Treatment of dental caries at different stages. The importance of timely diagnosis and treatment of fissure caries Oral not timely treatment of caries

There are a great variety of dental diseases, but caries is considered one of the most widespread and widespread. Translated from Latin, this word means “rotting.”

Dental caries - what is it?

Caries is a disease characterized by the gradual destruction of tooth tissue (enamel or dentin). The appearance of “holes in teeth” is caused by changes in microflora and the spread of infection in the oral cavity. This disease is equally dangerous for both adults and children.

Classification

Experts distinguish the following types of caries:

Uncomplicated forms of the disease:

• surface;
• average;
• deep.

Complicated forms of the disease:

• pulpitis;
• periodontitis.

In addition, there are bottle and cervical caries, which arise as a result of demineralization and softening of tooth tissue.

Following another classification, it can be primary or secondary. In the latter case, it appears on previously filled teeth.

Video about the occurrence of caries

Several reasons can lead to the formation of a carious cavity:

• unbalanced diet (excessive consumption of foods rich in carbohydrates, lack of vitamins and microelements);
• insufficient oral hygiene (untimely removal of plaque);
• special structure of the tooth surface (accumulation of plaque in fissures and spaces between teeth);
• insufficient salivation;
• genetic predisposition.

Symptoms

The pathogenesis or occurrence, the origin of caries occurs in several stages. At the initial stage or “spot” stage, a whitish or darkish speck forms on the enamel.

At the stage of average caries, dentin (mineralized tooth tissue) begins to undergo destruction, and a carious cavity is formed.

And finally, at the stage of deep caries, the cavity increases in size and exposure to it causes severe pain.

To better understand what the signs of caries look like, you need to look at the photo. Perhaps this measure will help you track the disease at an early stage.

Treatment

The appropriate method of caries treatment is selected by the dentist only after diagnosing the teeth and oral cavity, and it depends on the degree of development of the disease.

The goal of treatment is to remove damaged dentin or enamel and restore tooth function using a variety of filling materials (polymers, cements, metals).

But how can you get rid of acute caries without unnecessary pain? In this case, during treatment, infiltration and conduction anesthesia is used, for example, a lidocaine solution is injected.

Prevention

The main recommendations of dentists for the prevention of carious diseases are that you should eat right, pay attention to oral hygiene and come to the dentist for a preventive examination every six months. An additional measure against caries can be professional teeth cleaning.

Proper dental care and timely treatment will help you avoid the development of complications such as pulpitis, periodontitis, granuloma, etc.

On the dental portal you have the opportunity to make an appointment with qualified specialists who will conduct a full dental diagnosis and identify the main problems.

Caries is insidious because at first it does not cause serious concern on the part of the person. At an early stage, it does not cause concern and the patient gets the impression that the disease is not serious. And only when the affected tooth begins to hurt, most people turn to the dentist for help. And treating the consequences in an advanced stage is much more difficult than curing initial caries.

The disease is characterized by a complete absence of symptoms that warn of its development. The patient may be completely sincerely unaware of the presence of the disease. Only an experienced doctor can detect caries in the early stages. Therefore, it is important to follow the recommendations of dentists and visit the doctor at least 1-2 times a year.

So, what unpleasant consequences can caries lead to if left untreated:

1. There is a danger of such serious complications as pulpitis and periodontitis. Pulpitis is an acute inflammation of the pulp, in which the pain becomes simply unbearable. Periodontitis is an inflammatory disease of tissues and is also difficult and long to treat. Acute forms of caries cause inflammatory processes in the soft tissues of the gums, and sometimes the face, and the patient may swell not only the gums, but also the cheek.
2. A serious consequence of caries, especially if it is not treated at all, is presence of a constant source of infection in the human body, and this is fraught with more serious consequences - such as the development of diseases of the cardiovascular system, as well as inflammatory diseases of the joints. Agree that all this looks quite scary, and it is much easier to seek help from a dentist in a timely manner.
3. The presence of a constant source of infection in the mouth can lead to the development of various chronic allergic reactions. Sometimes the patient himself cannot understand what he is allergic to, since it seems that the body reacts to literally everything. And imagine the patient’s surprise when it turns out that the cause of the allergy is banal caries!
4. Without proper treatment, caries gradually completely destroys the tooth.. The absence of a tooth affects the quality of chewing food. And if food is not chewed properly, then this adversely affects the state of the gastrointestinal tract, and if not one, but several teeth are lost at once, and this situation lasts for years, serious stomach diseases can occur.
5. The aesthetic side of the issue also plays an important role. A smile looks beautiful if a person has healthy and strong teeth. If they are affected by caries, darkened, destroyed or fallen out, a beautiful smile is out of the question. You begin to feel embarrassed about your teeth, avoid communicating with friends, and feel uncomfortable in company. All this negatively affects the quality of life, inevitably leading to depression. So isn’t it easier to seek help in time and cure your teeth than to suffer and suffer for many years?

In the article, we did not set ourselves the goal of scaring you with the possible consequences of caries. We were just trying to warn you and explain how dangerous caries really is. We hope that our article helped you make the right decision and see a dentist, even if nothing is bothering you at the moment.

Going to the dentist is stressful for many. But this is a big mistake. The thing is that from time to time caries appears on the teeth and if the disease is not cured at the initial stage, caries may occur in the future. not very pleasant consequences.

Why does tooth decay occur?

Human saliva has natural acidity, which tends to decrease during meals, especially if the food is sweet. After eating, unnoticeable food residues remain on the teeth in which bacteria develop. When the acidity of saliva increases again, teeth may develop small cracks through which bacteria enter the tooth. Bacteria destroy enamel, resulting in caries.

The first signs of caries cause slight pain, which quickly subside. That is why the patient simply does not know that he has a disease and therefore does not contact the dentist in a timely manner. But if during adoption cold or hot food slight pain appears, this is the first sign that caries is taking place.

Why is caries dangerous?

It is generally accepted that caries is not a dangerous disease, but in reality this is far from the case. When the enamel is destroyed, the oral cavity loses its protection and any infection can get inside. That is why you should visit them at least 2 times a year.

It is also worth knowing that the primary stage of caries destroys only the enamel, but if treatment is not carried out for a long time, it will begin to soft dental tissue also deteriorates. As a result, pulpitis will occur, a more complex disease, the treatment of which takes a lot of time and money.

Pulpitis is an inflammation of the dental nerve, as a result of which the entire dental canal must be cleaned. Accordingly, after such protection, the tooth becomes lifeless and can collapse quite quickly. If you also start pulpitis, you can introduce many diseases into the body. Namely sinusitis, meningitis and other inflammatory infections.

Another consequence of caries is periodontitis, that is, inflammation of the gum tissue. When periodontitis occurs, gums become inflamed and cannot hold their teeth properly. Naturally, teeth begin to become loose and fall out over time. Cure periodontitis completely can be very difficult.

Prevention of caries

To avoid the occurrence of caries, it is necessary in a timely manner, and most importantly, to properly care for your own teeth.

• You need to give up sweet soda, which instantly damages tooth enamel.
• Costs reduce the amount of sweets, since sugar and other substances negatively affect not only the top layer of the tooth, but also the entire oral cavity as a whole.
• Selecting the right toothbrush, no matter what kind of toothpaste. Dentists have long been saying that expensive oral products differ only in their pleasant taste and aroma.
• After each meal it is necessary brush your teeth or at least rinse your mouth herbal balms.
• Visit the dentist at least 2 times a year.

Caries itself is not dangerous if it is treated in a timely manner. But if you do not pay attention to this disease, the consequences can be serious.

Tooth decay by caries is a pathological disease that develops in hard tissues. Doctors claim that the disease (at different stages) occupies a leading position among pathologies in dentistry. The development of dental caries occurs gradually, begins without pain with small spots, and ends with tooth loss. It is not difficult to detect the disease; the symptoms of dental caries are quite obvious. Why does the disease occur? How many methods are there to combat the disease, what to do with the affected areas and is it painful to be treated? Let's look further.

Caries - what is it?

The most common oral disease is caries. It affects more than half of the world's population. The emergence and development of the pathological process leads to damage to the enamel. Untimely treatment of caries completely destroys hard tissues. For greater clarity, pay attention to the photo of the affected teeth in comparison with healthy ones.

Signs of caries are as follows:

• the appearance of dark spots on the enamel;
• discomfort in destroyed areas;
• formation of "holes".

The etiology of the disease is quite complex. There are a number of other signs, including: pain in the gums and cheeks, discomfort when chewing, or eating hot or cold food. If you ignore the symptoms and start the process of spots developing, the following will happen:

• the diameter of the darkening that appears will increase;
• superficial damage will penetrate deep into dentin;
• further development of the pathological process will provoke the appearance of a “hole”.

Caries on the front teeth causes particular discomfort (the incisor hurts, acutely “reacting” to temperature changes), and also creates significant aesthetic inconvenience (see photo of caries above). Thanks to modern treatment methods, it is possible to stop the disease and carious changes, restoring a healthy smile, in one visit.

Signs with photos and symptoms of the disease

How quickly caries develops is primarily due to the reasons that caused it - we will talk about the most typical of them below. Now let's look at the characteristic signs of the disease. Carious cavities manifest themselves in different ways, which directly depends on the degree of damage. The first stage of enamel darkening has a slow hidden reaction. Tooth sensitivity may increase when eating the following foods:

• very hot food;
• cold snacks, drinks, etc.;
• salty foods.

Increased sensitivity is observed periodically, especially worsening after the white spot on the enamel gradually turns brown. The initial stage of the lesion is characterized by the following symptoms:

• chemical irritants lead to pain, but immediately after the pathogen has been eliminated, this factor goes away;
• when the dental neck is affected, pain occurs at the site of pressure when eating solid food.

The middle stage of caries disease has the following additional symptoms:

Deep caries is characterized by aggravation of previously diagnosed signs:

• any irritating factor provokes pain;
• carious cavities are large and dark.

When the first symptoms appear, you should consult a doctor so as not to cause harm or trigger the disease. It is important to recognize the development of caries in time and begin to treat it already at the “white spot” stage, when the basis of therapy can still be the use of medicinal remineralizing agents. If the process is started, caries treatment will already be invasive.

Types of carious lesions

Pathogenesis in dentistry is considered as the mechanism of the onset and progression of the disease. Typical causes of dental caries are:

• cariogenic microflora (including carbohydrates);
• violation of hygiene rules;
• reduced immunity.

Cariesogenic factors, which are based on a violation of the acid-base (chemical) balance and the development of pathogenic flora, primarily contribute to the destruction of enamel and dentin. Scientists call genetic predisposition a separate cariogenic factor.

Types of caries are classified depending on the degree of tooth damage, the depth of carious cavities, and their location. Stages of disease development with photo illustration:

• The initial stage is a superficial colorless lesion of the enamel, which is not diagnosed by the patient himself. The lateral part of the tooth surface is affected by fissure caries. The stage of manifestation of spots can be stopped if the spot is treated with topical medications and remineralizing agents.
• The pathogenesis of mid-level caries is characterized by spread to the upper layer of dentin. Such caries is dangerous due to the rapid destruction of the tooth. The doctor removes the affected area and fills the cavity.
• Deep dental caries in the process of its development causes destruction of the cavity to the level of dentin, which covers the pulp. Further infection and softening of the tissue occurs - urgent treatment is necessary, since the consequence of untreated caries can be the removal of the pulp and even the tooth itself.
• Atypical form. The cutting edge and tubercle are destroyed. It is treated using an invasive method with the installation of a filling. Complications from this caries are tooth destruction from top to bottom to the deep stage.

Severe advanced caries is difficult to cure. The progressive process inevitably leads to complications: pulpitis, periodontitis, etc.

Dentists also distinguish the following types of caries:

• multiple or systemic;
• root;
• cervical (most often affects the front teeth near the gums) (we recommend reading: photos of the front teeth before and after caries treatment);
• recurrent - occurs under a filling due to serious cariogenic factors.

Causes of caries formation in adults

What causes tooth decay? Streptococci are one of the types of dental microbes present in organic acids that destroy dentin and enamel.

The appearance and proliferation of bacteria begins during the development of pathological biochemical processes - with normal flora there are no pathogenic microbes in the mouth. The formation of a carious cavity is promoted by:

• poor nutrition and hygiene (carbohydrates and acids are formed due to the remains of rotting food);
• somatic diseases associated with the gastrointestinal tract;
• reduced levels of calcium, fluorine and vitamins in the body (pregnancy, chronic diseases, lack of adequate nutrition, radiation therapy, etc.);
• tartar (hard plaque);
• genetic predisposition.

Treatment - conservative and with removal of carious cavities

Dentists identify two main ways to eliminate the problem:

1. Non-invasive – treatment of superficial dental caries occurs conservatively, i.e. without drilling. This option is considered a modern type of treatment.
2. Invasive - treatment by cleaning out the lesions. Before drilling, a detailed examination, medicinal treatment of the carious cavity, removal of the affected areas, and filling are carried out.

How to stop caries? In order to cure caries at the white spot stage, it is enough to saturate the teeth with fluoride and calcium, i.e. remineralize the enamel.

It is possible to cure moderate and deep disease with the help of medicinal treatment of a carious cavity, followed by filling it. The standard stages of caries treatment are as follows:

1. removal of the affected part of the tooth;
2. restoration of the cavity by filling (the deep stage of the lesion is treated by installing two fillings - temporary and permanent).

Therapy methods in dentistry

Treatment of caries is almost painless. At the initial stage - the stage of the appearance of the stain - treatment of caries in adults and children is carried out without touching the dentin and pulp. Only the top layer of enamel is removed, so the procedure takes place without any discomfort.

The disease at a more serious stage, especially advanced carious lesions of dentin and its expansion inside the tooth, requires treatment of the oral cavity, removal of softened areas using a drill and subsequent installation of a filling.

Is it painful to treat?

The question of whether it is painful to treat caries is of interest to most patients. Treatment in dentistry is carried out at all stages of caries quickly and painlessly. At the first stage, after sanitation of the oral cavity, medicinal treatment is performed. Invasive removal of internal caries is carried out under anesthesia and does not cause discomfort. It is recommended to deal with the problem at the initial stage, then recovery will be quick and painless.

Consequences and complications of untimely treatment of caries

Deep caries is an advanced stage of dental damage, which is the last and requires urgent and high-quality treatment. In case of improper care, the carious cavity turns into pulpitis, characterized by severe pain. You can avoid the consequences by timely contacting the clinic to remove the pulp.

Recurrence can occur if cavities form between the filling and healthy teeth. A photo of this type of caries can be seen below.

Removing the filling, medicinal treatment and its replacement is a new therapeutic method of treating and combating the consequences of complications.

Preventive measures - how to stop the carious process?

After treatment, patients wonder how to prevent caries from occurring in the future. You can avoid the problem by following simple rules:

• take care of and monitor the cleanliness of the oral cavity (the main cause of pathology is the formation of plaque due to food debris);
• maintain a healthy diet (include foods high in microelements and vitamins in the menu);
• visiting a dentist once every six months is a chance that will allow you to diagnose pathology at an early stage and avoid a deep stage that is difficult to treat.

Vaccination against caries formation

There is no vaccine against carious teeth yet. However, some laboratories are conducting research and exchanging experience in this matter.

The human immune system is already “trained” with antibodies that destroy viruses and bacteria. For example, immunoglobulin found in saliva prevents pathogenic microorganisms from reaching the “right target.” Therefore, we repeat, today vaccination against carious lesions is nothing more than an invention of science fiction writers.

Protection products for every day

To effectively protect the oral cavity from caries, it is recommended to use pastes with calcium and fluoride. Such compositions are excluded when there are contraindications (for example, a high fluoride content in the water or fluorosis diagnosed in the patient). Purchasing expensive pastes is not necessary. The main thing is that active enzymes and the base filler help destroy plaque and food debris.

Additional oral care products include rinses and flosses that clean the interdental spaces. Special scrapers and brushes are useful for treating the tongue. However, the listed means are not able to stop the already existing destructive process.

Sometimes bacteria are transmitted through kissing, in which case it is recommended to use sugar-free chewing gum. The main thing is not to overdo it - you will not achieve strengthening of the enamel with chewing gum, but if you use it excessively, you can contribute to wear and abrasion of the tooth enamel.

The protocol for the management of patients “Dental Caries” was developed by the Moscow State Medical and Dental University (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., Wagner V.D.), Moscow Medical Academy named after. THEM. Sechenov Roszdrav (Vorobiev P.A., Avksentyeva M.V., Lukyantseva D.V.), Dental Clinic No. 2 of Moscow (Chepovskaya S.G., Kocherov A.M.., Bagdasaryan M.I., Kocherova M.A. .).

I. SCOPE OF APPLICATION

The “Dental Caries” patient management protocol is intended for use in the healthcare system of the Russian Federation.

II. NORMATIVE REFERENCES

- Decree of the Government of the Russian Federation dated November 5, 1997 No. 1387 “On measures to stabilize and develop healthcare 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 healthcare. Approved by the Ministry of Health and Social Development of Russia on July 12, 2004 - M., 2004. - 211 p.

III. GENERAL PROVISIONS

The “Dental Caries” patient management protocol was developed to solve the following problems:

- establishment of uniform requirements for the procedure for diagnosis and treatment of patients with dental caries;
- unification of the development of basic compulsory health insurance programs and optimization of medical care for patients with dental caries;
- ensuring optimal volumes, accessibility 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.

The strength of evidence scale used in this document is:

A) The evidence is compelling: There is strong evidence for the proposed statement.
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 based on other circumstances.
D) Negative evidence is sufficient: there is sufficient evidence to recommend against the use of this drug, material, method, technology in certain conditions.
E) Strong negative evidence: There is sufficiently convincing evidence to exclude the drug, method, technique from the recommendations.

IV. KEEPING RECORD

The “Dental Caries” Protocol is maintained by the Moscow State Medical and Dental University of Roszdrav. The management system provides for the interaction of the Moscow State Medical and Dental University with all interested organizations.

V. GENERAL ISSUES

Dental caries(K02 according to ICD-10) is an infectious pathological process that manifests itself after teething, during 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 dental system. The prevalence of caries in our country among adults aged 35 years and older is 98-99%. In the general structure of medical care for patients in dental treatment and prevention institutions, this disease occurs in all age groups of patients. If untimely or improperly treated, dental caries can cause the development of inflammatory diseases of the pulp and periodontium, tooth loss, and the development of purulent-inflammatory diseases of the maxillofacial area. Dental caries are potential foci of intoxication and infectious sensitization of the body.

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

Untimely treatment of dental caries, as well as tooth extraction 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 disturbances in the chewing process up to the final loss of this body function, which affects the digestion process.

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

ETIOLOGY AND PATHOGENESIS

The immediate cause of demineralization of enamel and the formation of a carious lesion are organic acids (mainly lactic acid), which are formed during the fermentation of carbohydrates by plaque microorganisms. Caries is a multifactorial process. Microorganisms of the oral cavity, the nature and diet, enamel resistance, the quantity and quality of mixed saliva, the general condition of the body, exogenous influences on the body, the fluoride content in drinking water influence the occurrence of a focus of enamel demineralization, the course of the process and the possibility of its stabilization. Initially, carious lesions occur due to frequent consumption of carbohydrates and insufficient oral care. As a result, adhesion and proliferation of cariogenic microorganisms occurs on the surface of the tooth and dental plaque is formed. Further intake of carbohydrates leads to a local change in pH to the acidic side, demineralization and the formation of microdefects in the subsurface layers of enamel. However, if the organic enamel matrix is ​​preserved, then the carious process at the stage of its demineralization can be reversible. The long-term existence of a 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 exists 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 stain; subsequently, a defect develops in the form of a cavity, and the main manifestation of developed caries is the destruction of the hard tissues of the tooth.

As the depth of the carious cavity increases, patients experience increased sensitivity to chemical, temperature and mechanical stimuli. The pain from the irritants is short-lived and quickly goes away after the irritant is removed. There may be no pain response. Carious lesions of chewing teeth cause dysfunction of chewing; patients complain of pain when eating and disturbances in aesthetics.

CLASSIFICATION OF DENTAL CARIES

In the international statistical classification of diseases and health problems of the World Health Organization, tenth revision (ICD-10), caries is included in a separate category.

K02.0 Enamel caries. Stage of "white (chalky) spot" [initial caries]
K02.I Dentin 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 location (according to Black)

Class I - cavities localized 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 breaking the cutting edge.
Class IV - cavities located on the contact surface of the incisors and canines with a violation of the angle of the coronal 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 cusps of molars and premolars and the cutting edges of incisors and canines.

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

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

The stage of cement caries 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 demineralization of the enamel).

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

GENERAL APPROACHES TO DIAGNOSIS OF DENTAL CARIES

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

Diagnostics are carried out for each tooth and are aimed at identifying factors that prevent the immediate start of treatment. Such factors may be:

- presence of intolerance to medications and materials used at this stage of treatment;
- concomitant diseases that complicate treatment;
- inadequate psycho-emotional state of the patient before treatment;
- acute lesions of the oral mucosa and red border of the lips;
- acute inflammatory diseases of organs and tissues of the oral cavity;
- a life-threatening acute condition/disease or exacerbation of a chronic disease (including myocardial infarction, acute cerebrovascular accident), which developed less than 6 months before seeking 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 treating patients with dental caries provide for the simultaneous solution of several problems:

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

Treatment for caries may include:

- elimination of microorganisms from the surface of teeth;
- remineralizing therapy at the “white (chalky) spot” stage;
- fluoridation of hard dental tissues in case of suspended caries;
- preservation, as far as possible, of healthy hard dental tissues, if necessary, excision of pathologically altered tissues with subsequent restoration of the tooth crown;
- issuing recommendations on the timing of re-application.

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

When treating dental caries, only those dental materials and medications are used that are approved for use on the territory of the Russian Federation in accordance with the established procedure.

ORGANIZATION OF MEDICAL CARE FOR PATIENTS WITH DENTAL CARIES

Treatment of patients with dental caries is carried out in dental treatment and prevention institutions, as well as in therapeutic dentistry departments and offices of multidisciplinary treatment and prevention institutions. As a rule, treatment is carried out in an outpatient setting.

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

Providing assistance to patients with dental caries is carried out mainly by dentists, dental therapists, orthopedic dentists, and dentists. Nursing staff and dental hygienists take part in the process of providing assistance.

VI. CHARACTERISTICS OF REQUIREMENTS

6.1. Patient model

6.1.1 Criteria and features defining the patient model

6.1.2 Procedure for including a patient in the Protocol

6.1.3. Requirements for outpatient diagnostics

6.1.4. Characteristics of algorithms and features of performing diagnostic measures

For this purpose, all patients must undergo anamnesis collection, examination of the oral cavity and teeth, as well as other necessary studies, the results of which are entered into the dental patient’s medical record (form 043/y).

History taking

All teeth are subject to examination; the examination begins with the upper right molars and ends 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 speed 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 used to identify pain reactions and clarify the diagnosis.

Percussion used to eliminate caries complications.

Vital staining of hard dental tissues. In cases that are difficult to differentiate from 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 patient model).

Oral hygiene indices determined before treatment and after training in oral hygiene for the purpose of control.

6.1.5. Requirements for outpatient treatment

6.1.6 Characteristics of algorithms and features of non-drug care

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

In order to develop the patient's oral care skills (brushing teeth) and the most effective removal of soft plaque from the surfaces of the teeth, the patient is taught oral hygiene techniques. Teeth brushing techniques are demonstrated on models.

Oral hygiene products are selected individually. Oral hygiene education helps prevent dental caries (level of evidence B).

Controlled teeth cleaning means brushing that the patient does independently in the presence of a specialist (dentist, dental hygienist) in a dental office or oral hygiene room, in the presence of the necessary hygiene products and visual aids. The purpose of this event is to monitor the effectiveness of the patient’s teeth brushing and correct deficiencies in the teeth brushing technique. Controlled brushing can effectively maintain oral hygiene (level of evidence B).

Professional oral hygiene includes the removal of supra- and subgingival dental plaque from the tooth surface and helps prevent the development of dental caries and inflammatory periodontal diseases (level of evidence A).

First visit

Complete the brushing with circular movements of the toothbrush with the jaws closed, 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 condition of the hard tissues of the teeth and periodontal tissues, the presence of dental anomalies, removable and non-removable orthodontic and orthopedic structures) ().

Second visit

First visit

Next visit

The patient is instructed to attend a preventive examination with 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 of hard dental tissues

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

Sealing the tooth fissure with sealant

To prevent the development of caries, 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 medications

The main methods of treating enamel caries in the spot stage are remineralization 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, if there are rough surfaces, they are sanded. 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 of remineralizing agents on the treated tooth surface for 15-20 minutes, changing the tampon every 4-5 minutes. Applications of a 1-2% sodium fluoride solution are carried out every 3rd visit, after application of a remineralizing solution on a cleaned and dried tooth surface for 2-3 minutes.

Fluoride varnish, an analogue of a 1-2% sodium fluoride solution, is applied to the teeth every 3rd visit after application of the remineralizing solution on the dried tooth surface. After 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 remineralization therapy and fluoridation is a reduction in the size of the focus of demineralization until it disappears, restoration of the shine of the enamel or less intense staining of the focus of demineralization (on a 10-point scale of enamel staining) with a 2% solution of methylene blue.

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

Patients with enamel caries in the spot 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 completing each treatment procedure, it is recommended not to eat or rinse your mouth for 2 hours. Limit the consumption of foods and drinks with low pH values ​​(juices, tonic drinks, yoghurts) and thoroughly rinse your mouth after taking them.

Limiting the presence of carbohydrates in the oral cavity (sucking, chewing candies).

6.1.12. Form of informed voluntary consent of the patient when implementing 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 signs defining the patient model

6.2.2. The procedure for including a patient in the Protocol

A patient's condition that meets the diagnostic criteria and signs of a given patient model.

6.2.3. Requirements for outpatient diagnostics

6.2.4. Characteristics of algorithms and features of performing diagnostic measures

History taking

When collecting anamnesis, they find out the presence of complaints of pain from irritants, an allergic history, and the presence of somatic diseases. They purposefully identify complaints of pain and discomfort in the area of ​​a specific tooth, food getting stuck, how long ago they appeared, when the patient paid attention to them. Particular attention is paid to clarifying the nature of the complaints, whether, in the patient’s opinion, they are always associated with a specific irritant. They find out the patient’s profession, whether the patient takes proper hygienic care of the oral cavity, and the time of his last visit to the dentist.

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

They 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 stains on the visible surfaces of the teeth, the presence of stains 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 speed of development of the process, the dynamics of the disease, and also differential diagnosis with non-carious lesions. When probing an identified carious cavity, attention is paid to its shape, location, size, depth, the presence of softened dentin, changes in its color, soreness or, conversely, lack of pain sensitivity. The approximal surfaces of the tooth are especially carefully examined. Thermal diagnostics are 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 performing electroodontometry, pulp sensitivity indicators for dentin caries are recorded in the range from 2 to 10 μA.

6.2.5. Requirements for outpatient treatment

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

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

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

Indications for prosthetics are:

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

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 prevention of the development of the Popov-Godon phenomenon in the area of ​​antagonist teeth;
- restoration of aesthetics of the dentition.

Treatment of dentin caries with fillings 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 teeth with a toothbrush and dental floss, using dental models, or other demonstration tools.

Teeth brushing begins with an area in the area of ​​the upper right chewing teeth, sequentially moving from segment to segment. The teeth on the lower jaw are cleaned in the same order.

Pay attention to the fact that the working part of the toothbrush should be positioned at an angle of 45° to the tooth, making cleaning movements from gum to tooth, while simultaneously removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the fibers of the brush penetrate deep into the fissures and interdental spaces. Clean the vestibular surface of the front teeth of the upper and lower jaws with the same movements as molars and premolars. When cleaning the oral surface, place the brush handle 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 the cleaning with circular movements of the toothbrush with the jaws closed, massaging the gums from right to left.

Cleaning duration is 3 minutes.

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

Second visit

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

Controlled teeth brushing algorithm

First visit

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

Next visit

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

Stages of professional hygiene:

Teaching the patient individual oral hygiene;
- removal of supra- and subgingival dental plaque;
- polishing of tooth surfaces, including root surfaces;
- elimination of factors contributing to the accumulation of plaque;
- applications of remineralizing and fluoride-containing agents (except for areas with high fluoride content in drinking water);
- patient motivation for the prevention and treatment of 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 must be observed:
- removal of tartar is carried out with application anesthesia;

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

In the field of metal-ceramic, ceramic, composite restorations, implants (when processing the latter, plastic instruments are used), a manual method of removing dental plaque is used.

Ultrasound devices should not be used in patients with respiratory or infectious diseases, or 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 - floss and abrasive strips. The polishing paste should be used from coarse to fine. Fluoride-containing polishing pastes are not recommended for use before certain procedures (fissure sealing, teeth whitening). When processing implant surfaces, fine polishing pastes and rubber caps should be used.

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

The frequency of professional oral hygiene depends on the patient’s dental status (oral hygiene, intensity of dental caries, condition of periodontal tissues, presence of fixed orthodontic appliances and dental implants). The minimum frequency of professional hygiene is 2 times a year.

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

It is possible to place a temporary filling (bandage) if it is impossible to place a permanent filling on the first visit or to confirm the diagnosis.

Anesthesia;
- “opening” 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 seal of the filling and prevent chipping of the enamel and filling material.

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

Features of preparation and filling of cavities

Class I cavities

One should strive to preserve the cusps on the occlusal surface as much as possible; for this, before preparation, areas of enamel that bear occlusal load are identified using articulating paper. The tubercles are removed partially or completely if the slope of the tuberosity is damaged at 1/2 of its length. If possible, preparation is carried out within the contours of natural fissures. If necessary, use the method of “preventive expansion” according to Black. The use of this method helps prevent caries relapse. This type of preparation is recommended primarily for materials that do not have good adhesion to tooth tissue (amalgam) and are retained in the cavity due to mechanical retention. When expanding the cavity to prevent secondary caries, it is necessary to pay attention 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. The cavity is formed. The quality of removal of affected tissue is checked using a probe and a caries detector.

When filling, it is necessary to use matrix systems, matrices, and interdental wedges. In case of extensive destruction of the crown part of the tooth, it is necessary to use a matrix holder. It is necessary to carry out anesthesia, since the application of a matrix holder or insertion of a wedge is painful for the patient.

A correctly formed contact surface of a tooth can in no case be flat - it must have a shape close to spherical. The contact zone between the teeth should be located in the equator area and slightly higher - as in intact teeth. You should not model the contact point at the level of the marginal ridges of the teeth: in this case, in addition to food getting stuck in the interdental space, chips of the material from which the filling is made are 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 discs. The presence of a slope of the edge ridge prevents the material from chipping in this area and food getting stuck.

Attention should be paid to the formation of tight contact between the filling and the adjacent tooth, preventing excessive introduction of material into the area of ​​the gingival wall of the cavity (creating an “overhanging edge”), ensuring optimal fit of the material to the gingival wall.

Class III cavities

When preparing, it is important to determine the optimal access. Direct access is possible if there is no adjacent tooth or if there is a prepared cavity on the adjacent contact surface of the adjacent tooth. Lingual and palatal approaches are preferred, as this allows preserving the vestibular enamel surface 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 adjacent 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 vestibular enamel, devoid of underlying dentin, if it does not have cracks or signs of mineralization.

Class IV cavities

Features of the preparation of a class IV cavity are a wide rebate, the formation in some cases of an additional platform on the lingual or palatal surface, and gentle preparation of tooth tissue during the formation of the gingival wall of the cavity in the event of the 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, restoration of the incisal edge should be carried out in two stages:

Formation of the lingual and palatal fragments of the incisal edge. The first illumination is carried out through the enamel or a previously applied composite on the vestibular side;
- formation of the vestibular fragment of the cutting edge; illumination is carried out through a hardened lingual or palatal fragment.

Class V cavities

Before starting the preparation, it is necessary to determine the depth of the process under the gum; if necessary, the patient is referred 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, 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 material for the temporary filling until the tissues of the gingival margin heal. Then filling is carried out.

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

To fill defects that are noticeable 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 and elderly patients, especially with xerostomia, amalgam or glass ionomers should be used. It is also possible to use compomers that have the advantages of glass ionomers and high aesthetics. Composite materials are indicated for filling defects in cases where the aesthetics of the smile is very important.

Class VI cavities

The characteristics of these cavities require gentle removal of the affected tissue. Burs should be used that are only slightly larger than the diameter of the cavity. It is acceptable to refuse anesthesia, especially if the cavity depth is insignificant. It is possible to preserve enamel devoid of underlying dentin, which is associated with a fairly large thickness of the enamel layer, especially in the area of ​​the molar cusps ().

Algorithm and features of inlay manufacturing

Indications for the manufacture of inlays for dentin caries are cavities of classes I and II according to Black. Inlays can be made from metals, 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 a crown for dentin caries can be decided only after removing all necrotic tissue.

The inlays are made over several visits.

First visit

During the first visit, the cavity is formed. The cavity under the inlay is formed after removing 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 must ensure that the insert is kept from moving in any direction;
- for an accurate marginal fit that ensures sealing, a bevel (rebate) should be formed within the enamel at an angle of 45° (in the manufacture of solid-cast inlays).

Cavity preparation is carried out under local anesthesia.

After the cavity is formed, the inlay is modeled in the oral cavity or an impression is taken.

When modeling a wax model, inlays pay attention to the accuracy of fitting the wax model according 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, and to giving the external surfaces of the wax model the correct anatomical shape. When modeling an inlay in a class II cavity, matrices are used to prevent damage to the interdental gingival papilla.

When making inlays using the indirect method, impressions are taken. Taking an impression after odontopreparation at the same appointment is possible in the absence of damage to the marginal periodontium. Silicone two-layer and alginate impression compounds and standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive tape before taking impressions for better retention of the impression material. It is advisable to use special glue to fix silicone impressions on the spoon. After the trays are removed from the mouth, the quality of the impressions is checked.

When making ceramic or composite inlays, color determination is carried out.

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

Next visit

After making the inlay, 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, approximal contacts, and the color of the inlay. If necessary, make corrections.

When making a solid-cast inlay, after polishing it, and when making ceramic or composite inlays, after glazing, the inlay is fixed with permanent cement.

The patient is instructed on the rules for using the insert and indicated the need for regular visits to the doctor once every six months.

Algorithm and features of manufacturing microprostheses (veneers)

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

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

First visit

When the decision is made to make a veneer, treatment begins at the same appointment.

Preparation for preparation

Tooth preparation for veneer is performed under local anesthesia.

When preparing, you should pay special attention to the depth: 0.3-0.7 mm of hard tissue is ground off. Before starting the main preparation, it is advisable to retract the gums and mark the depth of preparation using a special marking bur (disc) measuring 0.3-0.5 mm. It is necessary to pay attention to maintaining approximal contacts and avoid preparation in the cervical area.

An impression of the prepared tooth is taken at the same appointment. Silicone two-layer and alginate impression compounds and standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive tape before taking impressions for better retention of the impression material. It is advisable to use special glue to fix 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, absence of holes, etc.).

To fix the correct relationship of the dentition in the position of central occlusion, plaster or silicone blocks are used. The color of the veneer is determined.

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

Next visit

Application and fitting of veneer

Particular attention should be paid to the accuracy of the fit of the edges of the veneer to the hard tissues of the tooth; check that there are no gaps between the veneer and the tooth. Pay attention to approximal contacts and occlusal contacts with antagonist teeth. Contacts are especially carefully adjusted during sagittal and transversal movements of the lower jaw. If necessary, correction is carried out.

The veneer is fixed with permanent cement or composite material for dual-curing cementation. Pay attention to the color of the cement matching the color of the veneer. The patient is instructed on the rules for using veneers and is instructed to regularly visit the doctor once every six months.

Algorithm and features of manufacturing a solid-cast crown

The indication for making crowns is significant damage to the occlusal or cutting surfaces of the teeth while the vital pulp is preserved. Crowns are made on teeth after treatment of dentin caries with filling. Solid crowns for dentin caries are made for any teeth to restore the anatomical shape and function, as well as to prevent further tooth destruction. Crowns are made over several visits.

Features of manufacturing solid crowns:

When replacing molars, it is recommended to use a solid crown or a crown with a metal occlusal surface;
- when making a solid-cast metal-ceramic crown, an oral garland is modeled (a metal edging along the edge of the crown);
- plastic (ceramic if required) veneering is performed in the area of ​​the front teeth on the upper jaw only up to the 5th tooth inclusive and on the lower jaw up to the 4th tooth inclusive, then - as needed;
- when making crowns for antagonist teeth, a certain sequence must be followed:

• the first stage is the simultaneous production of temporary aligners for the teeth of both jaws to be prosthetized with maximum restoration of occlusal relationships and mandatory determination of the height of the lower part of the face; these aligners should reproduce the design of future crowns as accurately as possible;
• first, permanent crowns are made for 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 treatment. Before starting the preparation, impressions are taken to make temporary plastic crowns (aligners).

Preparing 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 using the gum retraction method, when taking an impression, attention is paid to the somatic status of the patient. If you have a history of cardiovascular diseases (coronary heart disease, angina pectoris, arterial hypertension, heart rhythm disturbances), auxiliary products containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

To prevent the development of inflammatory processes in the tissues of the marginal periodontium after preparation, anti-inflammatory regenerative therapy is prescribed (rinsing the mouth 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

When making solid crowns, it is recommended to make an appointment with the patient the next day or one day after preparation to take a working two-layer impression of the prepared teeth and an impression of the antagonist teeth, if they were not taken on the first visit.

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

In the case of using the gum retraction method, when taking impressions, attention is paid to the somatic status of the patient. If you have a history of cardiovascular diseases (coronary heart disease, angina pectoris, arterial hypertension, heart rhythm disturbances), auxiliary products containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

Next visit

Application and fitting of a solid crown frame. No earlier than 3 days after preparation, to exclude traumatic (thermal) damage to the pulp, repeated electrical odontometry is performed (possibly at the next visit).

Particular attention should be paid to the accuracy of the frame fit in the cervical area (marginal fit). Check that there is no gap between the crown wall and the tooth stump. Pay attention to the correspondence of the contour of the edge of the supporting crown to the contours of the gingival edge, to the degree of immersion of the edge of the crown into the gingival crevice, approximal contacts, occlusal contacts with antagonist teeth. If necessary, correction is carried out. If veneering is not provided, the solid crown is polished and fixed with temporary or permanent cement. To fix crowns, temporary and permanent calcium-containing cements should be used. Before fixing the crown with permanent cement, electroodontometry is performed to exclude inflammatory processes in the dental pulp. If there are signs of pulp damage, the issue of pulp removal is resolved.

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

Crowns with veneering 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 lateral teeth are not shown.

Next visit

Application and fitting of the finished solid crown with veneer

Particular attention should be paid to the accuracy of the fit of the crown in the cervical area (marginal fit). Check that there is no gap between the crown wall and the tooth stump. Pay attention to the correspondence of the contour of the crown edge to the contours of the gingival edge, on

the degree of immersion of the crown edge into the gingival crevice, approximal contacts, occlusal contacts with antagonist teeth.

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

Next visit

Fixation with permanent cement

When fixing with permanent cement, special attention must be paid to removing cement residues from the interdental spaces. The patient is instructed on the rules for using the crown and is instructed to regularly visit the doctor once every six months.

Algorithm and features of manufacturing a stamped crown

When properly manufactured, a stamped crown fully restores the anatomical shape of the tooth and prevents the development of complications.

First visit

After diagnostic studies, the necessary preparatory treatment measures and a decision on prosthetics, treatment begins at the same appointment. Crowns are made on teeth after treatment of dentin caries with filling.

Preparation for preparation

To determine the vitality of the pulp of supporting teeth, electroodontometry is performed before the start of all treatment measures.

Before starting the preparation, impressions are taken to make temporary plastic crowns (cannulas). If it is impossible to make temporary mouthguards due to the small volume of preparation, fluoride varnishes are used to protect the prepared teeth.

Tooth preparation

When preparing, you should pay attention to the parallelism of the walls of the prepared tooth (cylinder shape). When preparing several teeth, you should pay attention to the parallelism of the clinical axes of the tooth stumps after preparation. Tooth preparation is carried out under local anesthesia.

Taking an impression of prepared teeth at the same appointment is possible if there is no damage to the marginal periodontium during preparation. In the manufacture of stamped crowns, alginate impression compounds and standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive tape before taking impressions for better retention of the impression material. After the spoons are removed from the mouth, quality control is carried out.

To fix the correct relationship of the dentition in the position of central occlusion, plaster or silicone blocks are used. If it is necessary to determine the central relationship of the jaws, wax bases with occlusal ridges are made. When temporary mouth guards are made, they are fitted and, if necessary, re-positioned and fixed with temporary cement.

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

Next visit

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

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

Next visit

Next visit

Fitting and fitting of stamped crowns

Particular attention should be paid to the accuracy of the fit of the dirk in the cervical area (marginal fit). Check that there is no crown pressure on the marginal periodontal tissue. Pay attention to the correspondence of the contour of the edge of the supporting crown to the contours of the gingival edge, the degree of immersion of the edge of the crown into the gingival crevice (maximum 0.3-0.5 mm), approximal contacts, occlusal contacts with antagonist teeth.

If necessary, correction is carried out. When using combined stamped crowns (according to Belkin), after fitting the crown, an impression of the tooth stump is obtained using wax poured inside the crown. Determine the color of the plastic cladding. Crowns with veneering on the upper jaw are made up to the 5th tooth inclusive, on the lower jaw - up to the 4th inclusive. The lining of the chewing surfaces of the lateral teeth is not shown in principle. After polishing, fixation is performed with permanent cement.

Before fixing the crown with permanent cement, electrical odontometry is performed to identify inflammatory processes in the dental pulp. To fix the crowns, it is necessary to use permanent calcium-containing cements. If there are signs of pulp damage, the issue of pulp removal is resolved.

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

Algorithm and features of manufacturing an all-ceramic crown

The indication for the manufacture of all-ceramic crowns is significant damage to the occlusal or cutting surfaces of the teeth with preserved vital pulp. Crowns are made on teeth after treatment of dentin caries with filling.

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

Features of manufacturing all-ceramic crowns:

The main feature is the need to prepare a tooth with a circular rectangular shoulder at an angle of 90 degrees.
- When making crowns for antagonist teeth, a certain sequence must be followed:

• The first stage is the simultaneous production of temporary aligners for the teeth of both jaws to be prosthetized with maximum restoration of occlusal relationships and mandatory determination of the height of the lower part of the face. These aligners should reproduce the design of future crowns as accurately as possible;
• Permanent crowns are made one by one for 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 located at or below the gingival margin, it is always necessary to apply gingival retraction before taking an impression.

First visit

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

Preparation for preparation

To determine the viability of the pulp of prosthetic teeth, electroodontometry is performed before the start of treatment. Before starting the preparation, impressions are taken to make temporary plastic crowns (aligners).

Preparation of teeth for all-ceramic crowns

A preparation with a rectangular circular shoulder at an angle of 90° 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.

Preparation of teeth with vital pulp is carried out under local anesthesia. Taking an impression of prepared teeth at the same appointment is possible if there is no damage to the marginal periodontium during preparation. Silicone two-layer and alginate impression compounds and standard impression trays are used. It is recommended that the edges of the trays be edged with a narrow strip of adhesive tape before taking an impression for better retention of the impression material. It is advisable to use special glue to fix silicone impressions on the spoon. After the trays are removed from the mouth, the quality of the impressions is checked.

In the case of using the gum retraction method, when taking an impression, attention is paid to the somatic status of the patient. If you have a history of cardiovascular diseases (coronary heart disease, angina pectoris, arterial hypertension, heart rhythm disturbances), aids containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

To fix the correct relationship of the dentition in the position of central occlusion, plaster or silicone blocks are used. When temporary mouth guards are made, they are fitted and, if necessary, repositioned and fixed with temporary calcium-containing cement.

The color of the future crown is determined.

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

Next visit

Taking impressions

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

In the case of using the gum retraction method, when taking impressions, attention is paid to the somatic status of the patient. If you have a history of cardiovascular diseases (coronary heart disease, angina pectoris, arterial hypertension, heart rhythm disturbances), auxiliary products containing catecholamines (including threads impregnated with such compounds) should not be used for gum retraction.

Next visit

Application and fitting of an all-ceramic crown

No earlier than 3 days after preparation, to exclude traumatic (thermal) damage to the pulp, repeated electrical odontometry is performed (possibly at the next visit).

Particular attention must be paid to the accuracy of the fit of the crown to the ledge in the cervical area (marginal fit). Check that there is no gap between the crown wall and the tooth stump. Pay attention to the correspondence of the contour of the edge of the supporting crown to the contours of the edge of the ledge, approximal contacts and occlusal contacts with antagonist teeth. If necessary, correction is carried out.

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

Next visit

Fixation with permanent cement

Before fixing the crown with permanent cement, electroodontometry is performed to exclude inflammatory processes in the dental pulp. If there are signs of pulp damage, the issue of pulp removal is resolved. For vital teeth, permanent calcium-containing cements should be used to secure crowns.

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

The patient is instructed on the rules for using the crown and is instructed to regularly visit 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 medications

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

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

Prescribe rinses or baths with decoctions of one of the drugs: oak bark, chamomile flowers, sage 3-4 times a day for 3-5 days (level of evidence C). Applications to 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 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 monitoring.

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. Form of informed voluntary consent of the patient when implementing 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 a patient management protocol corresponding to the identified diseases and complications.

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

A) the section of this patient management protocol corresponding to the management of enamel caries;
b) 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 signs defining the patient model

6.3.2. The procedure for including a patient in the Protocol

A patient's condition that meets the diagnostic criteria and signs of a given patient model.

6.3.3. Requirements for outpatient diagnostics

6.3.4. Characteristics of algorithms and features of performing diagnostic measures

Diagnostics is aimed at establishing a diagnosis that corresponds to the patient’s model, excluding complications, and determining the possibility of starting treatment without additional diagnostic and treatment-and-prophylactic measures.

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

History taking

When collecting anamnesis, they find out the presence of complaints about the nature of pain from irritants, an allergic history, and the presence of somatic diseases. They purposefully identify complaints about pain and discomfort in the area of ​​a specific tooth, complaints about food getting stuck, how long ago they appeared, when the patient paid attention to them. They find out the patient’s profession, whether the patient takes proper hygienic care of the oral cavity, and the time of his last visit to the dentist.

Visual examination, examination of the oral cavity using additional instruments

When examining the oral cavity, the condition of the dentition is assessed, paying attention to the presence of fillings, the degree of their adherence, the presence of defects in the hard tissues of the teeth, and the number of teeth removed. The intensity of caries is determined (KPU index - caries, filling, removed), hygiene index. Pay attention to the condition of the oral mucosa, its color, moisture, and the presence of pathological changes. All teeth are subject to examination; the examination begins with the upper right molars and ends with the lower right molars. They 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 is used to determine the density of hard tissues, evaluate the texture and degree of surface uniformity, as well as pain sensitivity.

Pay attention to the fact that probing is carried out without strong pressure. The presence of stains on the visible surfaces of 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 an identified carious cavity, attention is paid to its shape, location, size, depth, the presence of softened tissues, changes in their color, pain or, conversely, the absence of pain sensitivity. The approximal surfaces of the tooth are especially carefully examined.

Thermal diagnostics are carried out.

Percussion is used to exclude complications of caries.

To confirm the diagnosis, radiography is performed.

6.3.5. Requirements for outpatient treatment

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

Non-drug assistance is aimed at preventing the development of the carious process and includes two main components: ensuring proper oral hygiene and filling the carious defect. Treatment of cement caries with filling allows for 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 teeth with a toothbrush and dental floss, using dental models, or other demonstration tools.

Teeth brushing begins with an area in the area of ​​the upper right chewing teeth, sequentially moving from segment to segment. The teeth on the lower jaw are cleaned in the same order.

Pay attention to the fact that the working part of the toothbrush should be positioned at an angle of 45° to the tooth, making cleaning movements from gum to tooth, while simultaneously removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the fibers of the brush penetrate deep into the fissures and interdental spaces. Clean the vestibular surface of the front teeth of the upper and lower jaws with the same movements as molars and premolars. When cleaning the oral surface, place the brush handle 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.

Finish cleaning with circular movements of the toothbrush with the jaws closed, massaging the gums from right to left. Cleaning duration is 3 minutes.

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

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

Second visit

In order to consolidate the acquired skills, supervised teeth cleaning is carried out.

Controlled teeth brushing algorithm

First visit

Treating the patient's teeth with a staining agent, determining the hygiene index, showing the patient the areas of greatest accumulation of plaque using a mirror.
- The patient brushes his teeth in his usual manner.
- Repeated determination of the hygiene index, assessment of the effectiveness of teeth brushing (comparing the hygiene index indicators before and after brushing), showing the patient, using a mirror, the stained areas where teeth were not successfully brushed.
- Demonstration of the correct technique for brushing teeth on models, recommendations to the patient on correcting deficiencies in hygienic oral care, the use of dental floss and additional hygiene products (special toothbrushes, dental brushes, mono-beam brushes, irrigators - according to indications).

Next visits

Determination of the hygiene index; if the level of oral hygiene is unsatisfactory, repeat the procedure.

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

Algorithm for professional oral and dental hygiene

Stages of professional hygiene:

Teaching the patient individual oral hygiene;
- removal of supra- and subgingival dental plaque;
- polishing of tooth surfaces, including root surfaces;
- elimination of factors contributing to the accumulation of dental plaque;
- applications of remineralizing and fluoride-containing agents (except for areas with high fluoride content in drinking water);
- patient motivation for the prevention and treatment of dental diseases.

The procedure is carried out in one visit.

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

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

In the field of metal-ceramic, ceramic, composite restorations, implants (when processing the latter, plastic instruments are used), a manual method of removing dental plaque is used.

Ultrasound devices should not be used in patients with respiratory or infectious diseases, or 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 - floss and abrasive strips. Polishing infusion should be used, starting with coarse and ending with fine. Fluoride-containing polishing pastes are not recommended for use before certain procedures (fissure sealing, teeth whitening). When processing implant surfaces, fine polishing pastes and rubber caps should be used.

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

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

Algorithm and features of filling

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

Before starting the preparation, be sure to determine the depth of the process under the gum; if necessary, the patient is referred 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, 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 material for the temporary filling until the tissues of the gingival margin heal. Then filling is carried out.

Before preparation, anesthesia is administered (application, infiltration, conduction). Before anesthesia is administered, the injection site is treated with an application of anesthetics.

General requirements for cavity preparation:

Anesthesia;
- maximum removal of pathologically altered tooth tissues;
- complete 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).

To fill defects, amalgams, glass ionomer cements and compomers are used.

In patients who neglect oral hygiene, it is recommended to use glass ionomer (polyalkenate) cements, which provide long-term fluoridation of dental 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 that have the advantages of glass ionomers and high aesthetics. Composite materials are indicated for filling defects in cases where the aesthetics of the 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 medications

Local anesthetics

Before preparation, anesthesia is administered (application, infiltration, conduction) according to indications. Before anesthesia, the injection site is treated with 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 always to polish 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. Form of voluntary informed consent of the patient when implementing 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 a patient management protocol corresponding to the identified diseases and complications.

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

A) the section of this patient management protocol corresponding to the management of enamel caries;
b) 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 signs defining the patient model

6.4.2. The procedure for including a patient in the Protocol

A patient's condition that meets the diagnostic criteria and signs of a given patient model.

6.4.3. Requirements for outpatient diagnostics

6.4.4. Characteristics of algorithms and features of performing diagnostic measures

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

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

The main differential diagnostic feature is the color of the spot: pigmented and not stained with methylene blue, in contrast to the “white (chalky) spot”, which is stained.

History taking

When collecting anamnesis, they find out the presence of complaints of pain from chemical and temperature irritants, an allergic history, and the presence of somatic diseases. Complaints of pain and discomfort in the area of ​​a specific tooth, complaints of food getting stuck, patient satisfaction with the appearance of the tooth, the timing of the onset of complaints, when the patient noticed the appearance of discomfort are purposefully identified. They find out whether the patient provides proper hygienic care for the oral cavity, the patient’s profession, the regions of his birth and residence (endemic areas of fluorosis).

Visual examination, external examination of the maxillofacial area, examination of the oral cavity using 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 adherence, the presence of defects in the hard tissues of the teeth, the number of teeth removed). The condition of the oral mucosa, its color, moisture content, and the presence of pathological changes are determined.

All teeth are subject to examination; the examination begins with the upper right molars and ends 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 matte 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 speed 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 exclude complications of caries.

Oral hygiene indices are determined before treatment and after oral hygiene training for control purposes.

6.4.5. Requirements for outpatient treatment

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

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

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

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

Remineralization therapy and, if necessary, filling treatment 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 teeth with a toothbrush and dental floss, using models of dental rads, and other demonstration tools.

Teeth brushing begins with an area in the area of ​​the upper right chewing teeth, sequentially moving from segment to segment. The teeth on the lower jaw are cleaned in the same order.

Pay attention to the fact that the working part of the toothbrush should be positioned at an angle of 45° to the tooth, making cleaning movements from gum to tooth, while simultaneously removing plaque from the teeth and gums. Clean the chewing surfaces of the teeth with horizontal (reciprocating) movements so that the fibers of the brush penetrate deep into the fissures and interdental spaces. Clean the vestibular surface of the front teeth of the upper and lower jaws with the same movements as molars and premolars. When cleaning the oral surface, place the brush handle 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.

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

Cleaning duration is 3 minutes.

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

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

Second visit

In order to consolidate the acquired skills, supervised teeth cleaning is carried out.

Controlled teeth brushing algorithm

First visit

Treating the patient's teeth with a staining agent, determining the hygiene index, showing the patient the areas of greatest accumulation of plaque using a mirror.
- The patient brushes his teeth in his usual manner.
- Repeated determination of the hygiene index, assessment of the effectiveness of tooth brushing (comparing the hygiene index indicators before and after brushing), showing the patient, using a mirror, stained areas where plaque was not removed during brushing.
- Demonstration of the correct technique for brushing teeth on models, recommendations to the patient on correcting deficiencies in hygienic oral care, the use of dental floss and additional hygiene products (special toothbrushes, dental brushes, mono-beam brushes, irrigators - according to indications).

Next visits

Determination of the hygiene index; if the level of oral hygiene is unsatisfactory, repeat the procedure.

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

Algorithm for professional oral and dental hygiene

Stages of professional hygiene:

Teaching the patient individual oral hygiene;
- removal of supra- and subgingival dental plaque;
- polishing of tooth surfaces, including root surfaces;
- elimination of factors contributing to the accumulation of plaque;
- applications of remineralizing and fluoride-containing agents (except for areas with high fluoride content in drinking water);
- patient motivation for the prevention and treatment of dental diseases.

The procedure is carried out in one visit.

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

Tartar removal 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 the teeth being treated from saliva;
- pay attention that the hand holding the instrument must be fixed on the patient’s chin or adjacent teeth, the terminal rod of the instrument is located parallel to the axis of the tooth, the main movements - lever-like and scraping - must be smooth and not traumatic. In the field of metal-ceramic, ceramic, composite restorations, implants (when processing the latter, plastic instruments are used), a manual method of removing dental plaque is used.

Ultrasound devices should not be used in patients with respiratory, infectious diseases and those on medication 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 - floss and abrasive strips. The polishing paste should be used from coarse to fine. Fluoride-containing polishing infusions are not recommended for use before certain procedures (fissure sealing, teeth whitening). When processing implant surfaces, fine polishing pastes and rubber caps should be used.

Pay attention to the need to eliminate factors that contribute to the accumulation of dental plaque: remove the overhanging edges of the fillings, and re-polish the fillings.

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

Sealing the tooth fissure with sealant

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

Algorithm and features of filling

First visit

Treatment is carried out in one visit.

A cavity is created by removing pigmented demineralized tissue. Pay attention to the fact that the cavity is formed within the enamel. If preventive expansion of the cavity is necessary to fix the filling, the transition of the enamel-dentin border is allowed. When treating chewing teeth, cavity formation is carried out in the contours of natural fissures. The edges of the cavity are finished, washed and dried before filling. Then filling is carried out. Pay attention to the mandatory restoration of the anatomical shape of the tooth, and check 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 medications

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

Fluoridation of hard dental tissues

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

Coating of teeth with fluoride varnish, as an analogue of 1-2% sodium fluoride solution, is carried out every 3rd visit after application of a remineralizing solution on the dried surface of the tooth. After application, the patient is not recommended to eat for 2 hours and brush his teeth for 12 hours. The criterion for the effectiveness of fluoridation 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 completing each treatment procedure, it is recommended not to take a mouthful or rinse your mouth for 2 hours.

Limit the consumption of foods and drinks with low pH values ​​(juices, tonic drinks, yoghurts) and thoroughly rinse your mouth after eating them. Limiting the presence of carbohydrates in the oral cavity (sucking, chewing candies).

6.4.12. Form of informed voluntary consent of the patient when implementing 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 a patient management protocol corresponding to the identified diseases and complications.

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

A) the section of this patient management protocol corresponding to the management of enamel caries;
b) 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. GRAPHICAL, SCHEMATIC AND TABULAR REPRESENTATION OF THE PROTOCOL

Not required.

VIII. MONITORING

CRITERIA AND METHODOLOGY FOR MONITORING AND EVALUATING THE EFFECTIVENESS OF PROTOCOL IMPLEMENTATION

Monitoring is carried out throughout the Russian Federation.

The list of medical institutions in which monitoring of this document is carried out is determined annually by the institution responsible for monitoring. The medical organization is informed about inclusion in the list of monitoring protocols in writing. Monitoring includes:

Collection of information: on the management of patients with dental caries in medical institutions of all levels;
- analysis of the received data;
- drawing up a report on the results of the analysis;
- submission of a report to the Protocol developer group in the Department of Standardization in Health Care of the Institute of Public Health and Health Management of the Moscow Medical Academy named after. I. M. Sechenov.

The initial data for monitoring are:

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

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

In medical and preventive institutions defined by the monitoring list, once every six months, based on medical documentation, a patient record () 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 of medical services of the mandatory and additional range, lists of medicines of the mandatory and additional range, disease outcomes, cost of medical care under the Protocol, etc.

PRINCIPLES OF RANDOMIZATION

This Protocol does not provide for randomization (of treatment facilities, patients, etc.).

PROCEDURE FOR EVALUATING AND DOCUMENTING SIDE EFFECTS AND DEVELOPMENT OF COMPLICATIONS

Information about side effects and complications that arose during the diagnosis and treatment of patients is recorded in the patient’s record (see).

PROCEDURE FOR EXCLUDING A PATIENT FROM MONITORING

A patient is considered included in monitoring when a Patient Card is filled out for him. Exclusion from monitoring is carried out if it is impossible to continue filling out the Card (for example, failure to show up for a medical appointment) (see). In this case, the Card is sent to the institution responsible for monitoring, with a note indicating the reason for excluding the patient from the Protocol.

INTERIM EVALUATION AND PROTOCOL CHANGES

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

Amendments to the Protocol are made if information is received:

A) about the presence in the Protocol of requirements that are detrimental to the health of patients,
b) upon receipt of convincing data on the need for changes to the mandatory level requirements of the Protocol.

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

PARAMETERS FOR ASSESSING 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 analogue scale (S) is used.

ASSESSMENT OF THE COST OF PROTOCOL IMPLEMENTATION AND PRICE OF QUALITY

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

COMPARISON OF RESULTS

When monitoring the Protocol, the results of fulfilling its requirements, statistical data, and performance indicators of medical institutions are annually compared.

PROCEDURE FOR FORMING A REPORT

The annual report on monitoring results includes quantitative results obtained during the development of medical records, and their qualitative analysis, conclusions, and 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 publicly.

Annex 1

LIST OF DENTAL MATERIALS AND INSTRUMENTS REQUIRED FOR THE WORK OF A DOCTOR MANDATORY RANGE

ADDITIONAL RANGE

Appendix 2

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

Appendix 3

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

Patient ____________________________________________________

FULL NAME _________________________________

receiving clarification regarding the diagnosis of caries, I received the following information:

about the features of the course of the disease ____________________________________________________________

probable duration of treatment_________________________________________________________________

about the probable prognosis______________________________________________________________________________

The patient is offered an examination and treatment plan, including _____________________________________________

The patient was asked________________________________________________________________________________

from materials _________________________________________________________________________________

The approximate cost of treatment is approximately __________________________________________________________

The patient knows the price list accepted at the clinic.

Thus, the patient received clarification about the purpose of treatment and information about the planned methods

diagnosis and treatment.

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

_____________________________________________________________________________________________

The patient is informed of the need during treatment

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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

The patient is informed about the probable course of the disease and its complications if treatment is refused. The patient had the opportunity to ask any questions he was interested in regarding his state of health, disease and treatment and received satisfactory answers to them.

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

The interview was conducted by a doctor________________________ (doctor’s signature).

"___"________________200___g.

The patient agreed with the proposed treatment plan, in which

signed with his own hand_______________________________________________________________________________

(patient signature)

signed by his legal representative_______________________________________________________________

What do those present during the conversation certify?

(doctor's signature)

_______________________________________________________

(witness signature)

The patient did not agree with the treatment plan

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

(patient signature)

or signed by his legal representative__________________________________________________________

(signature of legal representative)

What do those present during the conversation certify?

(doctor's signature)

_______________________________________________________

(witness signature)

The patient expressed a desire:

In addition to the proposed treatment, undergo an examination

Receive additional medical services

Instead of the proposed filling material, get

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

Since this method of examination/treatment is also indicated for the patient, it is included in the treatment plan.

(patient signature)

_________________________________

(doctor's signature)

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

"___" ___________________20____ _________________________________

(patient signature)

_________________________________

(doctor's signature)

Appendix 4

ADDITIONAL INFORMATION FOR THE PATIENT

1. Filled teeth should be brushed with a toothbrush and toothpaste in the same way as natural teeth - twice a day. After eating, you should rinse your mouth to remove any remaining food.

2. To clean the interdental spaces, you can use dental floss (floss) after training in their use and on the recommendation of a dentist.

3. If bleeding occurs when brushing your teeth, you cannot 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 closure of the teeth, then it is necessary to contact your doctor as soon as possible.

5. If you have fillings 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 filling the tooth.

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

7. If sharp pain occurs in a tooth, you must contact your dentist as soon as possible.

8. To avoid chipping the filling and the hard tooth tissue adjacent to the filling, it is not recommended to eat and chew very hard food (for example: nuts, crackers), or bite off large pieces (for example: 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).

Appendix 5

PATIENT CARD

Case history No. ____________________________

Name of institution

Date: start of observation_________________ end of observation___________________________

FULL NAME. ____________________________________________________age.

Main diagnosis ________________________________________________________________________________

Accompanying illnesses: ____________________________________________________________

Patient Model: ________________________________________________________________________

Volume of non-drug medical care provided:__________________________________________

Medication (specify the drug used):

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

Information about the patient has been transferred to the institution monitoring the Protocol:

(Name of institution) (Date)

Signature of the person responsible for monitoring the protocol

in a medical institution: ______________________________________________________________