying attention to the color, enamel relief, the presence of plaque, the presence of stains and their condition after drying the surface of the teeth, defects.

Pay attention to the presence of white matte spots on the visible surfaces of the teeth, the area, shape of the edges, surface texture, density, symmetry and multiplicity of lesions in order to establish the severity of changes and the rate of development of the process, the dynamics of the disease, as well as differential diagnosis with non-carious lesions. Fluorescent stomatoscopy can be used to confirm the diagnosis.

Thermodiagnostics It is used to identify pain reactions and clarify the diagnosis.

Percussion used to exclude complications of caries.

Vital staining of dental hard tissues. In cases difficult for differential diagnosis with non-carious lesions, the lesion is stained with a 2% solution of methylene blue. If a negative result is obtained, appropriate treatment is carried out (another model of the patient).

Indices of oral hygiene determined before treatment and after training in oral hygiene, in order to control.

6.1.5. Requirements for outpatient treatment

6.1.6 Characteristics of the algorithms and features of the implementation of non-drug care

Non-pharmacological care is aimed at ensuring proper oral hygiene in order to prevent the development of caries and includes three main components: oral hygiene education, supervised brushing and professional oral and dental hygiene.

In order to develop the patient's oral care skills (brushing teeth) and maximize efficient removal soft plaque from the surfaces of the teeth teach the patient oral hygiene techniques. Teeth brushing techniques are demonstrated on models.

Individually selected oral hygiene products. Oral hygiene education contributes to the prevention of dental caries (Level of Evidence B).

Supervised brushing of teeth means brushing that the patient performs independently in the presence of a specialist (dentist, dental hygienist) in the dental office or oral hygiene room, if available. necessary funds hygiene and visual aids. The purpose of this event is to control the effectiveness of brushing teeth by the patient, correcting the shortcomings of brushing technique. Supervised brushing is effective in maintaining oral hygiene (Level of Evidence B).

Professional oral hygiene includes the removal of supragingival and subgingival plaque from the tooth surface and helps prevent the development of dental caries and inflammatory periodontal disease (Level of Evidence A).

First visit

Finish cleaning in a circular motion toothbrush with closed jaws, massaging the gums, from right to left.

Individual selection of oral hygiene products is carried out taking into account the dental status of the patient (the state of hard tissues of the teeth and periodontal tissues, the presence of dentoalveolar anomalies, removable and non-removable orthodontic and orthopedic structures) ().

Second visit

First visit

Next visit

The patient is instructed to attend preventive examination see a doctor at least once every six months

- carry out antiseptic treatment of the oral cavity with an antiseptic solution (0.06% chlorhexide solution, 0.05% potassium permanganate solution);

Grinding hard tissues of teeth

Grinding is carried out before the start of the course of remineralizing therapy in the presence of rough surfaces.

Sealing the fissure of a tooth with a sealant

To prevent the development of a carious process, the fissures of the teeth are sealed with a sealant in the presence of deep, narrow (pronounced) fissures.

6.1.7. Requirements for outpatient drug care

6.1.8. Characteristics of algorithms and features of the use of medicines

The main treatments for enamel caries in the stain stage are remineralizing therapy and fluoridation (Level of Evidence B).

Remineralizing therapy

The course of remineralizing therapy consists of 10-15 applications (daily or every other day). Before starting treatment, in the presence of rough surfaces, they are ground off. Start a course of remineralizing therapy. Before each application, the affected tooth surface is mechanically cleaned of plaque and dried with a stream of air.

Applications with remineralizing agents on the treated tooth surface for 15-20 minutes with a change of tampon every 4-5 minutes. Applications of 1-2% sodium fluoride solution are carried out in every 3rd visit, after application of a remineralizing solution on a cleaned and dried tooth surface for 2-3 minutes.

Application of fluoride varnish on the teeth, as an analogue of 1-2% sodium fluoride solution, is carried out in every 3rd visit after application with a remineralizing solution, on the dried surface of the tooth. After the application, the patient is not recommended to eat for 2 hours and brush his teeth for 12 hours.

The criterion for the effectiveness of a course of remineralizing therapy and fluoridation is a decrease in the size of the demineralization focus until it disappears, restoration of enamel gloss or less intense staining of the demineralization focus (according to a 10-point enamel staining scale) with a 2% methylene blue dye solution.

6.1.9. Requirements for the regime of work, rest, treatment and rehabilitation

Patients with enamel caries in the stain stage should visit a specialist once every six months for observation.

6.1.10. Requirements for patient care and ancillary procedures

6.1.11. Dietary requirements and restrictions

After completion of each medical procedure it is recommended not to eat or rinse your mouth for 2 hours. Limiting the consumption of foods and drinks with low pH values ​​​​(juices, tonic drinks, yogurts) and thoroughly rinsing the mouth after taking them.

Limiting the stay of carbohydrates in the oral cavity (sucking, chewing sweets).

6.1.12. The form of informed voluntary consent of the patient during the implementation of the Protocol

6.1.13. Additional information for the patient and his family members

6.1.14. Rules for changing requirements when implementing the Protocol and terminating the requirements of the Protocol

6.1.15. Possible outcomes and their characteristics

6.1.16. Cost characteristics of the Protocol

6.2. PATIENT MODEL

6.2.1. Criteria and features that define the patient model

6.2.2. Procedure for including a patient in the Protocol

The patient's condition that satisfies the criteria and features of the diagnosis of this patient model.

6.2.3. Requirements for the diagnosis of outpatient

6.2.4. Characteristics of algorithms and features of the implementation of diagnostic measures

Collection of anamnesis

When collecting an anamnesis, they find out the presence of complaints of pain from irritants, an allergic history, the presence of somatic diseases. Purposefully identify complaints of pain and discomfort in the area of ​​a particular tooth, food jamming, how long ago they appeared, when the patient paid attention to them. Special attention they turn to clarifying the nature of complaints, whether they are always, in the patient's opinion, associated with a specific stimulus. Find out the profession of the patient, whether the patient provides proper hygienic care for the oral cavity, the time of the last visit to the dentist.

When examining the oral cavity, the state of the dentition is assessed, paying attention to the presence of fillings, the degree of their fit, the presence of defects in the hard tissues of the teeth, the number of teeth removed. The intensity of caries is determined (CPU index - caries, filling, removed), hygiene index. Pay attention to the condition of the oral mucosa, its color, moisture content, the presence of pathological changes. All teeth are subject to examination, starting with the right upper molars and ending with the lower right molars.

Examine all surfaces of each tooth, pay attention to the color, enamel relief, the presence of plaque, the presence of stains and their condition after drying the surface of the teeth, defects.

Pay attention to the fact that probing is carried out without strong pressure. Pay attention to the presence of spots on the visible surfaces of the teeth, the presence of spots and their condition after drying the surface of the teeth, the area, shape of the edges, surface texture, density, symmetry and multiplicity of lesions in order to establish the severity of the disease and the rate of development of the process, the dynamics of the disease, and also differential diagnosis with non-carious lesions. When probing the identified carious cavity, attention is paid to its shape, localization, size, depth, the presence of softened dentin, a change in its color, soreness, or vice versa, the absence pain sensitivity. Particularly carefully examine the proximal surfaces of the tooth. Thermodiagnostics are being carried out. To confirm the diagnosis, in the presence of a cavity on the contact surface and in the absence of pulp sensitivity, radiography is performed.

When conducting electroodontometry, the sensitivity of the pulp with dentin caries is recorded in the range from 2 to 10 μA.

6.2.5. Requirements for outpatient treatment

6.2.6. Characteristics of the algorithms and features of the implementation of non-drug care

Non-drug care is aimed at preventing the development of a carious process and includes three main components: ensuring proper oral hygiene, filling a carious defect, and, if necessary, prosthetics.

Caries treatment, regardless of the location of the carious cavity, includes: premedication (if necessary), anesthesia, opening of the carious cavity, removal of softened and pigmented dentin, formation, finishing, washing and filling of the cavity (if indicated) or prosthetics with inlays, crowns or veneers.

Indications for prosthetics are:

Damage to the hard tissues of the crown part of the tooth after preparation: for the group of chewing teeth, the index of destruction of the occlusal surface of the tooth (IROPZ) > 0.4 indicates the manufacture of inlays, IROPZ > 0.6 - the manufacture of artificial crowns is indicated, IROPZ > 0.8 - the use of pin structures is indicated followed by the manufacture of crowns;
- prevention of the development of deformities of the dentoalveolar system in the presence of neighboring teeth with fillings that replenish more? chewing surface.

The main goals of treatment:

Stopping the pathological process;
- restoration of the anatomical shape and function of the tooth;
- prevention of the development of complications, including the prevention of the development of the Popov-Godon phenomenon in the area of ​​the teeth of antagonists;
- restoration of the aesthetics of the dentition.

Treatment of dentinal caries with filling and, if necessary, prosthetics, allows for compensation of function and stabilization of the process (Level of Evidence A).

Algorithm for teaching oral hygiene

First visit

The doctor or dental hygienist determines the hygiene index, then demonstrates to the patient the technique of brushing and flossing the teeth, using dental arch models, or other demonstration tools.

Toothbrushing begins with a site in the region of the upper right chewing teeth, sequentially moving from segment to segment. In the same order, teeth are cleaned in the lower jaw.

Pay attention to the fact that the working part of the toothbrush should be placed at an angle of 45 ° to the tooth, make cleaning movements from gum to tooth, while removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the brush fibers penetrate deep into the fissures and interdental spaces. The vestibular surface of the frontal group of teeth of the upper and mandible clean with the same movements as molars and premolars. When cleaning the oral surface, the brush handle should be perpendicular to the occlusal plane of the teeth, while the fibers should be at an acute angle to the teeth and capture not only the teeth, but also the gums.

Complete cleaning with circular movements of the toothbrush with closed jaws, massaging the gums from right to left.

The cleaning time is 3 minutes.

For high-quality cleaning of the contact surfaces of the teeth, it is necessary to use dental floss.

Second visit

In order to consolidate the acquired skills, controlled brushing of the teeth is carried out.

Controlled brushing algorithm

First visit

Treatment of the patient's teeth with a staining agent, determination of the hygienic index, demonstration to the patient with the help of a mirror of the places of the greatest accumulation of plaque.
- Brushing the patient's teeth in his usual manner.
- Re-determination of the hygiene index, assessment of the effectiveness of brushing teeth (comparison of the hygiene index before and after brushing), showing the patient with a mirror of stained areas where plaque was not removed during brushing.
- Demo correct technique brushing teeth on models, recommendations to the patient on correcting deficiencies in hygienic care of the oral cavity, the use of dental floss and additional funds hygiene (special toothbrushes, toothbrushes, monopuff brushes, irrigators - according to indications).

Next visit

Determination of the hygienic index, with a satisfactory level of oral hygiene - repeat the procedure.

Stages professional hygiene:

Patient education in individual oral hygiene;
- removal of supra- and subgingival dental deposits;
- polishing of surfaces of teeth, including surfaces of roots;
- elimination of factors contributing to the accumulation of plaque;
- applications of remineralizing and fluoride-containing products (with the exception of areas with a high fluoride content in drinking water);
- motivation of the patient to prevent and treat dental diseases. The procedure is carried out in one visit.
- When removing supra- and subgingival dental deposits (tartar, dense and soft plaque), a number of conditions should be observed:
- removal of tartar with application anesthesia;

- isolate treated teeth from saliva;
- pay attention that the hand holding the instrument must be fixed on the patient's chin or adjacent teeth, the terminal shaft of the instrument is parallel to the axis of the tooth, the main movements - lever-like and scraping - must be smooth, not traumatic.

In the field of ceramic-metal, ceramic, composite restorations, implants (plastic instruments are used in the processing of the latter), a manual method is used to remove dental deposits.

Ultrasound devices should not be used in patients with respiratory, infectious diseases and in patients with pacemakers.

To remove plaque and polish smooth surfaces of teeth, it is recommended to use rubber caps, chewing surfaces - rotating brushes, contact surfaces - flosses and abrasive strips. Polishing paste should be used from coarse to fine. Fluoride-containing polishing pastes are not recommended before certain procedures (fissure sealing, teeth whitening). Fine polishing pastes and rubber caps should be used when processing implant surfaces.

It is necessary to eliminate the factors contributing to the accumulation of plaque: remove the overhanging edges of the fillings, re-polish the fillings.

The frequency of professional oral hygiene depends on the patient's dental status (hygienic condition of the oral cavity, the intensity of dental caries, the condition of periodontal tissues, the presence of non-removable orthodontic equipment and dental implants). The minimum frequency of professional hygiene is 2 times a year.

With caries of dentin, filling is carried out in one visit. After diagnostic studies and a decision on treatment at the same appointment, treatment is started.

It is possible to place a temporary filling (bandage) if it is not possible to put a permanent filling on the first visit or to confirm the diagnosis.

Anesthesia;
- "disclosure" of the carious cavity;


- excision of enamel, devoid of underlying dentin (according to indications);
- cavity formation;
- cavity finishing.

It is necessary to pay attention to the processing of the edges of the cavity to create a high-quality marginal fit of the seal and prevent chipping of the enamel and filling material.

When filling with composite materials, sparing preparation of cavities is allowed (level of evidence B).

Features of preparation and filling of cavities

Class I cavities

You should strive to keep the tubercles on the occlusal surface as much as possible; for this, before preparation, with the help of articulating paper, enamel areas that carry an occlusal load are identified. The tubercles are removed partially or completely if the slope of the tubercle is damaged by 1/2 of its length. The preparation, if possible, is carried out in the contours of natural fissures. If necessary, use the technique of "prophylactic expansion" according to Black. The use of this method helps to prevent the recurrence of caries. This type of preparation is recommended primarily for materials that do not have good adhesion to the tooth tissues (amalgam) and are retained in the cavity due to mechanical retention. When expanding the cavity to prevent secondary caries, attention must be paid to maintaining the maximum possible thickness of dentin at the bottom of the cavity.

Class II cavities

Before starting the preparation, the types of access are determined. Spend the formation of the cavity. The quality of the removal of affected tissues is checked using a probe and a caries detector.

When filling, it is necessary to use matrix systems, matrices, interdental wedges. With extensive destruction of the crown part of the tooth, it is necessary to use a matrix holder. It is necessary to perform anesthesia, since the imposition of a matrix holder or the introduction of a wedge is painful for the patient.

A properly formed contact surface of the tooth can never be flat - it must have a shape close to spherical. The contact zone between the teeth should be located in the equatorial region and slightly higher - as in intact teeth. The contact point should not be modeled at the level of the marginal ridges of the teeth: in this case, in addition to food getting stuck in the interdental space, chipping of the material from which the filling is made is possible. As a rule, this error is associated with the use of a flat matrix that does not have a convex contour in the equator region.

The formation of the contact slope of the marginal ridge is carried out using abrasive strips (strips) or disks. The presence of the slope of the edge ridge prevents material from chipping in this area and food getting stuck.

Attention should be paid to the formation of a tight contact between the filling and the adjacent tooth, the prevention of excessive introduction of the material into the region of the gingival wall of the cavity (creating an "overhanging edge"), ensuring the optimal fit of the material to the gingival wall.

Class III cavities

When preparing, it is important to determine the optimal approach. Direct access is possible in case of absence nearby standing tooth or in the presence of a prepared cavity on the adjacent contact surface of the adjacent tooth. Lingual and palatal accesses are preferred, as this allows preserving the vestibular surface of the enamel and providing a higher functional aesthetic level of tooth restoration. During preparation, the contact wall of the cavity is excised with an enamel knife or bur, having previously protected the intact neighboring tooth with a metal matrix. A cavity is formed by removing enamel devoid of underlying dentin, and the edges are treated with finishing burs. It is allowed to preserve the vestibular enamel, devoid of underlying dentin, if it does not have cracks and signs of mineralization.

Class IV cavities

Class IV cavity preparation features are a wide fold, the formation in some cases of an additional platform on the lingual or palatal surface, gentle preparation of tooth tissues during the formation of the gingival wall of the cavity in the event of a carious process spreading below the gum level. When preparing, it is preferable to create a retention form, since the adhesion of composite materials is often insufficient.

When filling, pay attention to the correct formation of the contact point.

When filling with composite materials, the restoration of the incisal edge should be carried out in two stages:

Formation of lingual and palatal fragments of the cutting edge. The first reflection is carried out through the enamel or previously applied composite from the vestibular side;
- formation of the vestibular fragment of the cutting edge; flashing is carried out through the cured lingual or palatal fragment.

Class V cavities

Before starting the preparation, it is imperative to determine the depth of the spread of the process under the gum, if necessary, the patient is sent for correction (excision) of the mucous membrane of the gingival margin to open the surgical field and remove the area of ​​hypertrophied gum. In this case, the treatment is carried out in 2 or more visits, because after the intervention, the cavity is closed with a temporary filling, cement or oil dentin is used as a temporary filling material until the tissues of the gingival margin heal. Then the filling is done.

The shape of the cavity should be round. If the cavity is very small, gentle preparation with ball burs is acceptable without creating retention zones.

For filling defects that are visible when smiling, you should choose a material with sufficient aesthetic characteristics. In patients with poor oral hygiene, it is recommended to use glass ionomer (polyalkenate) cements, which provide long-term fluoridation of tooth tissues after filling and have acceptable aesthetic characteristics. In elderly patients and old age, especially in cases of xerostomia, amalgam or glass ionomers should be used. It is also possible to use compomers with the advantages of glass ionomers and high aesthetics. Composite materials are indicated for filling defects in cases where the aesthetics of a smile is very important.

Class VI cavities

Features of these cavities require gentle removal of affected tissues. Burs should be used, the size of which is only slightly larger than the diameter of the carious cavity. Let us refuse anesthesia, especially with an insignificant depth of the cavity. It is possible to preserve enamel devoid of underlying dentin, which is associated with a rather large thickness of the enamel layer, especially in the region of the molars ().

Algorithm and features of manufacturing tabs

Indications for the manufacture of inlays for dentine caries are cavities of classes I and II according to Black. Inlays can be made from metals, as well as from ceramics and composite materials. Inlays allow you to restore the anatomical shape and function of the tooth, prevent the development of the pathological process, and ensure the aesthetics of the dentition.

Contraindications to the use of inlays for dentin caries are tooth surfaces that are inaccessible for the formation of cavities for inlays and teeth with defective, fragile enamel.

The question of the method of treatment with an inlay or crown for dentin caries can only be decided after the removal of all necrotic tissues.

Tabs are made in several visits.

First visit

During the first visit, a cavity is formed. The cavity under the tab is formed after the removal of necrotic and pigmented tissues affected by caries. It must meet the following requirements:

be box-shaped;
- the bottom and walls of the cavity must withstand chewing pressure;
- the shape of the cavity should ensure that the inlay is kept from displacement in any direction;
- for an accurate marginal fit that ensures tightness, a bevel (fold) should be formed within the enamel at an angle of 45 ° (when making solid inlays).

Cavity preparation is carried out under local anesthesia.

After the formation of the cavity, the insert is modeled in the oral cavity or an impression is obtained.

When modeling a wax model, the inlays pay attention to the accuracy of the wax model fit to the bite, taking into account not only central occlusion, but also all movements of the lower jaw, to exclude the possibility of the formation of retention areas, to give the outer surfaces of the wax model the correct anatomical shape. When modeling an inlay in class II cavities, matrices are used to prevent damage to the interdental gingival papilla.

In the manufacture of inlays by the indirect method, impressions are taken. Obtaining an impression after odontopreparation at the same appointment is possible in the absence of damage to the marginal periodontium. Two-layer silicone and alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. It is advisable to use special glue to fix the silicone impressions on the spoon. After the spoons are removed from the oral cavity, the quality of the impressions is checked.

In the manufacture of ceramic or composite inlays, color determination is carried out.

After modeling the inlay or obtaining impressions for its manufacture, the prepared tooth cavity is closed with a temporary filling.

Next visit

After the inlay is made, the inlay is fitted in the dental laboratory. Pay attention to the accuracy of the marginal fit, the absence of gaps, occlusal contacts with antagonist teeth, proximal contacts, the color of the inlay. If necessary, carry out a correction.

In the manufacture of an all-cast inlay, after polishing it, and in the manufacture of ceramic or composite inlays, after glazing, the inlay is fixed with permanent cement.

The patient is instructed about the rules for using the tab and indicates the need for regular visits to the doctor once every six months.

Algorithm and features of manufacturing micro prostheses (veneers)

For the purposes of this protocol, veneers should be understood as faceted veneers made on the anterior teeth of the upper jaw. Features of the manufacture of veneers:

Veneers are installed only on the front teeth in order to restore the aesthetics of the dentition;
- veneers are made of dental ceramics or composite materials;
- in the manufacture of veneers, the preparation of tooth tissues is carried out only within the enamel, while grinding the pigmented areas;
- veneers are made with overlapping of the cutting edge of the tooth or without overlapping.

First visit

When deciding on the manufacture of a veneer, treatment is started at the same appointment.

Preparation for preparation

Tooth preparation for veneer is performed under local anesthesia.

When preparing, special attention should be paid to the depth: 0.3-0.7 mm of hard tissues are ground off. Before starting the main preparation, it is advisable to retract the gums and mark the preparation depth using a special marking bur (disk) 0.3-0.5 mm in size. It is necessary to pay attention to the preservation of proximal contacts, to avoid preparations in the cervical area.

Obtaining an impression from the prepared tooth is carried out at the same reception. Two-layer silicone and alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. It is advisable to use special glue to fix the silicone impressions on the spoon. After removing the spoons from the oral cavity, the quality of the impressions is checked (accuracy of displaying the anatomical relief, the absence of holes, etc.).

Plaster or silicone blocks are used to fix the correct ratio of the dentition in the position of central occlusion. The color of the veneer is determined.

The prepared teeth are covered with temporary veneers made of composite material or plastic, which are fixed on a temporary calcium-containing cement.

Next visit

Placement and fitting of veneers

Particular attention must be paid to the accuracy of the fit of the edges of the veneer to hard tissues tooth, check the absence of gaps between the veneer and the tooth. Pay attention to approximal contacts, to occlusal contacts with antagonist teeth. Contacts are especially carefully verified during sagittal and transversal movements of the lower jaw. If necessary, a correction is made.

The veneer is cemented to a permanent cement or a dual-cure cementation composite. Pay attention to matching the color of the cement to the color of the veneer. The patient is instructed about the rules for using the veneer and indicates the need for regular visits to the doctor once every six months.

Algorithm and features of manufacturing a solid crown

An indication for the manufacture of crowns is a significant damage to the occlusal or cutting surface of the teeth with preserved vital pulp. Crowns are made on the teeth after the treatment of dentine caries by filling. Solid crowns for dentin caries are made on any teeth to restore the anatomical shape and function, as well as to prevent further tooth decay. Crowns are made in several visits.

Features of the manufacture of solid crowns:

When prosthetics of molars, it is recommended to use a one-piece cast crown or a crown with a metal occlusal surface;
- in the manufacture of a solid-cast metal-ceramic crown, an oral garland is modeled (a metal edging along the edge of the crown);
- plastic (on request - ceramic) cladding is made in the area of ​​the anterior teeth on the upper jaw only up to 5 teeth inclusive and on the lower jaw up to 4 teeth inclusive, then - on demand;
- when making crowns for antagonist teeth, it is necessary to follow a certain sequence:

• the first stage is the simultaneous production of temporary mouthguards for the teeth of both jaws to be prosthetics with the maximum restoration of occlusal relationships and the obligatory determination of the height of the lower face, these mouthguards should reproduce the design of future crowns as accurately as possible;
• first, permanent crowns are made on the teeth of the upper jaw;
• after fixing the crowns on the teeth of the upper jaw, permanent crowns are made on the teeth of the lower jaw.

First visit

Preparation for preparation

To determine the viability of the pulp of prosthetic teeth, electroodontometry is performed before the start of therapeutic measures. Before the start of the preparation, impressions are obtained for the manufacture of temporary plastic crowns (caps).

Preparation of teeth for crowns

The type of preparation is selected depending on the type of future crowns and the group affiliation of the prosthetic teeth. When preparing several teeth, special attention should be paid to the parallelism of the clinical axes of the tooth stumps after preparation.

In the case of the gingival retraction method, when taking an impression, attention is paid to the somatic status of the patient. If there is a history cardiovascular disease (coronary disease heart, angina, arterial hypertension, violations heart rate) adjuvants containing catecholamines (including threads impregnated with such compounds) should not be used for gingival retraction.

To prevent development inflammatory processes in the tissues of the marginal periodontal after preparation, anti-inflammatory regenerative therapy is prescribed (rinsing the oral cavity with tincture of oak bark, as well as infusions of chamomile, sage, etc., if necessary, application with an oil solution of vitamin A or other means that stimulate epithelialization).

Next visit

Taking impressions

In the manufacture of solid crowns, it is recommended to appoint a patient for an appointment the next day or the day after the preparation to take a working two-layer impression from the prepared teeth and an impression of the antagonist teeth, if they were not taken on the first visit.

Two-layer silicone and alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. It is advisable to use special glue to fix the silicone impressions on the spoon. After removing the spoons from the oral cavity, the quality of the impressions is monitored (display of the anatomical relief, absence of pores).

In the case of using the gingival retraction method, when taking impressions, attention is paid to the somatic status of the patient. If there is a history of cardiovascular diseases (ischemic heart disease, angina pectoris, arterial hypertension, cardiac arrhythmias), adjuvants containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

Next visit

Overlay and fitting of the frame of a solid crown. Not earlier than 3 days after the preparation, in order to exclude traumatic (thermal) damage to the pulp, a repeated electroodontometry is performed (it is possible to perform it at the next visit).

Particular attention should be paid to the accuracy of the fit of the framework in the cervical area (marginal fit). Check the absence of a gap between the wall of the crown and the stump of the tooth. Pay attention to the correspondence of the contour of the edge of the supporting crown to the contours of the gingival margin, to the degree of immersion of the edge of the crown into the gingival gap, proximal contacts, occlusal contacts with antagonist teeth. If necessary, a correction is made. If the lining is not provided, the cast crown is polished and fixed with temporary or permanent cement. To fix the crowns, temporary and permanent calcium-containing cements should be used. Before fixing the crown with permanent cement, an electroodontometry is performed to exclude inflammatory processes in the dental pulp. With signs of pulp damage, the issue of depulpation is resolved.

If a ceramic or plastic cladding is provided, the color of the cladding is selected.

Crowns with lining on the upper jaw are made up to the 5th tooth inclusive, on the lower jaw - up to the 4th inclusive. The veneers of the chewing surfaces of the posterior teeth are not shown.

Next visit

Placement and fitting of the finished cast crown with veneer

Particular attention should be paid to the accuracy of the fit of the crown in the cervical area (marginal fit). Check the absence of a gap between the wall of the crown and the stump of the tooth. Pay attention to the correspondence of the contour of the edge of the crown to the contours of the gingival margin, on

the degree of immersion of the crown edge into the gingival gap, proximal contacts, occlusal contacts with antagonist teeth.

If necessary, a correction is made. When using a metal-plastic crown after polishing, and when using a metal-ceramic crown - after glazing, fixation is carried out for temporary (for 2-3 weeks) or for permanent cement. To fix the crowns, temporary and permanent calcium-containing cements should be used. When fixing with temporary cement, special attention should be paid to the removal of cement residues from the interdental spaces.

Next visit

Fixation with permanent cement

When fixing with permanent cement, special attention should be paid to the removal of cement residues from the interdental spaces. The patient is instructed about the rules for using the crown and indicates the need for regular visits to the doctor once every six months.

Algorithm and features of manufacturing a stamped crown

A stamped crown, when properly made, fully restores the anatomical shape of the tooth and prevents the development of complications.

First visit

After diagnostic studies, the necessary preparatory therapeutic measures and a decision on prosthetics at the same appointment, treatment is started. Crowns are made on the teeth after the treatment of dentine caries by filling.

Preparation for preparation

To determine the viability of the pulp of the abutment teeth, electroodontometry is performed before the start of all therapeutic measures.

Before the start of the preparation, impressions are obtained for the manufacture of temporary plastic crowns (cannes). If it is impossible to make temporary mouthguards due to the small amount of preparation, fluoride varnishes are used to protect the prepared teeth.

Tooth preparation

During preparation, attention should be paid to the parallelism of the walls of the prepared tooth (cylinder shape). When preparing several teeth, attention should be paid to the parallelism of the clinical axes of the tooth stumps after preparation. Tooth preparation is performed under local anesthesia.

Obtaining an impression from the prepared teeth at the same appointment is possible in the absence of damage to the marginal periodontium during preparation. In the manufacture of stamped crowns, alginate impression masses and standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. After removing the spoons from the oral cavity, quality control is carried out.

Plaster or silicone blocks are used to fix the correct ratio of the dentition in the position of central occlusion. If it is necessary to determine central ratio jaws, wax bases with occlusal rollers are made. When temporary mouth guards are made, they are fitted, if necessary, they are relocated and fixed with temporary cement.

To prevent the development of inflammatory processes in the tissues of the marginal periodontium associated with injury during preparation, anti-inflammatory regenerative therapy is prescribed (rinsing the oral cavity with infusion of oak bark, chamomile, sage, if necessary, applications with an oil solution of vitamin A or other means that stimulate epithelization).

Next visit

Impressions are taken if they were not taken on the first visit.

Alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. After removing the spoons from the oral cavity, the quality of the impressions is monitored (display of the anatomical relief, absence of pores).

Next visit

Next visit

Trying and fitting stamped crowns

Particular attention should be paid to the accuracy of the fit of the dagger in the cervical region (marginal fit). Check the absence of crown pressure on the tissues of the marginal periodontium. Pay attention to the conformity of the contour of the edge of the supporting crown with the contours of the gingival margin, the degree of immersion of the edge of the crown into the gingival gap (maximum by 0.3-0.5 mm), proximal contacts, occlusal contacts with antagonist teeth.

If necessary, a correction is made. When using combined stamped crowns (according to Belkin), after fitting the crown, an impression of the tooth stump is obtained using wax poured into the crown. Determine the color of the plastic lining. Crowns with lining on the upper jaw are made up to the 5th tooth inclusive, on the lower jaw - up to the 4th inclusive. The veneers of the chewing surfaces of the posterior teeth are generally not shown. After polishing, it is fixed with permanent cement.

Before fixing the crown with permanent cement, an electroodontometry is performed to detect inflammatory processes in the dental pulp. To fix the crowns, permanent calcium-containing cements must be used. With signs of pulp damage, the issue of depulpation is resolved.

The patient is instructed about the rules for using crowns and indicates the need for regular visits to the doctor once every six months.

Algorithm and features of manufacturing an all-ceramic crown

An indication for the manufacture of all-ceramic crowns is a significant damage to the occlusal or cutting surface of the teeth with preserved vital pulp. Crowns are made on the teeth after the treatment of dentine caries by filling.

All-ceramic crowns for dentin caries can be made on any teeth to restore the anatomical shape and function, as well as to prevent further tooth decay. Crowns are made in several visits.

Features of the manufacture of all-ceramic crowns:

The main feature is the need to prepare a tooth with a circular rectangular ledge at an angle of 90°.
- When making crowns for antagonist teeth, it is necessary to follow a certain sequence:

• The first stage is the simultaneous production of temporary mouthguards for the teeth of both jaws to be prosthetics with the maximum restoration of occlusal relationships and the obligatory determination of the height of the lower face. These mouthguards should reproduce the design of future crowns as accurately as possible;
• alternately make permanent crowns on the teeth of the upper jaw;
• after fixing the crowns on the teeth of the upper jaw, permanent crowns are made on the teeth of the lower jaw;
• When the shoulder is at or below the gingival margin, gingival retraction must always be applied before taking the impression.

First visit

After diagnostic studies, the necessary preparatory therapeutic measures and a decision on prosthetics at the same appointment, treatment is started.

Preparation for preparation

To determine the viability of the pulp of the prosthetic teeth, electrodontometry is performed before the start of the treatment. Before the start of the preparation, impressions are obtained for the manufacture of temporary plastic crowns (caps).

Preparation of teeth for all-ceramic crowns

A 90° rectangular shoulder preparation is always used. When preparing several teeth, special attention should be paid to the parallelism of the clinical axes of the tooth stumps after preparation.

The preparation of teeth with vital pulp is performed under local anesthesia. Obtaining an impression from the prepared teeth at the same appointment is possible in the absence of damage to the marginal periodontium during preparation. Two-layer silicone and alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking the impression for better retention of the impression material. It is advisable to use special glue to fix the silicone impressions on the spoon. After the spoons are removed from the oral cavity, the quality of the impressions is checked.

In the case of the gingival retraction method, when taking an impression, attention is paid to the somatic status of the patient. If there is a history of cardiovascular diseases (ischemic heart disease, angina pectoris, arterial hypertension, cardiac arrhythmias), adjuvants containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

Plaster or silicone blocks are used to fix the correct ratio of the dentition in the position of central occlusion. When temporary mouth guards are made, they are fitted, if necessary, they are relined and fixed on a temporary calcium-containing cement.

The color of the future crown is being determined.

To prevent the development of inflammatory processes in the tissues of the marginal periodontal after preparation, anti-inflammatory regenerative therapy is prescribed (rinsing the oral cavity with tincture of oak bark, chamomile and sage, if necessary, applications with an oily solution of vitamin A or other means that stimulate epithelialization).

Next visit

Taking impressions

In the manufacture of all-ceramic crowns, it is recommended to appoint a patient for an appointment the next day or the day after the preparation to obtain a working two-layer impression from the prepared teeth and an impression from the antagonist teeth, if they were not obtained at the first visit. Two-layer silicone and alginate impression masses, standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive plaster before taking impressions for better retention of the impression material. It is advisable to use special glue to fix the silicone impressions on the spoon. After removing the spoons from the oral cavity, the quality of the impressions is monitored (display of the anatomical relief, absence of pores).

In the case of using the gingival retraction method, when taking impressions, attention is paid to the somatic status of the patient. If there is a history of cardiovascular diseases (ischemic heart disease, angina pectoris, arterial hypertension, cardiac arrhythmias), adjuvants containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

Next visit

Placement and fitting of an all-ceramic crown

Not earlier than 3 days after the preparation, to exclude traumatic (thermal) damage to the pulp, a repeated electroodontometry is performed (it is possible to perform it at the next visit).

Particular attention should be paid to the accuracy of the fit of the crown to the ledge in the cervical area (marginal fit). Check the absence of a gap between the wall of the crown and the stump of the tooth. Pay attention to the correspondence of the contour of the edge of the supporting crown to the contours of the edge of the ledge, proximal contacts and occlusal contacts with antagonist teeth. If necessary, a correction is made.

After glazing, fixation is carried out on temporary (for 2-3 weeks) or on permanent cement. To fix the crowns, temporary and permanent calcium-containing cements should be used. When fixing with temporary cement, special attention should be paid to the removal of cement residues from the interdental spaces.

Next visit

Fixation with permanent cement

Before fixing the crown with permanent cement, an electroodontometry is performed to exclude inflammatory processes in the dental pulp. With signs of pulp damage, the issue of depulpation is resolved. For vital teeth, permanent calcium-containing cements should be used to fix crowns.

When fixing with permanent cement, pay special attention to the removal of cement residues from the interdental spaces.

The patient is instructed about the rules for using the crown and indicates the need for regular visits to the doctor once every six months.

6.2.7. Requirements for outpatient drug care

6.2.8. Characteristics of algorithms and features of the use of medicines

The use of local anti-inflammatory and epithelizing agents is indicated for mechanical trauma to the mucous membrane.

Analgesics, non-steroidal anti-inflammatory drugs, drugs for the treatment rheumatic diseases and gout

Assign rinses or baths with decoctions of one of the preparations: oak bark, chamomile flowers, sage 3-4 times a day for 3-5 days (level of evidence C). Applications on the affected areas with sea buckthorn oil - 2-3 times a day for 10-15 minutes (level of evidence C).

vitamins

Applications are applied to the affected areas with an oil solution of retinol - 2-3 times a day for 10-15 minutes. 3-5 days (level of evidence C).

Drugs affecting the blood

Deproteinized hemodialysate - adhesive paste for the oral cavity - 3-5 times a day on the affected areas for 3-5 days (level of evidence C).

Local anesthetics

6.2.9. Requirements for the regime of work, rest, treatment and rehabilitation

Patients should visit a specialist once every six months for observation.

6.2.10. Requirements for patient care and ancillary procedures

6.2.11. Dietary requirements and restrictions

There are no special requirements.

6.2.12. The form of informed voluntary consent of the patient during the implementation of the Protocol

6.2.13. Additional information for the patient and his family members

6.2.14. Rules for changing requirements when implementing the Protocol and terminating the requirements of the Protocol

If signs are identified during the diagnostic process that require preparatory measures for treatment, the patient is transferred to the patient management protocol corresponding to the identified diseases and complications.

If signs of another disease are detected that require diagnostic and therapeutic measures, along with signs of enamel caries, medical care is provided to the patient in accordance with the requirements:

A) the section of this protocol for managing patients corresponding to the management of enamel caries;
b) a protocol for the management of patients with an identified disease or syndrome.

6.2.15. Possible outcomes and their characteristics

6.2.16. Cost characteristics of the Protocol

Cost characteristics are determined in accordance with the requirements of regulatory documents.

6.3. PATIENT MODEL

6.3.1. Criteria and features that define the patient model

6.3.2. Procedure for including a patient in the Protocol

The patient's condition that satisfies the criteria and features of the diagnosis of this patient model.

6.3.3. Requirements for the diagnosis of outpatient

6.3.4. Characteristics of algorithms and features of the implementation of diagnostic measures

Diagnosis is aimed at establishing a diagnosis corresponding to the patient model, excluding complications, determining the possibility of starting treatment without additional diagnostic and therapeutic measures.

For this purpose, all patients must take an anamnesis, examine the oral cavity and teeth, as well as other necessary studies, the results of which are entered in the medical record of the dental patient (form 043 / y).

Collection of anamnesis

When collecting an anamnesis, they find out the presence of complaints about the nature of pain from irritants, an allergic history, and the presence of somatic diseases. Purposefully identify complaints of pain and discomfort in the area of ​​a particular tooth, complaints of food jamming, how long ago they appeared, when the patient paid attention to them. Find out the profession of the patient, whether the patient provides proper hygienic care for the oral cavity, the time of the last visit to the dentist.

Visual examination, examination of the oral cavity with additional instruments

When examining the oral cavity, the state of the dentition is assessed, paying attention to the presence of fillings, the degree of their fit, the presence of defects in the hard tissues of the teeth, the number of teeth removed. The intensity of caries is determined (CPU index - caries, filling, removed), hygiene index. Pay attention to the condition of the oral mucosa, its color, moisture content, the presence of pathological changes. All teeth are subject to examination, starting with the right upper molars and ending with the lower right molars. Examine all surfaces of each tooth, pay attention to the color, enamel relief, the presence of plaque, the presence of stains, the presence of stains and their condition after drying the surface of the teeth, defects.

The probe determines the density of hard tissues, evaluates the texture and degree of surface uniformity, as well as pain sensitivity.

Pay attention to the fact that the sounding was carried out without strong pressure. The presence of spots on the visible surfaces of the teeth, the area, shape of the edges, surface texture, density, symmetry and multiplicity of lesions are detected in order to establish the severity of the disease and the rate of development of the process, the dynamics of the disease, as well as differential diagnosis with non-carious lesions. When probing the identified carious cavity, attention is paid to its shape, localization, size, depth, the presence of softened tissues, a change in their color, soreness, or vice versa, the absence of pain sensitivity. Particularly carefully examine the proximal surfaces of the tooth.

Thermodiagnostics are being carried out.

Percussion is used to rule out caries complications.

X-rays are taken to confirm the diagnosis.

6.3.5. Requirements for outpatient treatment

6.3.6. Characteristics of the algorithms and features of the implementation of non-drug care

Non-drug care is aimed at preventing the development of a carious process and includes two main components: ensuring proper oral hygiene and filling a carious defect. Treatment of caries with cement fillings can achieve compensation of function and stabilization (Level of Evidence A).

Algorithm for teaching oral hygiene

First visit

The doctor or dental hygienist determines the hygiene index, then demonstrates to the patient the technique of brushing and flossing the teeth, using dental arch models, or other demonstration tools.

Toothbrushing begins with a site in the region of the upper right chewing teeth, sequentially moving from segment to segment. In the same order, teeth are cleaned in the lower jaw.

Pay attention to the fact that the working part of the toothbrush should be placed at an angle of 45 ° to the tooth, make cleaning movements from gum to tooth, while removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the brush fibers penetrate deep into the fissures and interdental spaces. The vestibular surface of the frontal group of teeth of the upper and lower jaws should be cleaned with the same movements as molars and premolars. When cleaning the oral surface, the brush handle should be perpendicular to the occlusal plane of the teeth, while the fibers should be at an acute angle to the teeth and capture not only the teeth, but also the gums.

Complete cleaning with circular movements of the toothbrush with closed jaws, massaging the gums from right to left. The cleaning time is 3 minutes.

For high-quality cleaning of the contact surfaces of the teeth, it is necessary to use dental floss.

Individual selection of oral hygiene products is carried out taking into account the patient's dental status (the state of hard tissues of teeth and periodontal tissues, the presence of dentoalveolar anomalies, removable and non-removable orthodontic and orthopedic structures) (see).

Second visit

In order to consolidate the acquired skills, controlled brushing of the teeth is carried out.

Algorithm controlled brushing teeth

First visit

Treatment of the patient's teeth with a staining agent, determination of the hygienic index, demonstration to the patient with the help of a mirror of the places of the greatest accumulation of plaque.
- Brushing the patient's teeth in his usual manner.
- Re-determination of the hygiene index, assessment of the effectiveness of brushing teeth (comparison of the hygiene index before and after brushing teeth), showing the patient with a mirror the colored areas where the tooth was not successful when brushing.
- Demonstration of the correct technique of brushing teeth on models, recommendations to the patient on correcting deficiencies in hygienic oral care, using dental floss and additional hygiene products (special toothbrushes, toothbrushes, single-beam brushes, irrigators - according to indications).

Next visits

Determination of the hygienic index, with an unsatisfactory level of oral hygiene - repeat the procedure.

The patient is instructed to attend a preventive examination to the doctor at least once every six months.

Algorithm for professional oral and dental hygiene

Stages of professional hygiene:

Patient education in individual oral hygiene;
- removal of supra- and subgingival dental deposits;
- polishing of surfaces of teeth, including surfaces of roots;
- elimination of factors contributing to the accumulation of dentition;
- applications of remineralizing and fluoride-containing products (with the exception of areas with a high fluoride content in drinking water);
- motivation of the patient to prevent and treat dental diseases.

The procedure is carried out in one visit.

When removing supra- and subgingival dental deposits (tartar, dense and soft teeth), a number of conditions should be observed:

Removal of tartar is carried out with application anesthesia;
- carry out antiseptic treatment of the oral cavity with an antiseptic solution (0.06% chlorhexidine solution, 0.05% potassium permanganate solution);
- isolate treated teeth from saliva;
- pay attention that the hand holding the instrument must be fixed on the patient's chin or adjacent teeth, the terminal shaft of the instrument is parallel to the axis of the tooth, the main movements - lever-like and scraping - must be smooth, not traumatic.

In the field of ceramic-metal, ceramic, composite restorations, implants (plastic instruments are used in the processing of the latter), a manual method is used to remove dental deposits.

Ultrasound devices should not be used in patients with respiratory, infectious diseases, as well as in patients with a pacemaker.

To remove plaque and polish smooth surfaces of teeth, it is recommended to use rubber caps, chewing surfaces - rotating brushes, contact surfaces - flosses and abrasive strips. Polishing infusion should be used, starting with coarse and ending with fine. Fluoride-containing polishing pastes are not recommended before certain procedures (fissure sealing, teeth whitening). Fine polishing pastes and rubber caps should be used when processing implant surfaces.

It is necessary to eliminate the factors contributing to the accumulation of plaque: remove the overhanging edges of the fillings, re-polish the fillings.

The frequency of professional hygiene of the oral cavity and teeth depends on the patient's dental status (hygienic condition of the oral cavity, the intensity of dental caries, the condition of periodontal tissues, the presence of non-removable orthodontic equipment and dental implants). The minimum frequency of professional hygiene is 2 times a year.

Algorithm and features of sealing

In case of cement caries (usually class V cavities), filling is carried out in one or several visits. After diagnostic studies and a decision on treatment at the same appointment, treatment is started.

Before starting the preparation, it is necessary to determine the depth of the spread of the process under the gum, if necessary, the patient is sent for correction (excision) of the mucous membrane of the gingival margin to open the surgical field and remove the area of ​​hypertrophied gum. In this case, the treatment is carried out in 2 or more visits, because after the intervention, the cavity is closed with a temporary filling, cement or oil dentin is used as a temporary filling material until the tissues of the gingival margin heal. Then the filling is done.

Before preparation, anesthesia is performed (application, infiltration, conduction). Before anesthesia, the injection site is treated with an anesthetic application.

General requirements for cavity preparation:

Anesthesia;
- maximum removal of pathologically altered tooth tissues;
- full preservation of intact tooth tissues is possible;
- cavity formation.

The shape of the cavity should be round. If the cavity is very small, gentle preparation with ball burs without creating retention zones is acceptable (Level of Evidence B).

Amalgams, glass ionomer cements and compomers are used for filling defects.

In patients who neglect oral hygiene, it is recommended to use glass ionomer (polyalkenate) cements, which provide long-term fluoridation of tooth tissues after filling and have acceptable aesthetic characteristics.

In elderly and elderly patients, especially with symptoms of xerostomia (reduced salivation), amalgam or glass ionomers should be used. It is also possible to use compomers with the advantages of glass ionomers and high aesthetics. Composite materials are indicated for filling defects in cases where the aesthetics of a smile is very important (see).

Patients are scheduled to see a doctor at least once every six months for preventive examinations.

Requirements for outpatient drug care

Characteristics of algorithms and features of the use of medicines

Local anesthetics

Before preparation, anesthesia is performed (application, infiltration, conduction) according to indications. Before anesthesia, the injection site is treated local anesthetics(lidocaine, articaine, mepivacaine, etc.).

6.3.9. Requirements for the regime of work, rest, treatment and rehabilitation

Patients should visit a specialist once every six months for preventive examinations and, necessarily, for polishing composite fillings.

6.3.10. Requirements for patient care and ancillary procedures

No special requirements

6.3.11. Dietary requirements and restrictions

There are no special requirements.

6.3.12. The form of voluntary informed consent of the patient during the implementation of the Protocol

6.3.13. Additional information for the patient and his family members

6.3.14. Rules for changing requirements when implementing the Protocol and terminating the requirements of the Protocol

If signs are identified during the diagnostic process that require preparatory measures for treatment, the patient is transferred to the patient management protocol corresponding to the identified diseases and complications.

If signs of another disease are detected that require diagnostic and therapeutic measures, along with signs of enamel caries, medical care is provided to the patient in accordance with the requirements:

A) the section of this protocol for managing patients corresponding to the management of enamel caries;
b) a protocol for the management of patients with an identified disease or syndrome.

6.3.15. Possible outcomes and their characteristics

6.3.16. Cost characteristics of the Protocol

Cost characteristics are determined in accordance with the requirements of regulatory documents.

6.4. PATIENT MODEL

6.4.1. Criteria and features that define the patient model

6.4.2. Procedure for including a patient in the Protocol

The patient's condition that satisfies the criteria and features of the diagnosis of this patient model.

6.4.3. Requirements for the diagnosis of outpatient

6.4.4. Characteristics of algorithms and features of the implementation of diagnostic measures

The examination is aimed at establishing a diagnosis corresponding to the patient's model, excluding complications, determining the possibility of starting treatment without additional diagnostic and therapeutic measures.

For this purpose, all patients must take an anamnesis, examine the oral cavity and teeth, as well as other necessary studies, the results of which are entered in the medical record of the dental patient (form 043 / y).

Main differential diagnostic sign is the color of the spot: pigmented and does not stain with methylene blue, in contrast to the "white (chalky) spot", which is stained.

Collection of anamnesis

When collecting an anamnesis, they find out the presence of complaints of pain from chemical and temperature irritants, an allergic history, the presence of somatic diseases. Purposefully identify complaints of pain and discomfort in the area of ​​a particular tooth, complaints of food jamming, patient satisfaction with the appearance of the tooth, the timing of the appearance of complaints, when the patient noticed the appearance of discomfort. Find out whether the patient is carrying out proper hygienic care for the oral cavity, the profession of the patient, the regions of his birth and residence (endemic areas of fluorosis).

Visual examination, external examination of the maxillofacial region, examination of the oral cavity with additional instruments

When examining the oral cavity, the condition of the dentition is assessed, paying attention to the intensity of caries (the presence of fillings, the degree of their fit, the presence of defects in the hard tissues of the teeth, the number of extracted teeth). The state of the oral mucosa, its color, moisture content, and the presence of pathological changes are determined.

All teeth are subject to examination, starting with the right upper molars and ending with the lower right molars. All surfaces of each tooth are examined in detail, paying attention to the color, enamel relief, the presence of plaque, the presence of stains and their condition after drying the surface of the teeth, defects.

Pay attention to the presence of a dull and / or pigmented spot on the visible surfaces of the tooth, the area, shape of the edges, surface texture, density, symmetry and multiplicity of lesions in order to establish the severity of the disease and the rate of development of the process, the dynamics of the disease, as well as differential diagnosis with non-carious defeats. Fluorescent stomatoscopy can be used to confirm the diagnosis.

Thermodiagnostics is used to identify pain reactions and clarify the diagnosis.

Percussion is used to rule out caries complications.

Oral hygiene indices are determined before treatment and after oral hygiene training, in order to control.

6.4.5. Requirements for outpatient treatment

6.4.6. Characteristics of the algorithms and features of the implementation of non-drug care

Treatment of suspended caries, regardless of the location of the carious cavity, includes:

If the spread of the spot is less than 4 mm2 along the occlusal surface or one third of the contact surface, the application of fluorine-containing preparations and dynamic observation;
- if it is impossible to dynamically monitor the development of the process or if the prevalence of the lesion is more than 4 mm - the creation of a cavity and filling.

Non-drug care is aimed at preventing the development of a carious process and includes two main components: ensuring proper oral hygiene and, if necessary, filling a carious defect.

Remineralization therapy and, if necessary, filling treatment can provide stabilization (Level of Evidence B).

Algorithm for teaching oral hygiene

First visit

The doctor or dental hygienist determines the hygiene index, then demonstrates to the patient the technique of brushing the teeth with a toothbrush and dental floss, using models of dental rads, and other demonstration tools.

Toothbrushing begins with a site in the region of the upper right chewing teeth, sequentially moving from segment to segment. In the same order, teeth are cleaned in the lower jaw.

Pay attention to the fact that the working part of the toothbrush should be placed at an angle of 45 ° to the tooth, make cleaning movements from gum to tooth, while removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the brush fibers penetrate deep into the fissures and interdental spaces. The vestibular surface of the frontal group of teeth of the upper and lower jaws should be cleaned with the same movements as molars and premolars. When cleaning the oral surface, the brush handle should be perpendicular to the occlusal plane of the teeth, while the fibers should be at an acute angle to the teeth and capture not only the teeth, but also the gums.

Complete cleaning with circular movements of the toothbrush with closed jaws, massaging the gums from right to left.

The cleaning time is 3 minutes.

For high-quality cleaning of the contact surfaces of the teeth, it is necessary to use dental floss.

Individual selection of oral hygiene products is carried out taking into account the patient's dental status (the state of hard tissues of teeth and periodontal tissues, the presence of dentoalveolar anomalies, removable and non-removable orthodontic and orthopedic structures) (see).

Second visit

In order to consolidate the acquired skills, controlled brushing of the teeth is carried out.

Controlled brushing algorithm

First visit

Treatment of the patient's teeth with a staining agent, determination of the hygienic index, demonstration to the patient with the help of a mirror of the places of the greatest accumulation of plaque.
- Brushing the patient's teeth in his usual manner.
- Re-determination of the hygiene index, assessment of the effectiveness of brushing teeth (comparison of the hygiene index before and after brushing), showing the patient with a mirror of stained areas where plaque was not removed during brushing.
- Demonstration of the correct technique of brushing teeth on models, recommendations to the patient on correcting deficiencies in hygienic oral care, using dental floss and additional hygiene products (special toothbrushes, toothbrushes, single-beam brushes, irrigators - according to indications).

Next visits

Determination of the hygienic index, with an unsatisfactory level of oral hygiene - repeat the procedure.

The patient is instructed to attend a preventive examination to the doctor at least once every six months.

Algorithm for professional oral and dental hygiene

Stages of professional hygiene:

Patient education in individual oral hygiene;
- removal of supra- and subgingival dental deposits;
- polishing of surfaces of teeth, including surfaces of roots;
- elimination of factors contributing to the accumulation of plaque;
- applications of remineralizing and fluoride-containing products (with the exception of areas with a high fluoride content in drinking water);
- motivation of the patient to prevent and treat dental diseases.

The procedure is carried out in one visit.

When removing supra- and subgingival dental deposits (tartar, dense and soft plaque), a number of conditions should be observed:

Removal of tartar is carried out with application anesthesia;
- carry out antiseptic treatment of the oral cavity with an antiseptic solution (0.06% chlorhexidine solution, 0.05% potassium permanganate solution);
- isolate treated teeth from saliva;
- pay attention that the hand holding the instrument must be fixed on the patient's chin or adjacent teeth, the terminal shaft of the instrument is parallel to the axis of the tooth, the main movements - lever-like and scraping - must be smooth, not traumatic. In the field of ceramic-metal, ceramic, composite restorations, implants (plastic instruments are used in the processing of the latter), a manual method is used to remove dental deposits.

Ultrasound devices should not be used in patients with respiratory, infectious diseases and those on a medication regimen to control electrolyte balance, as well as in patients with a pacemaker.

To remove plaque and polish smooth surfaces of teeth, it is recommended to use rubber caps, chewing surfaces - rotating brushes, contact surfaces - flosses and abrasive strips. Polishing paste should be used from coarse to fine. Fluoride-containing polishing infusions are not recommended before certain procedures (fissure sealing, teeth whitening). Fine polishing pastes and rubber caps should be used when processing implant surfaces.

Attention is drawn to the need to eliminate the factors that contribute to the accumulation of plaque: the overhanging edges of the fillings are removed, the fillings are re-polished.

The frequency of professional hygiene depends on the patient's dental status (hygienic condition of the oral cavity, the intensity of dental caries, the condition of periodontal tissues, the presence of non-removable orthodontic equipment and dental implants). The minimum frequency of professional hygiene is 2 times a year.

Sealing the fissure of a tooth with a sealant

To prevent the development of a carious process, the fissures of the teeth are sealed with a sealant in the presence of deep, narrow (pronounced) fissures.

Algorithm and features of sealing

First visit

Treatment is carried out in one visit.

Create a cavity by removing pigmented demineralized tissue. Pay attention to the fact that the cavity was formed within the enamel. If a preventive expansion of the cavity is necessary to fix the filling, the transition of the enamel-dentin border is allowed. In the treatment of chewing teeth, the formation of a cavity is carried out in the contours of natural fissures. The cavity edges are finished, washed and dried before filling. Then the filling is done. Pay attention to the mandatory restoration of the anatomical shape of the tooth, align the occlusal and proximal contacts (see).

6.4.7. Requirements for outpatient drug care

6.4.8. Characteristics of algorithms and features of the use of medicines

The main method of treatment of suspended caries in the presence of a pigmented spot is fluoridation of the hard tissues of the tooth.

Fluoridation of dental hard tissues

Applications of 1-2% sodium fluoride solution are carried out in every 3rd visit. after application with a remineralizing solution on a cleaned and dried tooth surface for 2-3 minutes.

Coating of teeth with fluorine varnish, as an analogue of 1-2% sodium fluoride solution, is carried out in every 3rd visit after application of a remineralizing solution on a dried tooth surface. After the application, the patient is not recommended to eat for 2 hours and brush his teeth for 12 hours. The criterion for the effectiveness of fluorination is the stable state of the spot size.

6.4.9. Requirements for the regime of work, rest, treatment and rehabilitation

Patients with enamel caries should visit a specialist once every six months for observation.

6.4.10. Requirements for patient care and ancillary procedures

6.4.11. Dietary requirements and restrictions

After completion of each treatment procedure, it is recommended not to take a niche and not rinse your mouth for 2 hours.

Limiting the consumption of foods and drinks with low pH values ​​​​(juices, tonic drinks, yogurts) and thoroughly rinsing the mouth after taking them. Limiting the stay of carbohydrates in the oral cavity (sucking, chewing sweets).

6.4.12. The form of informed voluntary consent of the patient during the implementation of the Protocol

6.4.13. Additional information for the patient and his family members

6.4.14. Rules for changing requirements when implementing the Protocol and terminating the requirements of the Protocol

If signs are identified during the diagnostic process that require preparatory measures for treatment, the patient is transferred to the patient management protocol corresponding to the identified diseases and complications.

If signs of another disease are detected that require diagnostic and therapeutic measures, along with signs of enamel caries, medical care is provided to the patient in accordance with the requirements:

A) the section of this protocol for managing patients corresponding to the management of enamel caries;
b) a protocol for the management of patients with an identified disease or syndrome.

6.4.15. Possible outcomes and their characteristics

6.4.16. Cost characteristics of the Protocol

Cost characteristics are determined in accordance with the requirements of regulatory documents.

VII. GRAPHIC, SCHEMATICAL AND TABLE REPRESENTATION OF THE PROTOCOL

Not required.

VIII. MONITORING

CRITERIA AND METHODOLOGY FOR MONITORING AND EVALUATION OF THE EFFICIENCY OF THE IMPLEMENTATION OF THE PROTOCOL

Monitoring is carried out throughout the territory of the Russian Federation.

Scroll medical institutions where monitoring of this document is carried out is determined annually by the institution responsible for monitoring. Medical organization is informed about inclusion in the protocol monitoring list in writing. Monitoring includes:

Collection of information: on the management of patients with dental caries in medical institutions at all levels;
- analysis of the received data;
- drawing up a report on the results of the analysis;
- submission of a report to the Protocol development team to the Department of Standardization in Healthcare of the Institute of Public Health and Health Administration of the Moscow medical academy them. I. M. Sechenov.

The initial data for monitoring are:

Medical documentation - a medical card of a dental patient (form 043/y);
- tariffs for medical services;
- tariffs for dental materials and medicines.

If necessary, when monitoring the Protocol, other documents can be used.

In medical institutions, defined by the monitoring list, every six months, based on medical records, a patient card () is compiled on the treatment of patients with dental caries, corresponding to the patient models in this protocol.

The indicators analyzed during the monitoring process include: criteria for inclusion and exclusion from the Protocol, lists medical services mandatory and additional assortment, lists medicines mandatory and additional assortment, disease outcomes, cost of medical care under the Protocol, etc.

PRINCIPLES OF RANDOMIZATION

In this protocol, randomization ( medical institutions, patients, etc.) is not provided.

PROCEDURE FOR EVALUATION AND DOCUMENTATION OF SIDE EFFECTS AND DEVELOPMENT OF COMPLICATIONS

Information about side effects and complications that have arisen in the process of diagnosing and treating patients are recorded in the patient's record (see).

PROCEDURE FOR EXCLUDING A PATIENT FROM MONITORING

A patient is considered included in the monitoring when the Patient Card is completed for him. An exception from monitoring is carried out if it is impossible to continue filling out the Card (for example, failure to appear for a medical appointment) (see). In this case, the Card is sent to the institution responsible for monitoring, with a note on the reason for exclusion of the patient from the protocol.

INTERIM EVALUATION AND PROTOCOL AMENDMENTS

The evaluation of the implementation of the Protocol is carried out once a year based on the results of the analysis of information obtained during monitoring.

Amendments to the Protocol are carried out in case of receipt of information:

A) on the presence in the Protocol of requirements that are detrimental to the health of patients,
b) upon receipt of convincing evidence of the need to change the requirements of the Mandatory Level Protocol.

The decision on changes is made by the development team. The introduction of amendments to the requirements of the Protocol is carried out by the Ministry of Health and social development Russian Federation in the prescribed manner.

PARAMETERS FOR ASSESSING THE QUALITY OF LIFE WHEN IMPLEMENTING THE PROTOCOL

To assess the quality of life of a patient with dental caries, corresponding to the Protocol models, an analog scale (P) is used.

EVALUATION OF PROTOCOL IMPLEMENTATION COST AND QUALITY PRICE

Clinical and economic analysis is carried out in accordance with the requirements of regulatory documents.

COMPARISON OF RESULTS

When monitoring the Protocol, an annual comparison is made of the results of fulfilling its requirements, statistical data, and performance indicators of medical institutions.

PROCEDURE FOR FORMING THE REPORT

The annual monitoring results report includes quantitative results obtained during the development of medical records and their qualitative analysis, conclusions, proposals for updating the Protocol.

The report is submitted to the Ministry of Health and Social Development of the Russian Federation by the institution responsible for monitoring this Protocol. The results of the report may be published in the open press.

Attachment 1

LIST OF DENTAL MATERIALS AND INSTRUMENTS REQUIRED FOR THE DOCTOR'S WORK MANDATORY ASSORTMENT

ADDITIONAL ASSORTMENT

Appendix 2

GENERAL RECOMMENDATIONS FOR THE SELECTION OF HYGIENE PRODUCTS DEPENDING ON THE DENTAL STATUS OF THE PATIENT

Annex 3

FORM OF VOLUNTARY INFORMED CONSENT OF THE PATIENT WHEN IMPLEMENTING THE PROTOCOL APPENDIX TO THE MEDICAL CARD No. _____

A patient ____________________________________________________

FULL NAME _________________________________

receiving clarifications about the diagnosis of caries, received information:

about the features of the course of the disease ____________________________________________________________

probable duration of treatment _________________________________________________________________

about the probable forecast ___________________________________________________________________________

The patient was offered a plan of examination and treatment, including _________________________________

The patient was asked to __________________________________________________________________________

from materials _________________________________________________________________________________

The approximate cost of treatment is about ____________________________________________________

The patient knows the price list accepted in the clinic.

Thus, the patient received an explanation about the purpose of the treatment and information about the planned methods.

diagnosis and treatment.

The patient is informed about the need to prepare for treatment:

_____________________________________________________________________________________________

The patient was informed of the need during treatment

_____________________________________________________________________________________________

_____________________________________________________________________________________________

The patient received information about the typical complications associated with this disease, with the necessary diagnostic procedures and with treatment.

The patient is informed about the probable course of the disease and its complications in case of refusal of treatment. The patient had the opportunity to ask any questions of interest to him regarding his state of health, illness and treatment, and received satisfactory answers to them.

The patient received information about alternative methods of treatment, as well as their approximate cost.

The interview was conducted by the doctor ________________________ (physician's signature).

"___" ________________200___

The patient agreed with the proposed treatment plan, in which

signed with his own hand

(signature of the patient)

signed by his legal representative

that certify those present at the conversation __________________________________________________

(physician's signature)

_______________________________________________________

(witness signature)

The patient disagreed with the treatment plan

(refused the proposed type of prosthesis), which he signed with his own hand.

(signature of the patient)

or signed by his legal representative __________________________________________________________

(signature of legal representative)

that certify those who were present at the conversation ______________________________________________________

(physician's signature)

_______________________________________________________

(witness signature)

The patient expressed a desire:

In addition to the proposed treatment, undergo an examination

Get additional medical service

Instead of the proposed filling material, get

The patient received information about the specified method of examination/treatment.

Because the this method examination / treatment is also shown to the patient, he is included in the treatment plan.

(signature of the patient)

_________________________________

(physician's signature)

Since this method of examination/treatment is not indicated for the patient, it is not included in the treatment plan.

"___" ___________________20____ _________________________________

(signature of the patient)

_________________________________

(physician's signature)

Appendix 4

ADDITIONAL INFORMATION FOR THE PATIENT

1. Filled teeth must be brushed with a toothbrush and paste in the same way as natural teeth - twice a day. Rinse your mouth after eating to remove food debris.

2. To clean the interdental spaces, you can use dental floss (floss) after learning how to use them and on the recommendation of a dentist.

3. If bleeding occurs when brushing your teeth, do not stop hygiene procedures. If bleeding does not go away within 3-4 days, you should consult a doctor.

4. If, after filling and the end of anesthesia, the filling interferes with the closing of the teeth, then it is necessary to contact your doctor as soon as possible.

5. When fillings are made of composite materials, you should not eat food containing natural and artificial dyes (for example: blueberries, tea, coffee, etc.) during the first two days after tooth filling.

6. There may be a temporary appearance of pain (increased sensitivity) in a sealed tooth during the reception and chewing of food. If these symptoms do not go away within 1-2 weeks, you should contact your dentist.

7. If there is a sharp pain in the tooth, it is necessary to contact the attending dentist as soon as possible.

8. In order to avoid chipping the filling and the hard tissues of the tooth adjacent to the filling, it is not recommended to take and chew very hard food (for example: nuts, crackers), bite off large pieces (for example: from a whole apple).

9. Once every six months, you should visit a dentist for preventive examinations and necessary manipulations (for fillings made of composite materials - to polish the filling, which will increase its service life).

Annex 5

PATIENT CARD

Case history No. ____________________________

Name of institution

Date: start of observation _________________ end of observation _________________________________

FULL NAME. ____________________________________________________age.

Diagnosis main ________________________________________________________________________

Accompanying illnesses: ____________________________________________________________

Patient Model: ____________________________________________________________________________

The volume of non-drug medical care provided: ____________________________________

Drug assistance (specify the drug used):

Drug complications (indicate manifestations): Name of the drug that caused them: Outcome (according to the classifier of outcomes):

Information about the patient was transferred to the institution monitoring the Protocol:

(Institution name) (Date)

Signature of the person responsible for protocol monitoring

in a medical institution: _____________________________________________________________

There are several ways to classify caries, which allow you to combine different methodological approaches to diagnosis and treatment. In 1999, Russian health care institutions transferred statistical medical records to the international classification of diseases according to the World Health Organization (WHO). The classification of caries according to ICD-10 is used in combination with other systems.

Classification according to ICD-10

As a result of many attempts to create a unified classification system for diseases in the twentieth century, the International Classification (ICD) was created. Since 1948, it has been revised and supplemented more than once. The last, tenth, revision was in 1989. Since 1994, the ICD-10 system has been introduced in countries that are members of the World Health Organization. All diseases in it are sorted into sections and are indicated by a three-digit alphanumeric code. According to ICD-10, caries is assigned the code K02. It belongs to the section "Diseases of the digestive system" and the subsection "Diseases of the oral cavity".

Caries according to ICD-10

The classification of caries in this system begins with the code K02.0 and ends with the code K02.9 and includes seven points:

• white spot stage;
• dentin disease;
• cement damage;
• stationary (suspended) caries;
• odontoclasia (it includes melanodontoclasia and melanodentia);
• other caries (not included in the description);
• caries, unspecified.

The classification of caries according to ICD-10 does not fully satisfy clinicians and diagnosticians, because some types of disease are hidden under the vague terms "other" and "unspecified" caries. If caries is classified perfectly according to the depth of penetration, then not quite according to localization and other characteristics. Therefore, for more full description diseases, dentists have to combine the ICD-10 with other classifiers. Usually, the standard Black classification system (by localization) is used for this. There are other caries classification systems that describe the duration or severity of the disease.

Replacement of the ICD-10 classifier

Since 2012, work has been underway to improve the ICD-10 classification. The plans of the World Health Organization in 2018 to introduce new system- ICD-11. Experts are working on its development: diagnosticians, clinicians and practicing physicians. It is expected that there will be more sub-clauses of caries classification that can cover all medical cases. ICD-11 is designed to solve all the problems that doctors have with the classification of caries according to ICD-10.

The caries grading system is intended to order the extent of the lesion. It helps to choose a technique for further treatment.

Caries is one of the most famous and widespread dental diseases worldwide. If tissue damage is detected, mandatory dental treatment is required to prevent further destruction of the elements of the dentition.

General information

Doctors have repeatedly attempted to create a single, universal system of classifications of human diseases.

As a result, in the XX century, the "International Classification - ICD" was developed. Since the creation of a unified system (in 1948), it has been constantly revised and supplemented with new information.

The final, 10th revision was held in 1989 (hence the name - ICD-10). Already in 1994 International Classification began to be used in countries that are members of the World Health Organization.

In the system, all diseases are divided into sections and marked with a special code. Diseases of the mouth, salivary glands and jaws K00-K14 are classified under diseases of the digestive system K00-K93. It describes all the pathologies of the teeth, not only caries.

K00-K14 includes the following list of pathologies related to dental lesions:

• Item K00. Problems with the development and eruption of teeth. Adentia, the presence of extra teeth, anomalies in the appearance of the teeth, mottling (fluorosis and other darkening of the enamel), violations of the formation of teeth, hereditary underdevelopment of the teeth, problems with eruption.
• Item K01. Impacted (submerged) teeth, i.e. changed position during eruption, with or without an obstacle.
• Item K02. All types of caries. Enamel, dentine, cement. Suspended caries. Pulp exposure. Odontoclasia. Other types.
• Item K03. Various lesions of hard tissues of teeth. Abrasion, enamel grinding, erosion, granuloma, cement hyperplasia.
• Item K04. Damage to the pulp and periapical tissues. Pulpitis, degeneration and gangrene of the pulp, secondary dentin, periodontitis (acute and chronic apical), periapical abscess with and without a cavity, various cysts.
• Item K06. Pathology of the gums and the edge of the alveolar ridge. Recession and hypertrophy, injuries of the alveolar margin and gums, epulis, atrophic ridge, various granulomas.

Item K07. Changes in occlusion and various anomalies of the jaw. Hyperplasia and hypopalsia, macrognathia and micrognathia of the upper and lower jaws, asymmetry, prognathia, retrognathia, all types of malocclusion, torsion, diastema, tremas, displacement and rotation of teeth, transposition.

Incorrect closure of the jaws and acquired malocclusion. Diseases of the temporomandibular joint: looseness, clicking when opening the mouth, pain dysfunction of the TMJ.

• Item K08. Functional problems with the supporting apparatus and changes in the number of teeth due to impact external factors. Loss of teeth due to trauma, extraction or disease. Atrophy of the alveolar ridge due to the long absence of a tooth. Pathology of the alveolar ridge.

Let us consider in detail section K02 Dental caries. If the patient wants to know what kind of entry the dentist made in the card after the tooth treatment, you need to find the code among the subsections and study the description.

K02.0 Enamels

Initial caries or chalky spot is the primary form of the disease. At this stage, there is still no damage to hard tissues, but demineralization and high susceptibility of enamel to irritations are already diagnosed.

In dentistry, 2 forms of initial caries are defined:

• Active(White spot);
• stable(brown spot).

Caries in active form with treatment, it can either become stable or disappear completely.

The brown spot is irreversible, the only way to get rid of the problem is by preparation with a filling.

Symptoms:

1. Pain- not typical for the initial stage toothache. However, due to the fact that enamel demineralization occurs (its protective function decreases), a strong susceptibility to influences can be felt in the affected area.
2. External Violations- visible when caries is located on one of the teeth of the outer row. It looks like an inconspicuous spot of white or brown.

Treatment directly depends on the specific stage of the disease.

When the stain is chalky, then remineralizing treatment and fluoridation are prescribed. When caries is pigmented, preparation and filling is performed. At timely treatment and compliance with oral hygiene is expected to have a positive outlook.

K02.1 Dentin

The mouth is home to a huge number of bacteria. As a result of their vital activity, organic acids are released. It is they who are guilty of the destruction of the basic mineral components that make up the crystal lattice of enamel.

Dental caries is the second stage of the disease. It is accompanied by a violation of the structure of the tooth with the appearance of a cavity.

However, the hole is not always visible. It is often possible to notice violations only at the appointment with the dentist when the probe enters for diagnosis. Sometimes it is possible to notice caries on your own.

Symptoms:

• the patient is uncomfortable to chew;
• pain from temperatures (cold or hot food, sweet foods);
• external violations, which are especially visible on the front teeth.

Pain can be triggered by one or several foci of the disease at once, but quickly pass after the problem is eliminated.

There are only a few types of dentin diagnostics - instrumental, subjective, objective. Sometimes it is difficult to detect a disease, solely on the basis of the symptoms described by the patient.

At this stage, you can no longer do without a drill. The doctor drills diseased teeth and installs a filling. During the treatment, the specialist not only tries to preserve the tissues, but also the nerve.

K02.2 Cement

Compared to damage to the enamel (initial stage) and dentine, caries of the cementum (root) is diagnosed much less frequently, but is considered aggressive and harmful to the tooth.

The root is characterized by relatively thin walls, which means that the disease does not need much time for the complete destruction of tissues. All this can develop into pulpitis or periodontitis, which sometimes leads to tooth extraction.

Clinical symptoms depend on the location of the focus of the disease. For example, when placing the cause in the periodontal region, when the swollen gum protects the root from other influences, we can talk about a closed form.

With this outcome, there are no bright symptoms. Usually, with a closed location of cement caries, there are no pains or they are not expressed.

Photo of an extracted tooth with cement caries

With an open form, in addition to the root, the cervical region can also undergo destruction. The patient may be accompanied by:

• External disturbances (especially pronounced in front);
• Discomfort while eating;
• Pain from irritants (sweet, temperature, when food gets under the gum).

Modern medicine allows you to get rid of caries in a few, and sometimes in one visit to the dentist. Everything will depend on the form of the disease. If the gum closes the focus, bleeds or greatly interferes with filling, then the gum is corrected first.

After getting rid of soft tissues, the affected area (after or without exposure) is temporarily filled with cement and oil dentin. After tissue healing, the patient comes back for re-filling.

K02.3 Suspended

Suspended caries is a stable form of the initial stage of the disease. It manifests itself in the form of a dense pigment spot.

Typically, such caries is asymptomatic, patients do not complain about anything. It is possible to detect a stain during a dental examination.

Caries is dark brown, sometimes black. The surface of tissues is studied by probing.

Most often, the center of suspended caries is located in the cervical part and natural depressions (pits, etc.).

The method of treatment depends on various factors:

• Spot sizes- too large formations are dissected and sealed;
• From the wishes of the patient- if the stain is on the outer teeth, then the damage is eliminated with photopolymer fillings so that the color matches the enamel.

Small dense foci of demineralization are usually found during a time interval with a frequency of several months.

If the teeth are properly cleaned, and the amount of carbohydrates consumed by the patient decreases, then a stop to the future progressive development of the disease can be observed.

When the stain grows and becomes soft, it is dissected and sealed.

K02.4 Odontoclasia

Odontoclasia is a severe form of dental tissue damage. The disease affects the enamel, thinning it and leading to the formation of caries. No one is immune from odontoclasia.

A huge number of factors influence the appearance and development of damage. These prerequisites include even poor heredity, regular oral hygiene, chronic disease, metabolic rate, bad habits.

Main visible symptom odontoclasia - toothache. In some cases, due to a non-standard clinical form or increased pain threshold the patient does not feel it.

Then only the dentist will be able to make the correct diagnosis during the examination. The main visual sign that speaks of problems with enamel is damage to the teeth.

This form of the disease, like other forms of caries, is treatable. The doctor first cleans the affected area, then seals the painful area.

Only high-quality prophylaxis of the oral cavity and regular examinations at the dentist will help to avoid the development of odontoclasia.

K02.5 With pulp exposure

All tissues of the tooth are destroyed, including the pulp chamber - a partition that separates the dentin from the pulp (nerve). If the wall of the pulp chamber is rotten, then the infection penetrates into soft tissues tooth and causes inflammation.

The patient feels severe pain when food and water enter the carious cavity. After her cleansing, the pain recedes. In addition, in advanced cases, a specific smell from the mouth appears.

This condition is considered deep caries and requires a long and expensive treatment: mandatory removal of the “nerve”, cleaning of the canals, filling with gutta-percha. Several visits to the dentist are required.

Details of the treatment of all types of deep caries are described in the article.

Item added in January 2013.

K02.8 Other view

Other caries is a medium or deep form of the disease that develops in a previously treated tooth (recurrence or re-development near the filling).

Medium caries is the destruction of enamel elements on the teeth, accompanied by attacks or permanent painful sensations in the hearth area. They are explained by the fact that the disease has already passed to the upper layers of the dentin.

The form requires mandatory dental care, in which the doctor removes the affected areas, followed by their restoration and filling.

Deep caries is a form that is characterized by extensive damage to the internal dental tissues. It affects a significant area of ​​dentin.

The disease cannot be ignored at this stage, and failure to treat can lead to nerve (pulp) damage. In the future, if you do not use medical help, pulpitis or periodontitis develops.

The affected area is completely removed with subsequent restorative filling.

K02.9 Unspecified

Unspecified caries is a disease that develops not on living, but on depulped teeth (those in which the nerve has been removed). The reasons for the formation of this form do not differ from standard factors. Usually, unspecified caries occurs at the junction of a filling and an infected tooth. Its appearance in other places of the oral cavity is observed much less frequently.

The fact that a tooth is dead does not protect it from developing caries. Teeth depend on the presence of sugar to penetrate into oral cavity along with food and bacteria. After saturation of the bacteria with glucose, the formation of acid begins, leading to the formation of plaque.

Caries of a pulpless tooth is treated according to the standard scheme. However, in this case, there is no need to use anesthesia. The nerve responsible for pain is no longer in the tooth.

Prevention

The state of dental tissue is strongly influenced by the human diet. To prevent caries, you need to follow some recommendations:

• eat less sweet, starchy foods;
• balance the diet
• keep track of vitamins;
• chew food well;
• rinse your mouth after eating;
• brush your teeth regularly and properly;
• avoid simultaneous intake of cold and hot food;
• periodically examine and sanitize the oral cavity.

The video presents Additional Information on the topic of the article.

Timely treatment will help to quickly and painlessly get rid of caries. Preventive measures prevent damage to the enamel. It is always better not to bring to the disease than to treat it.

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Dental caries. Definition, classification, assessment of the intensity and prevalence of caries, methods of treatment.

Question 1. Definition of caries.

CARIES is a pathological process in the hard tissues of the tooth that occurs after teething and consists in focal demineralization of the enamel, followed by the formation of a cavity.

The main causes of dental caries.

Presence of dental plaque

Use in in large numbers easily fermentable carbohydrates

Factors contributing to the development of dental caries:

acid reaction of saliva

crowding of teeth

low concentration of minerals (fluorine) in the enamel

the presence in the oral cavity of additional conditions for plaque retention (braces, orthopedic constructions)

hyposalivation

Question 2. Classification of caries according to MMSI.

The classification of caries according to MMSI was developed taking into account the depth of the carious cavity:

1. Caries in the stain stage (MACULACARIOSA) - focal demineralization of the enamel, without the formation of a cavity:

white spot - indicates an active carious process

pigmented spot - indicates some stabilization of the process.

2. Superficial caries (CARIESSUPERFICIALIS) - carious cavity is localized within the enamel

3. Medium caries (CARIESMEDIA) - the carious cavity is localized within the dentin, slightly deeper than the enamel-dentin border.

4. Deep caries (CARIESPROFUNDA) - the carious cavity is localized in the dentin and predentin (near the pulp).

Question 3. WHO International Classification of Caries (from the International Classification of Diseases, 10th revision)

Initial caries (chalk spot stage).

Enamel caries.

Dental caries.

Cement caries.

Suspended caries.

RELATIONSHIP OF THESE TWO CLASSIFICATIONS:

Question 4. Black's classification of carious cavities.

Question 5. Diagnosis of dental caries.

Carious stain - when dried, a loss of enamel luster is detected, for differential diagnosis with non-carious lesions, vital enamel staining is used to detect focal demineralization. METHYLENE BLUE IS USED AS WELL AS SPECIAL SOLUTIONS - "CARIES-MARKERS".

Carious cavities are detected by probing

X-ray therapy reveals carious cavities on contact surfaces, as well as caries under fillings.

Question 6. Assessment of the prevalence of dental caries:

The dental caries prevalence index is used to estimate the prevalence of caries. The index is calculated as follows:

Question 7. Assessment of the intensity of caries:

The intensity of caries is assessed using the KPU index:

For each patient, the number of carious, sealed and extracted teeth is counted, then the results are summarized and divided by the number of examined patients.

In some cases (especially in children), they use the KPp index - the sum of sealed and carious surfaces (the extracted tooth is considered as 5 surfaces).

The KPU index makes it possible to evaluate not only the intensity of caries, but also the level of dental care: if the K and U components predominate, then the level of dental care should be considered unsatisfactory, if the P component predominates, it is good.

The main groups of the survey are 12-year-old children, 35-44 years old.

(for 12 years old)

very low level of caries intensity 0-1.1

low level of caries intensity 1.2-2.6;

average level of caries intensity 2.7-4.4;

high level of caries intensity 4.5-6.5;

very high level of caries intensity 6.6-7.4;

Question 8. Caries treatment methods:

non-invasive (remineralizing therapy)

invasive (preparation followed by filling).

Remineralizing therapy is most effective in the presence of a white carious spot. It is carried out as follows: professional hygiene, application of calcium preparations, application of fluoride preparations.

Practice - rubber dam.

Cofferdam - a system for isolating the working field from saliva, as well as protecting adjacent teeth and soft tissues of the oral cavity from damage by bur.

Indications:

dental caries treatment

endodontic treatment of teeth

dental restoration

use of Air Flow devices

Contraindications:

severe periodontitis

allergic to latex

patient reluctance.

The set includes: punch, clamp tongs, clamps, latex, chords or wedges.

Use of rubber dam:

holes are marked on the latex according to the pattern

holes are made using a punch

latex is put on the exposed teeth, clamps are fixed on the extracted tooth or on neighboring teeth, fixation with wedges or chords is also possible.

In the clinic, flosses are tied to clamps (to be pulled out if inhaled or swallowed)

Latex stretched over the frame

WHO classification of caries. Unfortunately, there is no single caries classification system that would fully satisfy the requirements of clinicians. To date, there are several dozen classifications of caries

When diagnosing a carious lesion of a tooth, dentists use the following classifications:
Caries classification:
1. According to the depth of damage to the tissues of the tooth:
- initial,
- superficial,
- average,
- deep
2. According to pathomorphological changes:
- caries in the stain stage (white spot, light brown spot, black spot),
- enamel caries (superficial caries),
- medium caries,
- medium deep caries (corresponds to the clinic of deep).
3. By localization:
- fissure,
- approximate,
- cervical.
4. According to the degree of disease activity:
- compensated form,
- subcompensated form,
- decompensated form.
5. Main: WHO classification of caries (ICD-10, 1995):
- enamel caries
- dentine caries
- cement caries.
6. Zonal classification (Lukomsky, 1949).
1. Carious spot: a) chalky-acute process; b) pigmented-chronic.
2. Superficial caries (enamel caries), acute and chronic.
3. Medium caries (dentine caries), acute and chronic.
4. Deep caries (caries of suprapulpal dentin), acute and chronic.

7. Classification of MMSI(1989)


I. Clinical forms:
1. Spot stage (carious demineralization):


a) progressive (white or light yellow spots);
b) intermittent (brown spots);
c) suspended (dark brown spots).


2. Carious defect (disintegration):


A. Enamel caries (superficial).
B. Dentinal caries:


a) average depth;
b) deep.


B. Cement caries.


II. By localization:


1) fissure caries;
2) caries of adjacent surfaces;
3) caries of the cervical region.


III. With the flow:


1) fast caries;
2) slow caries;
3) stable process.


IV. In terms of damage intensity:


1) single lesions;
2) multiple lesions;
3) systemic lesion.


In practice, the term secondary, or recurrent, caries is used, when the process develops next to the applied filling in a tooth with a living pulp.

International Classification of Diseases ICD-10
- codes and ciphers of diagnoses and diseases.

K00-K93 Diseases of the digestive system
.
K00-K14 Diseases of the mouth, salivary glands and jaws
.
K02 Dental caries
(Tooth decay,)
K02.0 Enamel caries
K02.1 Dentinal caries
K02.2 Cement caries
K02.3 Suspended dental caries
K02.4 Odontoclasia
K02.8 Other dental caries
K02.9 Dental caries, unspecified
(Tooth caries,)

Dental caries should be considered as a polymorphic pathological process characterized by focal demineralization of hard dental tissues with the formation of a carious cavity, capable of aggravating, stabilizing, acquiring different activity and being in varying degrees of compensation throughout life.