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

Question 1. Definition of caries.

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

The main reasons for the development of dental caries.

Presence of dental plaque

Consuming large amounts of easily fermentable carbohydrates

Factors contributing to the development of dental caries:

acidic saliva reaction

crowded teeth

low concentration of minerals (fluoride) in enamel

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

hyposalivation

Question 2. Classification of caries according to MMSI.

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

1. Caries in the spot stage (MACULACARIOSA) – focal demineralization of enamel, without cavity formation:

white spot - indicates an active carious process

pigmented spot - indicates some stabilization of the process.

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

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

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

Question 3. International classification of caries according to WHO (from the International Classification of Diseases, 10th revision)

Initial caries (chalk spot stage).

Enamel caries.

Dentin caries.

Cement caries.

Suspended caries.

RELATIONSHIP OF THESE TWO CLASSIFICATIONS:

Question 4. Classification of Black's carious cavities.

Question 5. Diagnosis of dental caries.

Carious stain - when dried, a loss of enamel shine is detected; for differential diagnosis with non-carious lesions, vital staining of the enamel is used to identify focal demineralization. METHYLENE BLUE IS USED, AS WELL AS SPECIAL SOLUTIONS – “CARIES MARKERS”.

Carious cavities are detected by probing

With the help of X-ray therapy, carious cavities on contact surfaces are revealed, as well as caries under fillings.

Question 6. Assessment of the prevalence of dental caries:

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

Question 7. Assessment of the intensity of caries:

The intensity of caries is assessed using the KPU index:

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

In some cases (especially in children), the KPP index is used - the sum of filled and carious surfaces (the extracted tooth is counted as 5 surfaces).

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

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

(for 12 years old)

very low level of caries intensity 0-1.1

low level of caries intensity 1.2-2.6;

average level of caries intensity 2.7-4.4;

high level of caries intensity 4.5-6.5;

very high level of caries intensity 6.6-7.4;

Question 8. Methods for treating caries:

non-invasive (remineralizing therapy)

invasive (preparation followed by filling).

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

Practice - rubber dam.

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

Indications:

treatment of dental caries

endodontic dental treatment

dental restoration

use of Air-Flow devices

Contraindications:

severe periodontitis

allergy to latex

patient's reluctance.

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

Using rubber dam:

holes are marked on the latex using a template

holes are made using a punch

latex is placed on the extracted teeth, clamps are fixed on the extracted tooth or on adjacent teeth, fixation with the help of wedges or chords is also possible.

At the clinic, flosses are tied to the clamps (so that they can be pulled out if inhaled or swallowed)

Latex is stretched over the frame

Due to the characteristics of the development of caries, several classifications have been identified. We present the main classifications of caries

In accordance with changes in hard tissues and clinical manifestations, several types of classification of dental caries have been created, they are based on various signs.

According to the WHO classification, caries is classified as a separate category.

Classification of caries ICD-10

• K02.0 enamel stage of chalk stain (initial caries)
• K02.1 Dentin caries
• K02.2 Cement caries
• K02.3 Suspended dental caries
• K.02.3 Odontoclasia
  Pediatric melanodentia
  Melanodontoclasia
• K02.8 Other dental caries
• K02.9 Dental caries, unspecified

The advantages of this classification include the introduction of the subcategories “arrested caries” and “cement caries”.

Topographic classification of dental caries

In our country, this classification is most widely used. It takes into account the depth of the lesion, which is very convenient for the practice of the dentist.

1. – focal demineralization of the hard tissues of the tooth is observed, and it can occur intensively (white spot) or slowly (brown spot).
2. – at this stage a carious cavity appears within the enamel.
3. – at this stage, the carious defect is located within the surface layer of dentin (mantle dentin).
4. – in this case, the pathological process reaches the deep layers of dentin (peripulpal dentin).

In clinical practice, the terms “secondary caries” and “recurrent caries” are also used; let’s take a closer look at what they are:

1)Secondary caries– these are all new carious lesions that develop next to the filling in a previously treated tooth. Secondary caries has all the histological characteristics of a carious lesion. The reason for its occurrence is a violation of the marginal seal between the filling and the hard tissues of the tooth; microorganisms from the oral cavity penetrate into the resulting gap and optimal conditions are created for the formation of a carious defect along the edge of the filling in the enamel or dentin.

2) Relapse of caries is the resumption or progression of the pathological process if the carious lesion was not completely removed during previous treatment. Recurrence of caries is often detected under the filling during an X-ray examination or along the edge of the filling.

Clinical classification of dental caries

1. Acute caries. It is characterized by the rapid development of destructive changes in the hard tissues of the tooth, the rapid transition of uncomplicated caries to complicated ones. The affected tissues are soft, slightly pigmented (light yellow, grayish-white), moist, and can be easily removed with an excavator.
2. Chronic caries is characterized as a slow process (several years). The spread of the carious process (cavity) is mainly in the planar direction. The altered tissues are hard, pigmented, brown or dark brown in color.
3. There are also other forms of caries, for example, “acute”, “blooming caries”.

Classification of carious cavities according to Black

Class 1 – cavities located in the area of ​​fissures and natural recesses (for example, the blind fossa of the lateral incisors);

Class 2 – cavities located on the contact surfaces of small and large molars;

Class 3 – cavities located on the contact surfaces of the incisors and canines while maintaining the cutting edge;

Class 4 – cavities located on the contact surfaces of the incisors and canines with violation of the angles and cutting edge of the crown;

Class 5 – cavities on the labial, buccal and lingual surfaces located in the gingival part of the crown.

Recently, class 6 has been identified, which Black did not describe; these are cavities located on the tubercles of the molars and on the cutting edge of the incisors and canines.

Depending on the nature of the changes occurring in the hard tissues of the tooth, as well as clinical manifestations, several ways have been created to classify dental caries.

Microbial caries presupposes the presence of various underlying signs. According to the WHO classification, caries is classified as a separate group.

Classification of caries according to ICD 10

The phenomenon of caries ICD 10 suggests dividing into the following points:

• K02.0 This is enamel caries, that is, the initial one, which can be called the chalk spot stage.
• K021 – caries affecting dentin;
• K02.2 – so-called cement caries;
• K02.3 – caries, which has currently stopped;
• K.02.3. This includes odontoclasia, melanodontoclasia, and meladonthenia in children;
• K02.8. Other types of dental caries;
• K02.9. Unrefined caries.

The classification of caries according to ICD 10 is currently one of the most popular. Among its advantages we can include the fact that sub-categories appeared in it in the form of suspended caries or cement caries.

Topographic classification

This classification of caries, like ICD10, is quite common in our country. For the practical part of a dentist’s work, it is extremely convenient, since it takes into account the depth of damage to the tooth.

• Stage of carious spot. At the same time, we can observe demineralization of the hard tissues of a particular tooth, which can be either slow in the form of brown or intense in the form of a whitened spot.
• Superficial caries. This stage suggests that the carious cavity appears within the boundaries of the human enamel.
• Average caries. Here we are talking about a carious defect, which is located within the boundaries of the mantle dentin - its surface layer.
• Deep caries. Here we are talking about a pathological process that affects the deep layers of dentin, known as peripulpar dentin.



In addition, clinical practice involves the use of the concepts of secondary caries and recurrent caries. Let's figure out what it is:

1. Under secondary caries It is generally accepted to understand all newly formed carious lesions that appear near the filling in a tooth that has been treated previously. This problem is also distinguished by all the histological features of carious lesions. It appears due to violations of the marginal contact between the hard tissues of the teeth and fillings. A gap appears into which microorganisms from the oral cavity penetrate; as a result, the conditions for the appearance of a carious defect at the boundaries of the filling in dentin or enamel become extremely favorable.
2. Recurrence of caries. This is progress or resumption of the pathological process when the carious lesion was not completely eliminated during the previous treatment. Most often, this problem is detected at the edges of the filling, during an X-ray examination of the patient.

Clinical classification

• Acute caries. It is characterized by the rapid development of changes in tooth tissues, the rapid transition of uncomplicated to complicated caries. In this case, after the lesion, the tissues become soft and weak pigments are expressed.
• Chronic caries. This is a slow process that does not go away over several years and spreads mainly in the planar direction. The tissues that are affected become hard and pigmented, acquiring brown tones.
• There are also other forms, such as blooming or sharp.

Black classification

1. Class. Cavities that are located in natural recesses and fissures;
2. Class. Cavities on the contact surfaces of molars, both large and small;
3. Class. Cavities on the contact areas of fangs and incisors, suggesting preservation of the cutting edge;
4. Class. These are cavities that are also found on the canines and incisors, but the angles and cutting edges are broken;
5. Class. We are talking about cavities on the lips, cheeks and tongue in the gingival parts.

Although Black did not describe Class 6, it is still often used today. It refers to the cavities that are located on the cusps of permanent teeth, the cutting edges of sharp teeth.

In the International Statistical Classification of Diseases and Related Health Problems of the World Health Organization, Tenth Revision (ICD-10):

K02.0 Enamel caries

Stage of “white (chalky) spot” [initial caries]

K02.1 Dentin caries

K02.2 Cement caries

K02.3 Suspended dental caries

K02.4 Odontoclasia

K02.8 Other dental caries

K02.9 Dental caries, unspecified

General approaches to the diagnosis and treatment 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 part of the tooth are established. Depending on the diagnosis, a treatment method is chosen.

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

Elimination of factors determining 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 for suspended caries;

Preservation of healthy hard dental tissues whenever possible, excision of pathologically altered tissues with subsequent restoration of the tooth crown;

At taking anamnesis 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).

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. REGULATORY 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) Sufficient negative evidence: 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 the development 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 tooth surface and a dental plaque is formed. Further intake of carbohydrates leads to a local change in pH towards 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, but the pulp is covered with 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 part 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;
- 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 performed on 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 preventive institutions, as well as in the departments and offices of therapeutic dentistry of multidisciplinary treatment and preventive 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

Nosological form: enamel caries
Stage: stage of “white (chalky) spot” (initial caries)
Phase: process stabilization
Complication: no complications
ICD-10 code: K02.0

6.1.1 Criteria and features defining the patient model


- Tooth without visible destruction and carious cavities.

- Focal demineralization of the enamel without cavity formation, there are foci of demineralization - white matte spots. When probing, the smooth or rough surface of the tooth is determined without disturbing the enamel-dentin junction.
- Healthy periodontium and oral mucosa.

6.1.2 Procedure for including a patient in the Protocol

6.1.3. Requirements for outpatient diagnostics

Code	Name	Multiplicity of execution
A01.07.001		1
А01.07.002		1
А01.07.005		1
A02.07.001		1
A02.07.005	Thermal diagnostics of the tooth	1
A02.07.007	Percussion of teeth	1
A02.07.008	Definition of bite	According to the algorithm
A03.07.001	Fluorescent stomatoscopy	As needed
A03.07.003		As needed
A06.07.003		As needed
A12.07.001		According to the algorithm
A12.07.003		According to the algorithm
A12.07.004		As needed

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

Code	Name	Multiplicity of execution
А13.31.007	Oral hygiene training	1
A14.07.004	Controlled teeth brushing	1
A16.07.089		1
A16.07.055		1
A11.07.013		According to the algorithm
A16.07.061		As needed
A25.07.001		According to the algorithm
A25.07.002		According to the algorithm

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

6.1.7. Requirements for outpatient drug care

6.1.8. Characteristics of algorithms and features of the use of 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

Outcome name	Frequency of development, %	Criteria and Signs
Function compensation	30		2 months
Stabilization	60		2 months	Dynamic observation 2 times a year
	5		At any stage	Providing medical care according to the protocol of the corresponding disease
	5

6.1.16. Cost characteristics of the Protocol

6.2. PATIENT MODEL

Nosological form: dentin caries
Stage: any
Phase: process stabilization
Complications: no complications
ICD-10 code: K02.1

6.2.1. Criteria and signs defining the patient model

- Patients with permanent teeth.
- The presence of a cavity with the transition of the enamel-dentin border.
- Tooth with healthy pulp and periodontium.

- When probing a carious cavity, short-term pain is possible.






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

Code	Name	Multiplicity of execution
A01.07.001	Collection of anamnesis and complaints for oral pathology	1
А01.07.002	Visual examination for oral pathology	1
А01.07.005	External examination of the maxillofacial area	1
A02.07.001	Examination of the oral cavity using additional instruments	1
A02.07.002		1
A02.07.005	Thermal diagnostics of the tooth	1
A02.07.007	Percussion of teeth	1
A12.07.003	Determination of oral hygiene indices	1
A02.07.006	Definition of bite	According to the algorithm
A03.07.003	Diagnosis of the condition of the dental system using methods and means of radiation visualization	As needed
A05.07.001	Electroodontometry	As needed
A06.07.003	Targeted intraoral contact radiography	As needed
A06.07.010		As needed
A12.07.001	Vital staining of hard dental tissues	As needed
A12.07.004	Determination of periodontal indices	As needed

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

Code	Name	Multiplicity of execution
А13.31.007	Oral hygiene training	1
A14.07.004	Controlled teeth brushing	1
A16.07.002.	Restoring a tooth with a filling	1
A16.07.055	Professional oral and dental hygiene	1
A16.07.003	Tooth restoration with inlays, veneers, half-crowns	As needed
A16.07.004	Tooth restoration with a crown	As needed
A25.07.001	Prescription of drug therapy for diseases of the oral cavity and teeth	According to the algorithm
A25.07.002	Prescribing dietary therapy for diseases of the oral cavity and teeth	According to the algorithm

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 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 tools 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 fit 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, gentle preparation of tooth tissue during the formation of the gingival wall of the cavity in the event of the spread of the carious process 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 all necrotic tissue has been removed.

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: grind off 0.3-0.7 mm of hard tissue. 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 of 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, electroodontometry 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

Outcome name	Frequency of development, %	Criteria and signs	Approximate time of comprehension	Continuity and phasing of medical care
Function compensation	50			Dynamic observation 2 times a year
Stabilization	30	No relapse or complications	Immediately after treatment	Dynamic observation 2 times a year
Development of iatrogenic complications	10	The appearance of new lesions or complications due to therapy (for example, allergic reactions)	At any stage	Providing medical care according to the protocol for the corresponding disease
Development of a new disease associated with the underlying	10	Recurrence of caries, its progression	6 months after the end of treatment in the absence of dynamic observation	Providing medical care according to the protocol for the corresponding disease

6.2.16. Cost characteristics of the Protocol

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

6.3. PATIENT MODEL

Nosological form: cement caries
Stage: any
Phase: process stabilization
Complications: no complications
ICD-10 code: K02.2

6.3.1. Criteria and signs defining the patient model

- Patients with permanent teeth.
- Healthy pulp and periodontium of the tooth.
- The presence of a carious cavity located in the cervical area.
- Presence of softened dentin.
- When probing a carious cavity, short-term pain is noted.
- Pain from temperature, chemical and mechanical stimuli, disappearing after the irritation stops.
- Healthy periodontium and oral mucosa.
- Absence of spontaneous pain at the time of examination and in the anamnesis.
- No pain when percussing the tooth.
- Absence of non-carious lesions of hard tooth tissues.

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

Code	Name	Multiplicity of execution
A01.07.001	Collection of anamnesis and complaints for oral pathology	1
А01.07.002	Visual examination for oral pathology	1
А01.07.005	External examination of the maxillofacial area	1
A02.07.001	Examination of the oral cavity using additional instruments	1
A02.07.002	Examination of carious cavities using a dental probe	1
A02.07.007	Percussion of teeth	1
A12.07.003	Determination of oral hygiene indices	1
A12.07.004	Determination of periodontal indices	1
A02.07.006	Definition of bite	According to the algorithm
A02.07.005	Thermal diagnostics of the tooth	As needed
A03.07.003	Diagnosis of the condition of the dental system using methods and means of radiation visualization	As needed
A06.07.003	Targeted intraoral contact radiography	As needed
A06.07.010	Radiovisiography of the maxillofacial area	As needed

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

Pay attention to the fact that 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 coloring 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 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 deposits (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 tools 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

Outcome name	Frequency of development, %	Criteria and signs	Estimated time to reach outcome	Continuity and staged provision of medical care
Function compensation	40	Restoration of the anatomical shape and function of the tooth	Immediately after treatment	Dynamic observation 2 times a year
Stabilization	15	No relapse or complications	Immediately after treatment	Dynamic observation 2 times a year
	25	The appearance of new lesions or complications due to therapy (for example, allergic reactions)	At any stage	Providing medical care according to the protocol for the corresponding disease
Development of a new disease associated with the underlying	20	Recurrence of caries, its progression	6 months after the end of treatment in the absence of dynamic observation	Providing medical care according to the protocol for the corresponding disease

6.3.16. Cost characteristics of the Protocol

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

6.4. PATIENT MODEL

Nosological form: suspended dental caries
Stage: any
Phase: process stabilization
Complications: no complications
ICD-10 code: K02.3

6.4.1. Criteria and signs defining the patient model

- Patients with permanent teeth.
- Presence of a dark pigmented spot.
- Absence of non-carious diseases of hard dental tissues.
- Focal demineralization of the enamel; upon probing, a smooth or rough surface of the tooth enamel is determined.
- A tooth with a healthy pulpa and periodontium.
- Healthy periodontium and oral mucosa.

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

Code	Name	Multiplicity of execution
A01.07.001	Collection of anamnesis and complaints for oral pathology	1
A0 1.07.002	Visual examination for oral pathology	1
А01.07.005	External examination of the maxillofacial area	1
A02.07.001	Examination of the oral cavity using additional instruments	1
A02.07.002	Examination of carious cavities using a dental probe	1
A02.07.007	Percussion of teeth	1
A02.07.005	Thermal diagnostics of the tooth	As needed
A02.07.006	Definition of bite	As needed
А0З.07.003	Diagnosis of the condition of the dental system using methods and means of radiation visualization	As needed
A05.07.001	Electroodontometry	As needed
A06.07.003	Targeted intraoral contact radiography	As needed
A06.07.010	Radiovisiography of the maxillofacial area	As needed
A12.07.003	Determination of oral hygiene indices	According to the algorithm
A12.07.004	Determination of periodontal indices	As needed

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

Code	Name	Multiplicity of execution
А13.31.007	Oral hygiene training	1
A14.07.004	Controlled teeth brushing	1
A16.07.055	Professional oral and dental hygiene	1
A11.07.013	Deep fluoridation of hard dental tissues	According to the algorithm
A16.07.002	Restoring a tooth with a filling	As needed
A16.07.061	Sealing the tooth fissure with sealant	As needed
A25.07.001	Prescription of drug therapy for diseases of the oral cavity and teeth	According to the algorithm
A25.07.002	Prescribing dietary therapy for diseases of the oral cavity and teeth	According to the algorithm

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 coloring 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 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 tools 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

Outcome name	Frequency of development, %	Criteria and signs	Estimated time to reach outcome	Continuity and phasing of medical care
Function compensation	30	Restoring the appearance of the tooth		Dynamic observation 2 times a year
Stabilization	50	Absence of both positive and negative dynamics	2 months for remineralization, for filling immediately after treatment	Dynamic observation 2 times a year
Development of iatrogenic complications	10	The appearance of new lesions or complications due to therapy (for example, allergic reactions)	At the stage of dental treatment	Providing medical care according to the protocol for the corresponding disease
Development of a new disease associated with the underlying	10	Recurrence of caries, its progression	6 months after the end of treatment and in the absence of follow-up	Providing medical care according to the protocol for the corresponding disease

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 to 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.

Appendix 1

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

1. A set of dental instruments (tray, mirror, spatula, dental tweezers, dental probe, excavators, smoothers, fillers)
2. Dental glasses for mixing
3. A set of tools for working with amalgams
4. A set of tools for working with KOMI books
5. Articulation paper
6. Turbine tip
7. Straight tip
8. Contra-angle handpiece
9. Steel burs for contra-angle handpiece
10. Diamond burs for a turbine handpiece for preparing hard dental tissues
11. Diamond burs for contra-angle handpieces for preparing hard dental tissues
12. Carbide burs for turbine handpiece
13. Carbide burs for contra-angle handpiece
14. Disc holders for contra-angle handpiece for polishing discs
15. Rubber polishing heads
16. Polishing brushes
17. Polishing discs
18. Metal strips of varying degrees of grain size
19. Plastic strips
20. Retraction threads
21. Disposable gloves
22. Disposable masks
23. Disposable saliva ejectors
24. Disposable glasses
25. Glasses for working with solar lamps
26. Disposable syringes
27. Carpule syringe
28. Needles for a carpule syringe
29. Color scale
30. Materials for dressings and temporary fillings
31. Silicate cements
32. Phosphate cements
33. Steloionomer cements
34. Amalgams in capsules
35. Double-chamber capsules for mixing amalgam
30. Capsule mixer
37. Chemically cured composite materials
38. Flowable composites
39. Materials for therapeutic and insulating pads
40. Adhesive systems for light-curing composites
41. Adhesive systems for chemically cured composites
42. Antiseptics for medicinal treatment of the oral cavity and carious cavity
43. Composite surface sealant, post-bonding
44. Abrasive pastes that do not contain fluoride for cleaning the tooth surface
45. Pastes for polishing fillings and teeth
46. ​​Lamps for photopolymerization of composites
47. Apparatus for electroodontodiagnostics
48. Wooden interdental wedges
49. Transparent interdental wedges
50. Metal matrices
51. Contoured steel matrices
52. Transparent matrices
53. Matrix holder
54. Matrix fixation system
55. Applicator gun for capsule composite materials
56. Applicators
57. Tools for teaching the patient about oral hygiene (toothbrushes, pastes, threads, holders for dental floss)

ADDITIONAL RANGE

1. Micromotor
2. High-speed handpiece (contra-angle) for turbine burs
3. Glasperlene sterilizer
4. Ultrasonic device for cleaning burs
5. Standard cotton rolls
6. Box for standard cotton rolls
7. Patient aprons
8. Paper blocks for kneading
9. Cotton balls for drying cavities
10. Quickdam (cofferdam)
11. Enamel knife
12. Gum edge trimmers
13. Tablets for coloring teeth during hygienic activities
14. Device for diagnosing caries
15. Tools for creating contact points on molars and premolars
16. Burs for fissurotomy
17. Strips for isolating the ducts of the parotid salivary glands
18. Safety glasses
19. Protective screen

Appendix 2

to the Protocol for the management of patients “Dental caries”

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

Patient population	Recommended hygiene products
Population of areas with fluoride content in drinking water less than 1 mg/l. The patient has foci of moss demineralization and hypoplasia	A soft or medium-hard toothbrush, anti-caries toothpastes - fluoride- and calcium-containing (according to age), dental floss (floss), fluoride-containing rinses
Population of areas with fluoride content in drinking water of more than 1 mg/l. The patient has manifestations of fluorosis	A soft or medium-hard toothbrush, fluoride-free, calcium-containing toothpastes; dental floss (floss) not impregnated with fluoride, rinses not containing fluoride
The patient has inflammatory periodontal diseases (during exacerbation)	Toothbrush with soft bristles, anti-inflammatory toothpastes (with medicinal herbs, antiseptics*, salt additives), dental floss, rinses with anti-inflammatory components *Note: The recommended course of use of toothpastes and rinses with antiseptics is 7-10 days
The patient has dental anomalies (crowding, dystopia of teeth)	A medium-hard toothbrush and therapeutic and prophylactic toothpaste (according to age), dental floss, dental brushes, rinses
The presence of braces in the patient's mouth	Orthodontic toothbrush of medium hardness, anti-caries and anti-inflammatory toothpastes (alternating), dental brushes, monotuft brushes, dental floss, rinses with anti-caries and anti-inflammatory components, irrigators
The patient has dental implants	Toothbrush with different heights of tufts of bristles*, anti-caries and anti-inflammatory toothpastes (alternating), tooth brushes, single-tuft brushes, dental floss (floss), alcohol-free rinses with anti-caries and anti-inflammatory components, irrigators Do not use toothpicks or chewing gum *Note: Toothbrushes with evenly trimmed bristles are not recommended due to their lower cleaning efficiency
The patient has removable orthopedic and orthodontic structures	Toothbrush for removable dentures (double-sided, with stiff bristles), tablets for cleaning removable dentures
Patients with increased tooth sensitivity.	Toothbrush with soft bristles, toothpastes to reduce tooth sensitivity (containing strontium chloride, potassium nitrate, potassium chloride, hydroxyanatite), dental floss, rinses for sensitive teeth
Patients with xerostomia	Toothbrush with very soft bristles, toothpaste with enzyme systems and low pricing, alcohol-free mouthwash, moisturizing gel, dental floss

Appendix 3

to the Protocol for the management of patients “Dental caries”

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

to the Protocol for the management of patients “Dental caries”

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 spaces between teeth, 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. With 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 tooth filling.

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

to the Protocol for the management of patients “Dental caries”

PATIENT CARD

Case history No. ____________________________

Name of institution

Date: start of observation_________________ end of observation___________________________

Full name ____________________________________________________age.

Main diagnosis ________________________________________________________________________________

Concomitant diseases: ____________________________________________________________

Patient Model: ______________________________________________________________________________

Volume of non-drug medical care provided:__________________________________________

Code medical	Name of medical service	Multiplicity of execution
DIAGNOSTICS
A01.07.001	Collection of anamnesis and complaints for oral pathology
А01.07.002	Visual examination for oral pathology
А01.07.005	External examination of the maxillofacial area
A02.07.001	Examination of the oral cavity using additional instruments
A02.07.005	Thermal diagnostics of the tooth
A02.07.006	Definition of bite
A02.07.007	Percussion of teeth
A03.07.001	Fluorescent stomatoscopy
А0З.07.003	Diagnosis of the condition of the dental system using methods and means of radiation visualization
A06.07.003	Targeted intraoral contact radiography
A12.07.001	Vital staining of hard dental tissues
A12.07.003	Determination of oral hygiene indices
A12.07.004	Determination of periodontal indices
A02.07.002	Examination of carious cavities using a dental probe
A05.07.001	Electroodontometry
A06.07.0I0	Radiovisiography of the maxillofacial area
A11.07.013	Deep fluoridation of hard dental tissues
А13.31.007	Oral hygiene training
A14.07.004	Controlled teeth brushing
A16.07.002	Restoring a tooth with a filling
A16.07.003	Tooth restoration with inlays, veneers, half-crown
A16.07.004	Tooth restoration with a crown
A16.07.055	Professional oral and dental hygiene
A16.07.061	Sealing the tooth fissure with sealant
A16.07.089	Grinding of hard tooth tissues
A25.07.001	Prescription of drug therapy for diseases of the oral cavity and teeth
A25.07.002	Prescribing dietary therapy for diseases of the oral cavity and teeth

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: ______________________________________________________________

CONCLUSION WHEN MONITORING	Completeness of implementation of the mandatory list of non-drug assistance	Yes	No	NOTE
	Meeting deadlines for medical services	Yes	No
	Complete implementation of the mandatory list of medicinal products	Yes	No
	Compliance of treatment with protocol requirements in terms of timing/duration	Yes	No





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