Index score for dental caries. The main indicators of dental caries (intensity, prevalence, incidence, reduction of caries growth)
Evaluation and registration of the state of hard tissues of teeth. Indices of caries intensity (KPU, KPU + kp, kp of teeth and surfaces).
Purpose of the lesson: to study and learn how to register the state of hard tissues of teeth using caries intensity indices (KPU, KPU + kp, kp).
Requirements for the initial level of knowledge: To fully master the topic, students need to repeat from:
Anatomy - anatomy of temporary and permanent teeth.
Histology - the structure of the enamel of temporary and permanent teeth.
Therapeutic dentistry - classification of dental caries according to Black. Immune zones of teeth to caries.
Review questions:
Classification, formation mechanism, composition, structure of dental deposits.
Controlled brushing of teeth and methods of its implementation.
Means of hygienic care for the oral cavity and the requirements for them.
Evaluation of the cariogenicity of dental plaque.
Summary of the topic:
Prevalence of dental caries characterized by the number of people with caries, among all surveyed of a particular locality, region, age: professional group, etc.
This indicator is expressed as a percentage. It is calculated by dividing the number of persons with caries-affected teeth by the total number of those examined.
Example: Of the 1200 examined individuals, 990 were found to have carious teeth.
1200 people - 100% X= 990* 100% = 82,5 %
990 people - X 1200
The prevalence of caries less than 30% is considered low, from 31% to 80% - medium, more than 81% - high.
Intensity of caries characterized by the degree of damage to the teeth by caries and is determined by the average value of the indexes KPU, KP, KPU + KP of teeth and cavities, the intensity index reflects the degree of damage to teeth and cavities.
The intensity index reflects the degree of damage to the teeth of one child.
This indicator in an adult is characterized by the sum of carious teeth (C), sealed (P) and removed (U) for caries or its complications (CPU).
KPU+kp- for a changeable bite,
kp- for a temporary bite.
KPU cavities- the sum of carious + sealed cavities.
The intensity of caries in one person is expressed as a whole number.
For the intensity of tooth damage in a given contingent of persons, the sum of the KPU indices of teeth in all examined is found and divided by the number of examined.
For instance: Find the average intensity of caries. When examining 1200 people, 8587 carious, filled and extracted teeth were found.
8587/ 1200 = 7.1 - the average intensity of caries.
WHO proposes the following levels of assessment of the intensity of dental caries according to the KPU index in 12-year-old children
|
Intensity |
|
|
very low very high |
6.6 and up |
Incidence (increase in the intensity of caries) is defined as the average number of teeth in which new carious cavities have appeared over a certain period, for example, per year, per one child with caries. This indicator is used in planning and forecasting the needs of the population in dental care, as well as assessing the effectiveness of ongoing preventive measures.
To determine the increase in the intensity of caries, it is necessary to subtract the intensity indicator that characterizes this person (or the average person) during the previous examination from the number characterizing the intensity of caries in a particular person (or average person) at the present time.
caries reduction.
In the two younger groups of the kindergarten, the average caries intensity
was 2.0. In the experimental group, the intensity of caries was 3.2, in the other - 3.7. Define reduction.
We find the increase in caries in both groups 3.7 - 2.0 = 1.7
increase in caries in numerical values
We find the increase in caries in% value.
X= 1,2 * 100 = 70 %
increase in the intensity of caries from 100%
100% - 70% = 30% - reduction, i.e. % of undeveloped caries.
Based on the magnitude of the intensity of dental caries damage and the presence of focal enamel demineralization, T.F. Vinogradova developed a method for determining the degree of activity of caries in children of school age.
Istage of caries activity (compensated caries) - such a condition of the teeth, when the KPU or KPU + KP index does not exceed the indications of the average intensity of caries of the corresponding age group, there are no signs of focal demineralization and initial caries. For Moscow, the average value of the intensity of caries for children in grades 1-3 is 5, for children in grades 4-7. - 4, for 8 -10 cells. -6.
IIstage of caries activity (subcompensated caries)- such a condition of the teeth, in which the intensity of caries according to the indices KPU, KPU + KP is more than the average intensity value for this age group by a certain statistically calculated value. There are no actively progressive focal demineralization and the initial form of caries. For Moscow, this form of caries is determined by the following values of the intensity of caries: for children in grades 1 - 7 up to 8 inclusive, for grades 8 - 10 - up to 9 inclusive.
IIIstage of caries activity (decompensated caries)- a condition in which the KPU, KPU + KP indicators exceed the previous indicators, with any lower value of the KPU, active progressive foci of demineralization and initial caries are detected.
Situational tasks
Dentists have been talking about the danger of caries and the importance of its prevention for more than a dozen years. At the same time, there is a need to somehow measure the effectiveness of preventive and therapeutic work. To do this, doctors carefully collect data. Also, experts have developed a special coefficient with which you can trace and identify the intensity of the spread of dental caries. More details in today's article.
Why statistics are kept on the prevalence and intensity of caries
Modern medicine does not skimp on conducting a variety of studies that help not only to understand the extent of a particular problem, but also to build preventive work and evaluate its effectiveness. This also applies to the prevalence of caries: dentists from different countries transmit statistical data on the frequency of detection of the disease, its course, age, social status patients and even comorbidities.
Such statistical studies allow us to analyze the situation and draw the following conclusions:
- how different factors influence the formation and development of carious lesions,
- which population groups are most at risk of caries,
- how to develop a strategy to reduce the likelihood of developing the disease not only in risk groups, but also in social and age groups less prone to caries,
- how effective are the methods of prevention and treatment of the disease,
- how to give medical care patients with identified diagnoses, as well as to create new methods of diagnosis and treatment.
When developing methods for the treatment and prevention of caries, doctors rely on two indicators - the prevalence and intensity of the disease. At the same time, different criteria for the disease are analyzed.
Why caries is a serious threat to society: interesting statistics
According to WHO data collected over the past few decades, the incidence of caries in people in different countries and regardless of their standard of living, living conditions and education, it is 80-98% (although in Africa and Asia the problem is less common, but in America, in the north and in the polar region it is more common).
In recent years, the statistics among children with this pathology has grown very strongly - among young patients aged six and seven years, the prevalence of carious lesions of different depths is up to 90%. About 80% of teenagers also have carious dental problems at the time of graduation. But this is not the only thing that worries doctors. Nowadays, the prevalence of periodontal diseases is gaining momentum - most often problems occur in two age groups: 15-19 years old (55-89%), 35-44 years old (65-98%). Data collected in 53 countries around the world.
On a note! An interesting study in 2016 was conducted by GfK experts in 17 countries around the world. Experts have found that the biggest concern among the populations of Japan and Korea is aging and wrinkles. But Russia turned out to be the only country where the problem of missing and losing teeth due to dental diseases has become one of the main reasons for concern among residents of different cities.
And researchers from the University of Washington were even able to calculate that the number of cases of toothache caused by caries increased from 164 million to 220 million between the 1990s and 2013. And these are only cases registered by doctors!
Criteria for caries
Here, doctors highlight several important points. Let's look at each of them in detail.
1. By stage of development
Like any other disease, a carious lesion begins with mild forms and gradually turns into a severe, complicated diagnosis. In this regard, dentists distinguish the following stages of the disease:
- initial: it is also called the stain stage, when the enamel demineralizes, due to which white rough spots appear on it and the natural shine disappears,
- superficial: caries begins to destroy tooth enamel, but does not yet penetrate more soft tissues- dentin,
- medium: the area of destruction affects the dentin,
- deep: caries passes to the internal tissues of the tooth pulp or root, complications begin that are not always treatable and lead to tooth loss.
2. By place of origin
Localization of the lesion also requires special study. According to this criterion, doctors distinguish several types of caries:
- multiple: diagnosed on several teeth at once, most often adjacent,
- fissure: localized in the depressions between the masticatory tubercles of premolars and molars,
- interdental: it can be found between adjacent teeth, in a space that is hard to reach for toothbrushes,
- circular: affects the enamel around the entire circumference of the crown near the gum, as a rule, is diagnosed immediately on several adjacent teeth,
- cervical: destroy the protective surface of the tooth near the gums, but not around the circumference, but from one edge,
- root: destruction proceeds deep under the gum, which makes it difficult to diagnose this type of caries, often occurs against the background of gum disease,
- secondary: the destruction begins next to the filling or under it and indicates that the doctor poorly removed the previously affected enamel or dentin.
3. By type of teeth
Treatment and prevention of caries also depends on which teeth the lesion develops: on milk or permanent teeth. Temporary teeth have thinner enamel, while the child's immunity has not yet formed to fully protect itself from bacteria, so "milk" caries develops more rapidly, and children suffer from carious lesions more often than adults.
Disease intensity
The intensity of caries (IC) is a concept that shows the degree of damage to the crowns according to the KPU, kp, KPU + kp indices in one person. In this case, the letters in the abbreviations mean the following:
- K - caries on permanent teeth,
- P - fillings on permanent teeth,
- Y - removed permanent teeth,
- k - caries on milk teeth,
- p - fillings on milk teeth.
Important! When identifying the intensity of the disease by indices, it is not taken into account initial stage. Moreover, if at the time of the examination the patient had a complete replacement of teeth, then the KPU or KPUp indices are applied to him; if the change of teeth is not completed, then the doctor focuses on the KPU + kp indices, and if the milk teeth have not yet begun to fall out, then the kpu index is applied.
The total intensity is considered as the sum of all teeth (except for "eights") ever affected by caries (including sealed and removed). Separately, the intensity of the disease on the root or crown is calculated. IC can be calculated both for one examined person and for a group that is similar in some way (for example, for children, for pregnant women, etc.).
It is difficult for a person who is not related to medicine to operate with such abbreviations and concepts, however, these designations help dentists to keep statistics that are very useful for their activities, which report on the effectiveness, or vice versa, on the inefficiency of work in each specific region of the country, on the needs for dental industries.
Different hit ratios: how do they differ
When examining, dentists operate with two concepts KPU(s) and KPU(p). They reveal the general picture of human morbidity and detail it.
So, KPU(z) is the sum of units affected, sealed and removed due to caries in one patient, divided by the total number of teeth in the mouth (except for the “eights”).
KPU(p) is the sum of affected, filled and removed dental surfaces in one patient, also divided by the number of all surfaces. To calculate the KPU (p) of the incisors, four surfaces are taken into account (frontal, lingual and two lateral), and for molars, five surfaces are taken into account (chewing is added to the previous four). For example, if a patient has two surfaces affected on one tooth and there is a filling, then such a tooth receives 3 units.
For children, during the change of temporary teeth to permanent ones, the indices KPU (p) and kp (p) are calculated, that is, the surfaces of the crowns are summed up, and only those teeth that were removed from the jaw ahead of schedule, that is, before resorption of the roots, are considered removed.
Attention! For a more accurate assessment of the condition of the affected teeth, doctors derive the KPP indicator. Often there are, for example, two diseased surfaces and one filling on one unit. In this case, the IC will be three units. This method allows for a more qualitative analysis at a low intensity of the disease.
What is the CPU index
In modern dentistry, there are five levels of IC. For comparison, you can see how the KPU index changes in patients of different ages, for example, 12 and 35 years old (the first and second values, respectively):
- very low level:<1,1 и <1,5,
- low level:<2,6 и <6,2,
- average level:<4,4 и <12,7,
- high level:<6,5 и <16,2,
- very high level: >6.6 and >16.3.
As you can see, there are a lot of people with a high intensity of caries at the age of 35. And yes, there are a lot of teenagers.
Often, along with the KPU indices, doctors also calculate the increase in the disease. This is an indicator of the change in the number of carious units over a certain period of time (most often a year) in one patient. The increase can be positive if the number of affected teeth has increased, or negative if it has decreased or reduced to zero.
Disease prevalence
The prevalence of caries (PR) is the percentage of patients who have been diagnosed with at least one sign of this lesion at any stage, to the total number examined. In children 12-13 years of age (the age when the change of milk teeth should be completed), the prevalence of the disease can be low (less than 30%), medium (31-80%) and high (81-100%).
Assessment of the prevalence of caries
In addition to the direct indicator of RK, there is also an inverse one. It shows the percentage of examined people who do not have caries, to the number of patients with this diagnosis. Accordingly, in this vein, the RC can be high (the number free from the disease is less than 5%), medium (5-20%) and low (more than 20% of the examined patients did not have caries).
Assessment of the Republic of Kazakhstan is needed in order to have a picture of the incidence in a particular region, in certain age or social groups. In particular, in our country, this disease in most regions has a high rate, and in some it is very high. For example, for preschoolers, the RC is 84%, and the IC for the kpu(s) index is 4.83.
Interesting! In those Russian regions where the fluoride content in tap water exceeded 0.7 mg/l, the number of people with identified caries was much less than in regions where water fluoridation was insufficient. This trend is especially clearly illustrated by survey indicators of different children's age groups - 6, 12 and 16 years old. In adults, the destruction of enamel is influenced by additional factors (bad habits, pregnancy, stress, harmful working conditions, etc.).
Epidemiological indicators
The epidemiology of caries is a concept in statistical medical research that shows how widespread and intense this disease is in a country and its regions. In addition, it shows how well medical care is provided to the population and how much their needs for this help are covered. In addition to dental clinics, this statistics is very useful for educational institutions that train specialists of a particular profile: it is important for them to understand how many medical personnel are required in order to fully provide medical care to the population.
Also, manufacturers of hygiene products (toothpastes, brushes, rinses, etc.) are interested in indicators of the epidemiology of caries in order to determine the scope of work and the direction of research in the field of prevention of this disease. The same applies to companies producing equipment and materials for dental clinics. Their developments are aimed at improving the quality of diagnosis and treatment of the disease.
When detecting RC, the indicators of patients of the same age group are taken into account, while the indicators of different groups are not summed up and are not mixed. Separately, there are children with milk teeth: they have their own risk factors. People with permanent teeth are conditionally divided into several categories: children from 12-15 years old, young (from 16 to 30 years old), middle-aged (30-45 years old), mature age (45-60 years old) and elderly (over 60 years old).
When analyzing the situation in a particular region, factors that provoke the development of the disease are taken into account, including the following: the presence of daylight hours a year, the strength of solar radiation, the presence of microelements (calcium, phosphorus, fluorine, zinc and others) in drinking water that are responsible for healthy functioning of tooth enamel and dentin.
The factor of unbalanced nutrition, stress and a sedentary lifestyle is also evaluated. All this affects the metabolism, and hence the delivery of useful substances to the tissues of the teeth. Do not discount the lack of oral hygiene, as well as bad habits (alcohol, drug addiction and smoking).
How research is done
In order for these studies to be reliable, it is important to comply with the following conditions:
- age groups: it is important to conduct research for each age group separately, because it has its own characteristics and its own tasks. So, for example, in children, the intensity of the disease is observed in dynamics, in young people, periodontal disease is observed, and for elderly patients, the problems of prosthetics are more relevant than treatment,
- indicators of objectivity: these are important to consider when conducting the survey itself. For example, it is important that an equal number of people of both sexes be examined, that data on the indigenous population be processed separately from data on visitors (relevant for regions where there are many enterprises working on a rotational basis),
- qualification of specialists: a very important point that ultimately affects all statistical data, because the quality of the examination depends on the level of training of the dentist,
- technical equipment of the clinic: this aspect also affects the quality of the examination,
- computer program: it is needed for multi-level data processing and providing a statistical report to higher organizations and the Ministry of Health.
Clinical examination and prevention
Based on the data obtained on the prevalence and intensity of the above pathology, the Ministry of Health carries out preventive work with the population. It is expressed both in informational alerts about the danger of the disease and methods for its prevention, and in practical actions: the inclusion of a scheduled examination at the dentist for children of different ages (the second year of life, before getting a ticket to kindergarten, before starting school, etc. ), scheduled inspections of employees of enterprises and institutions, students, employees of government agencies, etc.
In addition, the prophylaxis of dental diseases is also assigned to the prophylactic medical examination of the population. In addition, during the medical examination, it is very convenient to collect statistical information and analyze the dynamics of the prevalence and intensity of a dental disease.
Related videos
1 Cherkasov S.M. Analysis of the prevalence of diseases of the dentoalveolar system that form the demand for dental services. Scientific journal "Fundamental Research", 2014.
The intensity and prevalence of caries are considered the main sources of statistics for this disease. Data are regularly collected on the frequency and rate of the course of the disease for all age groups of patients, depending on the influence of external and internal factors on their dental system. Thanks to the quantitative accounting of disease outbreaks, scientists can conduct scientific research, and dentists can carry out preventive and curative work in the fight against caries.
For dentistry, caries is considered an urgent problem that has to be dealt with daily. However, working with the disease separately, it is impossible to achieve positive results in the form of reducing mass outbreaks of lesions. That is why disease statistics are kept all over the world.
The collected data help not only to increase the professional level of dentists, but also to introduce the latest methods of diagnosis and treatment into practice. As a result, dental caries statistics help to improve the quality of dental services.
To establish a diagnosis, the dentist interviews the patient and writes down all the information in the medical record - the main document of the doctor's work record. When the treatment ends, the card remains with the dentist for five years, then it is archived for 75 years. Thanks to a well-coordinated storage system, it is possible to track and collect caries development statistics at any time.
The main tasks of statistics
Dental research is based on statistical data on caries, its prevalence, intensity and duration in different patients. When collecting information, the following tasks are set:
- study of the mechanism of origin and development of the disease in its individual manifestations;
- study of the origin of the disease in general: the conditions and causes of its occurrence;
- division of the population according to the degree of risk of developing the disease;
- drawing up future forecasts for the development of the disease for planning preventive care and adequate provision of dental services to the population;
- evaluation of the effectiveness of the created preventive and therapeutic methods;
- determination of the degree of development of the disease in the examined group of patients to correct the errors that have appeared and plan new directions in the methods of prevention and treatment.
Important indicators when collecting information
Conducting mass examinations, dentists take into account, first of all, the age of patients. Children have different susceptibility to caries, besides, they have two types of teeth: temporary and permanent. Milk teeth are known to be more susceptible to caries. Accordingly, children belong to a separate, pediatric group of patients. In addition to this age group, there is a group of adults, consisting of three subgroups: young (adolescent), middle and old.
The next point in collecting information on the spread of caries are external and internal factors of influence. This includes the patient's place of residence: is the climate suitable for his health, is there enough sunlight, is the required amount of minerals, micro and macro elements present in drinking water.
The diet of the patient also plays an important role in the appearance of dental damage. An unbalanced diet is the cause of a deficiency of vitamin and mineral substances in the body. As a result, the human immunity weakens, often causing disease. The rest of the causes of the disease can be found in the article.
The prevalence of the disease
According to the list of terms used by WHO - the World Health Organization, four main parameters are used to assess dental damage: the intensity of dental caries, its prevalence, the increase and decrease in intensity over a specific period of time.
The prevalence of a disease is a calculation of a certain ratio, expressed as a percentage. When calculating, they take the number of patients in whom at least one sign of tooth damage was noticed during the examination, and the number of all examined patients. The formula for calculating the desired number: ((patients with caries)/(total number of examined patients))×100%.
The incidence of caries depends on the result obtained: up to 30% - low, from 31% to 80% - medium, more than 80% - high.
In some cases, a term is used that is more suitable for the purposes of statistics on the manifestation of the disease - patients without caries. As a result, the indicator, the inverse of prevalence, is calculated according to the formula: ((patients without caries)/(total number of examined patients))×100%.
The low prevalence of the disease means that patients without caries are more than 20% of the total percentage examined, the average - from 5% to 20%, high - up to 5%.
Conservative, sedentary parameter
In each region, research results are used to a limited extent, only to improve the level of preventive measures against caries. All obtained indicators of the prevalence of the disease are compared among themselves in different regions, aiming at the mass eradication of the problem.
This state of affairs is associated with the specifics of the disease - if a person has a toothache, then he will forever remain in the group of patients. Even if it was a long time ago, but caries was stopped or cured. Accordingly, the prevalence of the disease is a sedentary, routine parameter. That is why the evaluation of the effectiveness of preventive measures is possible only by comparing large groups of patients of different ages and with different places of residence.
Disease intensity
To solve statistical problems, it is necessary to take into account not only the fact of the development of the disease. To improve the level of dental services, an assessment of the intensity of caries is needed.
To calculate the degree of intensity of the disease, scientists from WHO came up with a special index of the amount of damaged teeth - KPU, where K - teeth affected by caries, P - filled teeth, U - teeth removed. The intensity of dental caries is calculated according to the formula: ((R+P+U)/(total number of surveyed)).
For children with temporary (milk) teeth, the index kp is allocated, where k - teeth affected by caries, n - filled teeth. For children whose temporary teeth are being replaced by permanent ones, the intensity of the disease is calculated by the KPU + kp index.
In mass studies of the degree of intensity of the disease in children, it begins to be calculated from about 12 years old, when the change of temporary teeth to permanent ones has ended. Such restrictions are considered the most informative, since the level of caries in milk teeth is a relative concept, not a constant one. WHO identifies five degrees of disease intensity, which can be found in the table:
Increasing and Decreasing Intensity
The increase in caries activity is studied in each patient individually. Dentists examine how many healthy teeth the disease has affected in a certain time. Usually the doctor examines the patient every two to three years, in case of sharp deterioration - every three to six months.
The increase in morbidity is the difference in the indicators of the KPU index between the last examination of the patient and the previous one. Thanks to these studies, the dentist can plan a method of treatment and a method of prevention, based on the needs of each patient.
Based on this, the scientist T.F. Vinogradova identified three types of activity in the development of the disease, which can be found in the article.
If prevention and treatment help, the activity of the caries lesion begins to weaken - the reduction of the disease. This information is measured by the formula: ((Mk-M)/Mk))×100%.
Mk is the increase in the disease in patients before preventive and curative work, M is the increase in the disease after undergoing dental procedures.
The degree of provision of dental services to the population
In certain areas of public service, the following indicators of the provision of dental services are investigated:
- the number of people who applied for help;
- availability of services;
- providing dentists with jobs;
- the ratio of the number of dentists to the number of people living in a particular area;
- providing the population with dental chairs.
In large-scale studies of the provision of dental services to the population, in certain regions, several groups of patients are simultaneously examined, each of which should contain at least 20 people. Formula for identifying the level of dental care (DCE): 100%-((k+A)/(KPU))×100, where k is the average number of teeth affected by caries, without treatment, A is the average number of extracted teeth without restoring their functions with the help of prostheses. If the indicator is more than 75%, then the USP is good, 50% -74% - satisfactory, 10% -49% - insufficient, less than 9% - poor.
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In 1981, the WHO set a goal: to reduce the intensity of caries in 12-year-old children to CPV=3. In 20 years, about 70% of the world's countries have achieved this goal. However, the low intensity of dental caries in the population as a whole does not exclude the high intensity of caries in a part of the population. In recent years, the "dental inequality" has become more and more noticeable: while a significant part of the population remains free from caries, the brunt of dental caries falls on the least protected minority of the population. In 2000, Brathole introduced the Significant Caries Index (SiC) to draw attention to disadvantaged populations in pursuit of the WHO strategic goal of Health for All. This index is an average IPC calculated for a third of the surveyed population, which has the highest IPC index for this population (Fig. 5.9).
Rice. 5.9. An example of preparing epidemiological survey data for calculating the SiC index.
SiC calculation algorithm:
1) calculation of an individual CPSU for all examined;
2) selection of a third of the population with the highest values of the IPC;
3) calculation of the average IPC for the selected subgroup.
In Figure 5.9, the data from the epidemiological survey are presented as a graph of the frequency distribution of the IPC. Approximately 45% of the members of the population are free from caries (CWH=0). The mean CVAC for the entire population is 1.91. The vertical line shows the selection of the subgroup for which SiC was calculated. This indicator of caries intensity turned out to be much higher: SiC=4.61.
A new global target for improved dental health by 2015 has been formulated: achieving SiC levels
Indicators of the intensity of dental caries make it possible to determine the form of the course (degree of activity) of caries (T.F. Vinogradova). CVUS values (CVUS + CVUS) that do not exceed the average values of these indicators for a given age group (CVUS=M) are regarded as an indicator of a compensated course of caries. To calculate the boundaries of CPUS for subcompensated and decompensated caries, use the statistical value a - the standard deviation:
b = (KPUSmax - KPUSmin)/K
where K=6.5.
The boundaries of the subcompensated course of caries were determined: in this group, the value of CVUS exceeds the average value of M, but does not go beyond the boundaries of the value equal to M + 30 (M
In the case of decompensated caries, CPUS exceeds the value equal to M+30 (CPUS>M+Sb).
The form of the course of dental caries in a school-age child can be determined using the table (see Table 5.4), the data of which are calculated using these formulas based on the results of an epidemiological survey of Moscow schoolchildren conducted in the 1970s and 1980s.
Table 5.4. Forms of the course of caries in children 
Since the form of the course of caries is regarded as a reliable prognostic sign that predicts the further development of the carious process in a given person, it serves as a measure for the rational and effective distribution of preventive efforts: maximum attention is paid to children with sub- and decompensated forms of caries.
The change in indicators of CPUS over time is defined as an increase in the intensity of caries. The increase in the intensity of dental caries AKPUZ is calculated as the difference between the final and initial values of the CIPUZ index:
LKPUZ = KPU32-KPU31,
Where KPU32 is registered after some time (a year, two or more) after the registration of KPUZ,.
In one person or in a group with the same composition, the CPSS may remain unchanged or increase over time. The increase may be more or less pronounced depending on a number of conditions, including the nature of the preventive measures taken during the observation period.
The concept of the growth of CPUS underlies the scale for determining the level of intensity of dental caries PEC (P. ALeus). The individual PIC is calculated as the quotient of the CVUS (kpuz) and the number of years lived by the patient (N), i.e. average annual growth of CPSU:
PEC=CPU/N
When calculating the PEC of permanent teeth in children aged 9-19, the first 5 years of life are not taken into account, i.e. Years before permanent teeth erupt:
PEC=CPU/(N-5)
Based on the statistical analysis of the UIC of various age groups of the population in many countries, a table (Table 5.5) has been compiled, which makes it possible to give a relative assessment of the value of the UIC of each person. An assessment of the activity of caries of the patient's teeth can also be made using the detailed table 5.6, which presents the ready-made results of the calculations of the UIC for all ages for all options for the intensity of caries.
Table 5.5. Evaluation of caries activity according to the values of PEC 
Table 5.6. Caries activity at different values of CVUS (CVUS+cvs, cvs) in different age groups 
The reduction in the increase in the intensity of caries is another dynamic indicator of the incidence of caries, indicating the relative magnitude of the differences (in percent) between two homogeneous values. Most often, the decrease in the increase in the intensity of dental caries in the group participating in the preventive program is calculated in relation to the increase in the intensity of caries obtained over the same period in the control group.
An example of calculating the reduction in the increase in the intensity of caries.
Before the introduction of the preventive program in 6"A" class KPUZA = 2.8; in 6"B" - KPUZB1 = 3.0. Then for two years in the 6th "A" class, oral hygiene lessons were conducted, in the 6th "B" - lessons in hygiene and application of fluorine varnish. After two years of the preventive program:
. in 6"A" class - KPUZA2 = 4.8;
. in 6"B" class - KPUZB2 = 4.5.
. increase in AKPU32_, in 6 "A" class: KPUZA2 - KPUZA1 \u003d 4.8-2.8 \u003d 2.0.
. increase in DKPU32_, in 6"B" class: KPUZB2 - KPUZB1 \u003d 4.5-3.0 \u003d 1.5.
Estimation of the growth of caries in 6"B" class compared with the growth of caries in 6"A":
2.0 (AKPUZ 6A) - 100%; 1.5 (AKPU3 6B) -x%; according to the properties of proportion:
X \u003d (1.5 / 2) * 100 \u003d 75%.
The reduction in the increase in the intensity of caries can also be calculated using equivalent formulas:
Reduction \u003d 100% - ((AKPUZprof) / (AKPUZkontr)) * 100%
Knowing the values of K, P and Y in a group or population, it is possible to determine which part of the problems of the population associated with carious tooth decay has already been solved, and which part still needs dental care. The level of dental care (USP, P.A. Leus) is calculated based on the knowledge of the components of the CPUZ, as well as data on the replacement of missing teeth with prostheses:
USP = 100% - ((K+A)/KPUZ)*100%
where K is the average number of carious teeth in need of treatment; A - the average number of extracted teeth not restored with prostheses (part of U); KPUZ - the average value of the intensity of dental caries of the examined group.
Values for SLR are interpreted as follows: SLR less than 10% corresponds to a poor level of dental care; USP from 10 to 49% - insufficient level, from 50 to 79% - satisfactory, over 80% - good level of accessibility of therapeutic and orthopedic care.
Intensity of caries of tooth surfaces
The intensity of caries of the surfaces of the teeth is determined by the index of CPMC, developed by Klein and Palmer. The study of the teeth is carried out by the same methods as in the calculation of the CPUS, but the state of each surface of each tooth is recorded, i.e. five surfaces for molars and premolars, four for the incisor and canine. To register the state of surfaces, special schemes are used (see Fig. 5.10).
Rice. 5.10. Schematic representation of the molar and premolar (a), canine and incisor (b).
The criteria for inclusion of a surface in the "K" and "P" categories are the same as those in the IPUZ index. If the crown of the tooth is completely destroyed or the tooth is removed, all its (5 or 4) surfaces are considered affected.
Often a carious lesion of one surface extends to adjacent surfaces of the tooth. It is customary to consider as damaged only one, the main surface, until the damage to the adjacent surface exceeds more than 1/3 of its area.
The value of CPMC (permanent teeth) can range from 0 to 128; klub (temporary teeth) - from 0 to 88.
Calculate the individual and group KUPP (KUPP + kpup, kpup), its growth and reduction.
Recording and counting the intensity of surface caries is technically more difficult, so this indicator has a lower reproducibility1 than ICPU. On the other hand, this indicator is more sensitive, which makes it possible to distinguish between the effectiveness and mechanisms of action of various means and methods of prevention. Thus, the reduction in the intensity of dental caries under the influence of water fluoridation for the chewing surface is 20%, for the remaining surfaces of the teeth - 80%.
Accounting for carious foci
To obtain operational data on the significance of certain pathogenic, preventive or therapeutic effects on tooth tissues, an indicator of the intensity of growth or reduction of carious foci is used. Most often, the initial forms of caries in situ are under observation, therefore the index reflecting the number of carious foci is called IS. The IS index is a good prognostic criterion and is recommended for use in planning individual prevention.T.V. Popruzhenko, T.N. Terekhova
Dental caries(Fig. 2.1) still remains an urgent problem in dentistry. This disease occurs after teething. It is based on the process of demineralization and proteolysis of hard dental tissues, leading to the formation of a defect in the form of a cavity.
Rice. 2.1. Dental caries
2.1. CRITERIA FOR ASSESSING CARIOUS LESIONS
The criteria for assessing the state of hard tissues of teeth in a population are the prevalence and intensity of caries in temporary and permanent teeth.
Prevalence of dental caries - this is the ratio of the number of persons with at least one of the signs of dental caries (carious, filled or extracted teeth) to the total number of examined, expressed as a percentage.
WHO assessment criteria for the prevalence of dental caries in 12-year-old children.
Prevalence of dental caries in 12-year-olds (WHO criteria): low 0-30%; average 31-80%; high 81-100%.
The intensity of dental caries - this is the sum of clinical signs of carious lesions (carious, filled and extracted teeth), calculated individually for one patient or group of patients.
For rate intensity of caries of temporary teeth indexes are used:
. kpu (h)- the sum of caries-affected, filled and extracted teeth in one examined child;
. kpu (p)- the sum of the surfaces of the teeth affected by caries, filled and removed in one examined child.
Note. When determining the number of extracted teeth or surfaces, only those that are removed prematurely, before the physiological resorption of the roots, are considered.
For rate intensity of caries in permanent teeth indexes are used:
. KPU (h)- the amount of caries-affected, filled and removed teeth due to complications of caries in one examined;
. KPU (p)- the sum of the surfaces of the teeth affected by caries, sealed and removed due to complications of caries in one examined.
Note. If a tooth of the anterior group is removed, then when calculating the KPU index (n), 4 surfaces are taken into account, if a tooth of the chewing group is removed - 5 surfaces. When determining the indices of caries intensity, its initial form in the form of focal enamel demineralization is not taken into account.
For rate the intensity of caries during the period of changing teeth(from 6 to 12 years old) use indices CPU and kp teeth and surfaces. The intensity of caries of temporary and permanent teeth and surfaces is calculated separately.
The intensity of caries in the group of examined- this is the ratio of the sum of individual indices of the intensity of caries of teeth or surfaces to the number of examined.
The level of intensity of dental caries (according to the KPU index) in 12-year-old children and adults (WHO criteria):
2.2. PREVALENCE AND INTENSITY OF DENTAL CARIES AMONG THE POPULATION OF RUSSIA
Currently, dental caries is one of the most common dental diseases among children and adults in the Russian Federation.
According to the epidemiological dental survey (2009), conducted among the key age groups of the Russian population, prevalence of dental caries in 6-year-old children was 84%, average intensity of caries of temporary teeth according to the kpu (h) index - 4.83, while the "k" component is 2.9, "p" - 1.55, "y" - 0.38.
Average prevalence and intensity of caries in permanent teeth in the population of Russia:
The given data is the result of a national epidemiological dental examination of 55,391 people living in 47 regions of the Russian Federation. The survey was conducted in 2007-2008. using codes and criteria for assessing dental status proposed by WHO.
According to the results obtained, the incidence of caries in different areas is not the same. The most significant relationship was found between the intensity of caries in temporary and permanent teeth and the fluoride content in drinking water: at a fluoride concentration of more than 0.7 mg/l, it is lower and increases if the fluoride content is less than 0.7 mg/l. This dependence is more clearly seen in the age groups of 6, 12 and 15 years. Among the adult population, this trend is less pronounced, which is probably due to the action of many cariogenic factors (Fig. 2.2, 2.3).
Rice. 2.2. The average intensity of caries in temporary teeth in areas with different levels of fluoride in drinking water
Rice. 2.3. The average intensity of caries in permanent teeth in areas with different levels of fluoride in drinking water
The average indicators of the intensity of caries in the urban and rural population did not differ significantly.
A low level of caries intensity according to WHO gradation in 12-year-olds was registered in 27 regions, medium - in 19, and high - in one region.
The level of intensity of dental caries in the adult population in most regions was assessed according to the WHO gradation as high.
When analyzing the results of the second national epidemiological dental survey, a trend towards a decrease in the average intensity of caries in permanent teeth in the children's population was revealed compared to the data of 10 years ago (1999), but in adults and the elderly they still remain high.
2.3. NEED FOR DENTAL TREATMENT
POPULATION OF RUSSIA
The results of the survey of the population made it possible to determine the need for various types of treatment of hard dental tissues. Thus, 52% of six-year-old children require filling of one surface, and 45% - of two or more surfaces of temporary teeth. 13% and 22%, respectively, need endodontic treatment and tooth extraction.
The need for treatment of permanent teeth in this age group was mainly reduced to the need for preventive measures, in particular, sealing the fissures of the first permanent molars (52%), prescribing remineralizing therapy (51%), as well as filling one (13%) and two (5% ) surfaces of permanent teeth.
In the group of 12-year-olds, the need for filling teeth sharply increases (46% - one, 21% - two surfaces or more), endodontic treatment and removal of permanent teeth (8 and 10%, respectively), and the need for preventive measures (sealing fissures of the second permanent molars) remains high (48%).
In 15-year-olds, the need for the listed types of dental care increases, the need for orthopedic treatment is determined - the manufacture of artificial crowns.
The adult population continues to have a high need for fillings, prosthetics (55%) and extractions (23%) of teeth, while the elderly mostly needed prosthetics (63%) and extractions (35%).
2.4. RISK FACTORS FOR DENTAL CARIES
Local factors:
The presence of plaque (poor oral hygiene);
High content of easily fermentable carbohydrates in the diet;
Change in the quantitative and qualitative composition of the oral fluid;
Low caries resistance of enamel;
Incomplete mineralization of enamel of fissures of permanent teeth during their eruption;
The presence of factors contributing to the retention of plaque (anomalies in the position of the teeth, non-removable orthodontic and orthopedic structures, overhanging edges of fillings, etc.).
General factors:
Low fluoride content in drinking water;
Unbalanced diet, nutritional deficiency of minerals (primarily calcium and phosphates), vitamins;
Somatic diseases (chronic pathology of the digestive tract, endocrine system), metabolic disorders, hypovitaminosis; congenital anomalies of the maxillofacial region;
Extreme effects on the body, stress;
Unfavorable environmental conditions. The following groups are most at risk for caries:
Pregnant women and young children (from 0 to 3 years);
Children during the eruption of permanent teeth;
Persons who have difficulty in hygienic care of the oral cavity (having non-removable orthodontic and orthopedic constructions, anomalies in the position of the teeth, etc.);
Workers in hazardous industries (chemical, confectionery, etc.).
2.4.1. METHODS FOR DETERMINING THE RISK OF DENTAL CARIES
HYGIENE ASSESSMENT
MOUTH
Plaque are detected visually when examining the oral cavity with a dental probe and when using indicator means:
1) tablets, solutions containing erythrosin, fuchsin (tablets Espo Plak("Paro"), "RedCote" ("Butler"), plaque indicator solution ("President") and etc.;
2) iodine-containing solutions (Lugol, Schiller-Pisarev solutions) (Fig. 2.4);
3) preparations containing fluorescein for the visualization of dental plaque in ultraviolet rays.
Rice. 2.4. Plaque stained with Schiller-Pisarev solution
INDICES FOR DETERMINING THE HYGIENIC STATE OF THE ORAL CAVITY
1. Plaque assessment index in young children(from the moment of eruption of the first teeth up to 3 years) (Kuzmina E.M., 2000).
To assess this index visually or using a dental probe, the presence of plaque on all teeth in the oral cavity is determined.
Codes and evaluation criteria:
0 - there is no plaque;
1 - the presence of dental plaque. Index calculation:
where IG is the hygiene index in young children. Interpretation of results
2. Fedorov-Volodkina index(1971).
Recommended for assessing the hygienic condition of the oral cavity in children under the age of 5-6 years. To assess the index, the vestibular surface of the six anterior teeth of the lower jaw is stained: 83, 82, 81, 71, 72, 73.
Codes and evaluation criteria:
1 - lack of staining;
2 - staining 1/4 of the surface of the tooth crown;
3 - staining 1/2 of the surface of the tooth crown;
4 - staining 3/4 of the surface of the tooth crown;
5 - staining of the entire surface of the tooth crown. Index calculation
where IG is the Fedorov-Volodkina hygiene index.
Interpretation of results
3. Cavity Hygiene Performance Index
mouth RNR(Podshadley A.G., Haley P., 1968). Index teeth:
16, 11, 26, 31 - vestibular surface;
36, 46 - oral surface.
In the absence of an index tooth, the adjacent tooth is stained within the group of the same name.
The examined tooth surface is divided into 5 sections:
1 - medial; 2 - distal;
3- mid-occlusal;
4- central; 5 - mid-cervical.
Codes and evaluation criteria:
0 - lack of staining;
1 - coloring of any intensity. Index calculation:
where РНР is the index of effectiveness of oral hygiene.
Interpretation of results
4. Oral hygiene index IGR-U
(OHI-S - Oral Hygiene Index-Simplified; Greene J.S., Vermillion J.K., 1964).
Determines the presence of plaque (by staining the surfaces of index teeth with indicator solutions) and tartar (by probing).
Index teeth:
16, 11, 26, 31 - vestibular surface; 36, 46 - oral surface. Codes and criteria for assessing plaque:0 - no plaque was detected;
1 - soft plaque covering no more than 1/3 of the tooth surface, or the presence of any amount of pigmented plaque;
2 - soft plaque covering more than 1/3, but less than 2/3 of the tooth surface;
3 - soft plaque covering more than 2/3 of the tooth surface.
Codes and criteria for assessing tartar:
0 - tartar was not detected;
1 - supragingival tartar covering no more than 1/3 of the tooth surface;
2 - supragingival calculus covering more than 1/3, but less than 2/3 of the tooth surface, or the presence of separate deposits of subgingival calculus in the cervical region of the tooth;
3 - supragingival calculus covering more than 2/3 of the tooth surface, or the presence of significant deposits of subgingival calculus around the cervical region of the tooth.
Index calculation:
where IGR-U is a simplified index of oral hygiene.
Interpretation of results
5. API Proximal Plaque Index(Lange D.E., Plagmann H.,
1977).
With the help of staining, the presence of plaque on the contact surfaces of the teeth and in the interdental spaces is determined:
II and IV quadrants - from the vestibular surface; I and III quadrants - from the oral surface.
Criteria for evaluation:
0 - there is no plaque;
1 - the presence of plaque in the interdental space. Index calculation:
where API is the plaque index on the proximal surfaces of the teeth.
Interpretation of results
2.5. EVALUATION OF PROPERTIES OF ORAL FLUID AND PLAQUE
Determination of the rate of saliva secretion.
It is recommended to collect saliva 1.52 hours after a meal. The patient is warned in advance that during this time one should refrain from chewing gum, sweets, smoking, drinking plenty of water, and rinsing the mouth.
For determining rate of unstimulated salivation the patient at rest spits the saliva in the oral cavity into a test tube with a funnel for 5 minutes. Selection speed stimulated saliva determined by collecting in a test tube saliva secreted when chewing a paraffin ball.
In both cases, the volume of collected saliva is recorded and the rate of salivation is determined (ml/min).
Norm:
The rate of unstimulated salivation is 0.2-0.5 ml/min;
With mechanical stimulation - 1-3 ml / min.
Determination of the viscosity of saliva. The test is carried out using an Oswald viscometer on an empty stomach or 3 hours after a meal. Measurements are carried out three times.
Norm - 4.16 units; an increase in the viscosity of saliva by 2 times or more indicates a low caries resistance of the enamel.
Express method for diagnosing the buffer properties of saliva using the CRT buffer system.
The system includes a test indicator strip and a control tone scale. A drop of stimulated saliva is applied with a sterile pipette to the pad of the test strip. After 5 minutes, evaluate the result by comparing the color of the strip with the color table (Fig. 2.5).
Indicator strip color:
. blue (pH>6.0)- high (normal) buffer capacity;
. green (рН=4.5-5.5)- average (below the norm) buffer capacity;
. yellow (pH<4,0) - low buffer capacity of saliva.
Note. If the staining turned out to be inhomogeneous, interpret the result towards a lower value.
Rice. 2.5. Determination of the buffer capacity of saliva using the CRT buffer system
pH-metry of oral fluid and plaque. Accurate pH determination oral fluid and plaque is carried out using a pH-selective electrode. Mixed saliva is collected on an empty stomach in the morning in an amount of 20 ml. After
three times the study of the same sample calculate the average. You can measure the pH of the oral fluid directly in the patient's oral cavity by placing the electrode in the sublingual region (the norm at rest is 6,8-7,4; at pH less than 6.0, saliva contributes to the process of enamel demineralization).
To determine the pH of plaque, the tooth is isolated from saliva using cotton rolls and dried with air. The electrode is placed sequentially on the vestibular and oral surfaces of the teeth in the cervical region and the readings of the device are recorded (normal at rest 6,5-6,7, the critical pH value of plaque, at which the enamel demineralization process begins, - 5,5-5,7).
Express method for determining the number of cariogenic bacteria (S. mutans and lactobacilli) using the CRT bacteria system. For research, stimulated saliva or plaque samples are collected and seeded on an agar-coated plate (it is a selective nutrient medium for S. mutans or lactobacilli) which is incubated for 48 hours at 37°C.
Compare the density of the colonies grown on the agar surfaces with the density value in the reference table. Colony Density S. mutans and Lactobacillimore than 10 5 CFU/ml indicates a high risk of dental caries, less than 10 5 cfu/ml- about low (Fig. 2.6).
Note. Before the examination, patients should not use antibacterial rinses, professional oral hygiene is not recommended.
Despite the obvious progress in the prevention of dental caries, this disease still poses a serious public health problem in most countries of the world, especially in connection with the steady increase in the cost of restorative treatment and new evidence of the relationship between caries complications and a number of general somatic diseases.
Rice. 2.6. Variants of Lactobacilli colony density determined using the CRT bacteria system
For the convenience of designating teeth in the dental arch and recording the result of dental examination, various schemes are used.
For a long time in our country, the Zigmond-Palmer scheme, proposed in 1876, was used. According to this scheme, the teeth in each quadrant are numbered from 1 to 8, i.e. from central incisors to wisdom teeth. Arabic numerals are used to designate permanent teeth, and Roman numerals are used for milk teeth. The belonging of the tooth to the upper or lower jaw and the side of the location is determined by the direction of intersection of the horizontal and vertical lines separating the quadrants (Fig. 2.7).
At present, it is advisable to use digital systems, which are more convenient. The system of the International Federation of Dentists (FDI) is widely used in the world. This system is recommended by the World Health Organization (WHO) and the International Organization for Standardization (ISO). In this system, each permanent tooth in each quadrant is designated by a number from 1 to 8, as in the Zsigmond-Palmer system. Temporary teeth are also indicated by numbers from 1 to 5. The quadrants are numbered clockwise
ke, starting from the upper right quadrant. In the permanent bite, the quadrants are numbered from 1 to 4, in the milk bite - from 5 to 8. Thus, each tooth is designated by two numbers: the first number is the number of the quadrant, the second is the number of the tooth in the quadrant. So, for example, the second left maxillary premolar will be designated as tooth 24, and the left upper lateral temporary incisor - 62 (Fig. 2.8).
2.6. THEORIES OF DENTAL CARIES
Rice. 2.7. Zsigmond-Palmer system
Rice. 2.8. FDI system
temperature 37 ° C for 4-6 weeks. Under the influence of lactic acid fermentation products, enamel demineralization occurred, to some extent similar to changes in it during caries.
In 1928 D.A. Entin developed the physicochemical theory of caries, according to which the hard tissues of the tooth are a semi-permeable membrane at the boundary of two media - oral fluid (saliva) and dental pulp (blood). The scientist believed that the predominance of osmotic currents in the centripetal direction causes pathological changes in the hard tissues of the teeth, as the nutrition of the enamel from the pulp is disturbed and the effect of external agents on the enamel, in particular microorganisms, increases, which leads to caries.
Other theories are known: the neurotrophic theory of D.A. Entina (1928), biological theory of caries by I.G. Lukomsky (1948), the exchange theory of A.E. Sharpenak (1949), the working concept of the pathogenesis of dental caries A.I. Rybakova (1971).
It has been established that dental caries is an infectious process that manifests itself after teething, in which demineralization and proteolysis of hard tooth tissues occur, followed by the formation of a defect in the form of a cavity.
The main cause of enamel demineralization and the formation of a carious focus are
cal acids. Lactic acid plays the main role. Acids are formed during the fermentation of dietary carbohydrates by plaque microorganisms.
Excessive consumption of carbohydrates and insufficient hygienic care of the oral cavity lead to the fact that cariogenic microorganisms accumulate and multiply on the surface of the tooth and plaque is formed. The continued consumption of carbohydrates contributes to a local change in pH in it to the acid side. In clinical and experimental studies, this is convincingly demonstrated by the Stefan curve, which reflects the dynamics of changes in the pH of plaque when monosaccharides, such as glucose, enter it (Fig. 2.9).
First, there is a sharp decrease in the pH of plaque - up to 4.5, and then the indicator is slowly restored to normal within 30-40 minutes. If in the future the decrease in pH is constantly repeated, then as a result of demineralization, subsurface lesions (carious spot) are formed, and subsequently carious cavities. In this case, the state of the structure of the hard tissues of the tooth is of great importance.
Resistance (caries resistance) of teeth to caries is formed with a complete chemical composition, structure, permeability of enamel and other tooth tissues. Equally important are the amount of oral fluid (saliva) and its mineralizing potential. A carbohydrate-balanced diet, good oral hygiene and optimal fluoride content in drinking water are also components of dental caries resistance.
In case of violations that occur during the development of dental tissues, enamel maturation when the parameters of the oral fluid change, insufficient
Rice. 2.9. Stefan Curve
2.7. THE ROLE OF PLAQUE, SALIVA AND ENAMEL PERMEABILITY IN CARIES
It is known that a number of superficial formations are determined on the enamel. The cuticle, which is a reduced epithelium of the enamel organ, disappears soon after tooth eruption as a result of abrasion during chewing and partially remains only in the subsurface layer of enamel.
The surface of a functioning tooth is further covered with a pellicle (acquired cuticle), which is a protein-carbohydrate complex formed under the influence of saliva. The pellicle is firmly connected to the surface of the enamel by penetrating into its surface layer.
The next surface formation is formed on the pellicle plaque, which is soft deposits on the surface of the enamel. To refer to this substance, terms such as "dental plaque", "biofilm" are used.
Most often, plaque acts as a powerful cariogenic factor, which makes it necessary to carefully and regularly remove it.
An important stage in the formation of plaque is the incorporation of various types of microorganisms into its matrix. The relationship of these microorganisms between themselves and the body as a whole provides a certain microbial homeostasis in plaque, in which the teeth and periodontal tissues remain intact. Violation of the existing balance under the influence of adverse internal and external factors leads to the development of pathology, such as caries.
Among a significant variety of types of plaque microorganisms, acid-forming microorganisms are considered as potentially cariogenic. According to modern concepts, acid-forming strains are among the most likely infectious agents of the carious process. St. mutans and lactobacilli. It is assumed that St. mutans initiates the onset of enamel demineralization in caries. Lactobacilli are included in the process later and are active in caries in the defect stage.
The formation, composition, properties and functions of plaque are closely related to the state of the oral cavity and the body as a whole. Considered to be cariogenic
The potential of plaque can be realized only with such general and local risk factors as, for example, excessive consumption of sugar in food, lack of fluoride in drinking water, poor oral hygiene, etc.
The composition and properties of plaque are closely related to saliva. The susceptibility or resistance of teeth to caries is determined by saliva parameters such as secretion rate, buffer capacity, hydrogen ion concentration (pH), bactericidal activity, content of mineral and organic components.
In the process of washing the teeth with saliva, substances are cleared in plaque and tooth tissues. An exchange of calcium and phosphate ions occurs between saliva and tooth enamel, as a result of which their equilibrium is established in the surface layer of enamel, plaque and saliva. This is facilitated by oversaturation of saliva with calcium and phosphorus ions.
An important role in protecting teeth from caries is played by the buffer capacity of saliva, which neutralizes acids and alkalis. The buffering capacity of saliva is based on carbonates, phosphates and proteins.
The concentration of hydrogen ions in saliva is in the neutral range. In plaque, pH in the absence of a cariogenic situation is practically equal to saliva pH and is largely controlled by the saliva buffer system.
In addition, due to the buffering ability of saliva, remineralization of the subsurface lesion during caries and the suspension of further demineralization are possible.
The protective function of saliva. Saliva has mineralizing properties. The most direct evidence of this fact is the development of "blooming" caries after the cessation of the functioning of the salivary glands as a result of high doses of radiation in tumors of the head and neck. Such caries is so destructive that within a few weeks it affects the usually caries-resistant surfaces of the teeth and causes complete destruction of the teeth.
The main properties of saliva that provide protection against caries:
Dilution and clearance of sugars entering the oral cavity with food;
Neutralization of acids in plaque;
Source of ions for remineralization of hard dental tissues.
Human teeth do not dissolve in saliva because it is oversaturated with calcium, phosphate and hydroxyl ions. The mineral fraction of teeth consists mainly of these ions. In the dynamic equilibrium of the metabolic process, the supersaturation of saliva with calcium and phosphate ions provides protection.
from demineralization. The supersaturated state of saliva is overcome only when the pH of the plaque is low enough for the concentration of hydroxyl and phosphate ions to fall below the critical value.
enamel permeability. One of the few physiological properties available for research is the permeability of hard dental tissues and especially enamel.
The permeability of enamel depends on many factors and conditions. There is evidence that some ions can penetrate into crystals and participate in intracrystalline exchange. For example, fluorine displaces the hydroxyl ion in the surface layer of enamel hydroxyapatite crystals, thus increasing its acid resistance.
The degree of mineralization of hard tissues, which increases with age, has a great influence on the rate and depth of penetration of substances into the enamel. In addition, the level of enamel permeability can change under the influence of physical and chemical factors. The speed and depth of penetration of substances into the enamel depend on the nature of the penetrating substance, the time of its contact with the tooth. The fluorine ion penetrates the enamel no more than 15-80 microns.
2.8. CLASSIFICATION OF DENTAL CARIES
In domestic dentistry, the most widely used topographic classification caries.
1. Initial caries, or caries in the stain stage.
2. Superficial caries.
3. Medium caries.
4. Deep caries.
Rational systematization of caries is given in the recommended WHO International Classification of Dental Diseases ICD-C-3, based on ICD-10, according to which caries (code K02) is classified as follows:
K02.0. Enamel caries. The stage of a white (chalky) spot (initial caries). K02.1. Dental caries. K02.2. Cement caries. K02.3. Suspended dental caries. K02.4. Odontoclasia. Children's melanoma. Melanodontoclasia.
Excluded from this section are internal and external pathological tooth resorption (K03.3). K02.8. Other specified dental caries. K02.9. Dental caries, unspecified. In ICD-C-3 there is no diagnosis of "deep caries". Currently, in connection with the transition of clinical dentistry to the ICD classification, the exclusion of the diagnosis of "deep caries" is justified, since the clinical picture and treatment of deep caries fit into the framework of the ICD-C-3 and allow us to attribute deep caries to the section of dental pulp diseases and consider it as the initial pulpitis or pulp hyperemia according to code K04.00.
The classification of dental caries proposed by E.V. Borovsky and P.A. Leus (1979), includes the clinical forms of the disease, taking into account the depth of the lesion, localization, course and intensity of the lesion.
CLASSIFICATION OF BOROVSKY-LEUS DENTAL CARIES
2.9. PATHOLOGICAL ANATOMY OF DENTAL CARIES
With caries in the stain stage in the enamel, a lesion is revealed in the form of a triangle, the base of which is turned to the outer surface, and the apex is directed towards the enamel-dentin border.
With polarization microscopy, depending on the extent of the lesion in the enamel, from three to five zones with varying degrees of demineralization are determined (Fig. 2.10).
Rice. 2.10. Schematic representation of demineralization zones during caries in the stain stage (polarizing microscopy): 1 - surface (intact) layer; 2 - the body of the lesion; 3 - dark zone; 4 - transparent zone
Zone 1 - a surface layer up to 50 µm wide relative to intact enamel.
Zone 2 - the central zone (the body of the lesion), in which demineralization is even more pronounced, the volume of microspaces increases up to 25%. Very high degree of enamel permeability.
Zone 3 is a dark zone in which the volume of microspaces lies within 15-17%.
Zone 4 - the inner layer, or transparent zone, the volume of microspaces is
0,75-1,5%.
Dental caries. Dentin caries begins with the destruction of the enamel-dentin junction and spreads along the dentinal tubules towards the pulp. Protective processes take place in the dentin and pulp. The dentinal tubules are sclerosed, and the processes of the odontoblasts are sheared off.
move in the central direction. As a result of a protective reaction at the border of dentin and pulp, the formation of replacement, or irregular, dentin occurs, which differs from the normal one by a less oriented arrangement of dentinal tubules.
In caries, the structural integrity of dentin is violated due to demineralization of its mineral component, disintegration and dissolution of the organic matrix. In the focus of carious lesions of dentin, 5 zones are distinguished
(Fig. 2.11).
Rice. 2.11. Damage zones in dentin in case of dental caries: 1 - intact dentin; 2 - translucent dentin; 3 - transparent dentin; 4 - muddy dentine; 5 - infected dentin
Zone 1 - normal dentin. In this zone, the structure of the dentinal tubules is not changed; the processes of odontoblasts fill the dentinal tubules.
Zone 2 - translucent dentin. A layer of translucent dentin is formed as a result of demineralization of dentin between the dentinal tubules. In addition, mineral deposits are observed inside the dentinal tubules. Microorganisms are not detected in this zone.
Zone 3 - transparent dentin. The degree of demineralization of this zone is more pronounced. Clinically, this is manifested by softening of the dentin. However, part of the collagen fibers remains intact, which may provide the possibility of remineralization of this zone under favorable conditions. There are no microorganisms in this zone.
Zone 4 - cloudy dentin. In this zone, the expansion of the dentinal tubules is determined. Due to the significant disintegration of collagen fibers, remineralization of this dentine zone is practically impossible. In this zone, microorganisms are always present in dilated dentinal tubules. Clinically, the dentin is softened and, as a rule, must be removed.
Zone 5 - infected dentin. Zone of decay of all structures of dentin, saturated with microorganisms. This area should be completely removed during treatment. With caries, changes can also occur in the pulp. The severity of these changes depends on the course and depth of the lesion. With caries in the white spot stage and with superficial caries, there are usually no changes in the pulp. If the carious process extends to the dentin, pronounced morphological changes in the vessels and nerve fibers are found in the pulp. Disorientation and a decrease in the number of odontoblasts are observed. Irritation of odontoblasts leads to the formation of replacement dentin.
2.10. DIAGNOSIS, CLINICAL PICTURE, DIFFERENTIAL DIAGNOSIS OF DENTAL CARIES
2.10.1. METHODS FOR DIAGNOSTICS OF DENTAL CARIES
With initial caries, mainly in the white spot stage, it is advisable to visually examine the accessible surfaces of the tooth. Usually for this, the teeth are cleaned of plaque and dried with a stream of air. As a result of this procedure, areas where there are subsurface defects in the form of white or less pigmented spots differ in color from healthy enamel.
The high permeability of the enamel in the initial lesions allows you to establish the localization and, to some extent, the degree of demineralization in caries in the stain stage by vital staining of the tooth tissues. For such a study, it is necessary to clean the surface of the tooth from plaque, isolate it from saliva and dry it. Stained usually with 2% methylene blue solution. The color intensity of the affected areas after washing off the solution, depending on the degree of demineralization, varies from pale blue to dark blue (Fig. 2.12).
This method is convenient for the differential diagnosis of initial caries with non-carious lesions of the hard tissues of the tooth (hypoplasia, fluorosis), in which staining does not occur. It can also serve to monitor the effectiveness of remineralizing therapy.
To detect the initial forms of caries, secondary caries around fillings, inlays, the transillumination method is used: tooth tissues shine through a light guide with a directed beam of light from a halogen lamp. For this purpose, apply
special irradiators. Affected areas appear darker on transillumination.
Rice. 2.12. Foci of enamel demineralization stained with 2% methylene blue solution
In addition, for the diagnosis of caries, dental tissues are examined in reflected light and their luminescence is used in ultraviolet light. Recently, the luminescence of hard dental tissues is determined using laser light sources.
Using the Machine KaVo DIAGNOdent
For the early detection of initial carious lesions, including those on hard-to-view surfaces of the teeth, the apparatus is used. KaVo DIAGNOdent.
Principle of operation. The laser diode generates pulsed light waves of the red spectrum of a certain length (655 nm). Light waves are concentrated using a fiber-optic element and brought directly to the tooth surface in the form of a beam of cold light using a flexible fiber-optic light guide and a tip with special nozzles. Pathologically altered tooth tissues reflect light waves of a different wavelength than intact enamel. The length of the reflected waves is analyzed by the apparatus electronics. When demineralized tooth tissues are detected, a sound signal appears. The device reacts even to minimal damage to the enamel; the diagnostic accuracy is 90%. Fluorescence intensity is determined by numerical values:
0-10 - intact enamel;
10-25 - demineralization within the enamel;
25 and more - dentine caries.
Methodology. The tooth surface is thoroughly cleaned of plaque, isolated from saliva, dried, then the tip of the device with the nozzle is slowly advanced along the area under study (the nozzle is placed perpendicularly, in contact with the tooth surface or at a distance of no more than 1.5 mm) (Fig. 2.13). For greater accuracy, repeated measurements are carried out, determining the average value.
Rice. 2.13. Diagnosis of initial carious lesions with "KaVo DIAGNOdent"
Of great importance is the method of probing the tissues of the tooth, in which the initial stages of enamel damage are determined in the form of areas with a rough surface. As caries develops
using this method, you can assess the depth of the lesion and identify areas of pain.
Thermometry is quite informative, which allows differential diagnosis of various stages of caries and diseases of the dental pulp.
Electroodontodiagnostics (EOD) has a certain value in the diagnosis of dental caries. This method allows you to determine the condition of the pulp of the tooth. Healthy teeth respond to currents from 2 to 6 μA. With deep caries, the electrical excitability of tissues can decrease to 10-15 μA.
To diagnose caries, the X-ray method is widely used, which makes it possible to identify approximal and subgingival carious lesions, secondary caries under fillings, as well as to determine the depth of the carious cavity and its relationship with the tooth cavity.
Naturally, along with these important methods, the main methods of research - questioning and examination - are of paramount importance.
2.10.2. CLINICAL PICTURE OF DENTAL CARIES
2.10.2.1. CLINICAL PICTURE OF ENAMEL CARIES IN THE STAGE OF WHITE (CHALK-LIKE) SPOT
(INITIAL CARIES) (K02.0)
2.10.2.2. CLINICAL PICTURE OF ENAMEL CARIES IN THE PRESENCE OF A DEFECT WITHIN ITS LIMITS (K02.0) (SUPERFICIAL CARIES)
2.10.2.4. CLINICAL PICTURE OF INITIAL PULPITIS (HYPEREMIA OF THE PULPO) (K04.00)
(DEEP CARIES)
2.10.3. DIFFERENTIAL DIAGNOSIS OF DENTAL CARIES
2.10.3.1. DIFFERENTIAL DIAGNOSIS OF ENAMEL CARIES IN THE STAGE OF WHITE (CHALK-LIKE) SPOT (INITIAL CARIES) (K02.0)
2.10.3.2. DIFFERENTIAL DIAGNOSTICS OF ENAMEL CARIES IN THE PRESENCE OF A DEFECT WITHIN ITS LIMITS (K02.0) (SUPERFICIAL CARIES)
2.10.3.3. DIFFERENTIAL DIAGNOSIS OF DENTINAL CARIES (K02.1) (MEDIUM CARIES)
2.10.3.4. DIFFERENTIAL DIAGNOSIS OF INITIAL PULPITIS (PULP HYPEREMIA) (K04.00) (DEEP CARIES)
2.10.4. CARIES OF CEMENT (K02.2)
Along with the crown part, the root of the tooth can also be affected by caries. Root caries is mainly found in people older than 35-45 years. When the root is damaged, caries of the cementum (K02.2), caries of the dentin of the root (K02.1) can develop, and under certain conditions, suspension of caries (K02.3) is possible.
A prerequisite for the development of root caries is gum recession, as a result of which part of the root is exposed. Great importance is attached to poor oral hygiene. An important role is played by age, excess carbohydrates in the diet, inflammatory periodontal disease.
The direct cause of cementum caries is organic acids that accumulate in plaque as a result of the enzymatic activity of cariogenic microorganisms with an excess of carbohydrates in the diet and poor oral hygiene. The pH value of plaque below the critical level leads to demineralization of the cementum or dentin of the tooth root.
Visually, lesions in cement caries after drying the root surface look like small yellow spots. The cement has a small thickness, so it is quickly abraded from the surface of the exposed root area during chewing or hygiene procedures. As a result, cementum caries spreads very quickly to the root dentin. The defeat of caries of the dentin of the root, as well as cement in the initial stages, is accompanied by a change in its color as a result of demineralization. The course of root caries is often chronic. The lesion spreads to a greater extent along the surface of the root and to a lesser extent in depth. Usually the process is asymptomatic until the dental pulp is involved. Patients are more concerned about the cosmetic aspect.
Differential diagnosis of caries of the cementum and dentin of the root should be carried out with caries of the cervical part of the tooth crown, wedge-shaped defect, enamel erosion.
Treatment of cement caries and root dentine caries in the initial stages should consist in the appointment of rational hygiene procedures, remineralizing therapy. As a result of conservative treatment, subject to high-quality oral hygiene, the affected areas gradually become pigmented, acquiring various shades of brown. The affected tissue becomes dense and shiny. The carious cavity must be filled. The effect of filling largely depends on the thoroughness of patient compliance with hygiene recommendations. A balanced diet in terms of carbohydrates is important.
Carious cavities are prepared according to Black's class V. Silver amalgam, glass ionomer cements and composite materials can be used as filling materials.
2.10.5. SUSPENDED DENTAL CARIES (K02.3)
It has now been proven that even with an actively ongoing carious process, enamel remineralization occurs simultaneously with pronounced demineralization. Under certain conditions and the degree of enamel demineralization, the carious process may stop. A prerequisite for remineralization is the integrity of the organic matrix of the enamel.
From the anamnesis, it can be found out that the foci of discolored enamel exist for a long time. The nature of the defect in the defeat of several teeth is the same. Examination reveals roughness of the enamel surface in the area of the stain, but the integrity of the surface layer is not broken.
The variety of color shades of carious spots allows us to attribute white carious spots to rapidly progressive demineralization. Light brown spots are characteristic of intermittent enamel demineralization, while dark brown and black carious spots indicate a suspended demineralization process. Transitional cases are observed when there is a combination of white areas of demineralization with different shades of pigmentation in the area of one spot. This may be due to the uneven processes of demineralization and remineralization in different areas of the carious spot.
It is assumed that caries can stop at any stage of the development of a carious spot, however, stabilization or suspension of the demineralization process is possible only when a white carious spot changes into a pigmented one. With white and light brown spots, the pathological process is mainly intermittent.
The appearance of a pigmented substrate is a sign of an intermittent demineralization process, which depends on the intensity of two opposite processes - demineralization and remineralization, and can lead to disintegration or stabilization of the pathological process, which in most cases is a brown or black spot.
The onset of acid exposure to the enamel does not necessarily mean the development of a carious defect in it. Due to the buffering properties of saliva, remineralization is possible, partially demineralized
chiselled enamel. The processes of demineralization and remineralization depend not only on local factors (carbohydrates, plaque, the level of oral hygiene, the presence of fluoride in drinking water), they are closely interconnected with the general state of the body (age, diseases, etc.), as well as with medical and social factors (lifestyle, education, income, etc.). The general state of the body affects the development of caries indirectly, through saliva, by changing the rate of secretion, its quantity and buffer properties of the oral fluid.
Important in the development of suspended caries is the preservation of the outer, largely intact surface layer of enamel, which, having the properties of an ion-selective membrane, provides the opportunity not only for the development of a subsurface focus of demineralization, but also for remineralization.
With a white carious spot, if the cariogenic situation is eliminated, reverse development or suspension of demineralization can occur independently due to the remineralizing properties of the oral fluid or as a result of the use of remineralizing drugs.
With a pigmented carious spot, which is a stabilized stage of caries, remineralizing therapy, as a rule, does not work. The tactics of a dentist in the presence of a pigmented spot may be as follows. In cases where carious spots are insignificant in area or located in places accessible to hygienic procedures, it is possible to dynamically monitor their condition. In other cases, especially when the spots are localized on the contact surfaces, it is advisable to excise the altered tissues with subsequent filling of the defect.
CLINICAL SITUATION 1
A 30-year-old patient came for a preventive examination. When examining the oral cavity, it was revealed that the gums were hyperemic, swollen, and bled when probing. The teeth are covered with a soft coating. After removal of plaque on the vestibular surface in the cervical region of teeth 13, 33, 32, 31, 41, 42, white chalky spots were found, loss of the natural luster of enamel. A change in the color of the enamel of the corresponding teeth was not previously detected.
1. What lesions does this pathology refer to?
2. Make a diagnosis.
3. What additional diagnostic methods can be used?
4. Conduct a differential diagnosis of dental diseases.
5. Make a plan for the treatment of this disease.
CLINICAL SITUATION 2
The patient came for a checkup. When examining the oral cavity, it was revealed that the gums were pale pink, moderately moistened. There are pigmented fissures on the chewing surfaces of teeth 35, 36, 47. Probing is painless, the probe lingers in the fissure.
1. Make an examination plan.
2. Conduct a differential diagnosis of dental diseases.
3. Make a diagnosis.
GIVE ANSWER
1. Criteria for evaluating carious lesions:
4) the intensity of dental caries;
5) the rate of saliva secretion.
2. Enamel permeability increases with the following diseases:
1) fluorosis;
2) enamel erosion;
3) caries in the stage of a white carious spot;
4) dentine caries;
5) generalized periodontitis of moderate severity.
3. The Stefan curve reflects:
1) the dynamics of changes in the viscosity of saliva in caries;
2) change in the rate of saliva secretion during caries;
3) hygienic condition of the oral cavity;
4) the dynamics of changes in the pH of plaque under the influence of carbohydrates;
5) the degree of enamel permeability in dental caries.
4. Vital staining of hard tissues of the tooth is carried out:
1) in order to diagnose caries in the stage of a white carious spot;
2) for the treatment of caries in the stage of a white carious spot;
3) for the diagnosis of dentin caries;
4) to determine the hygienic condition of the oral cavity;
5) in order to diagnose chronic periodontitis.
5. The following complaints are characteristic of dentine caries:
1) night pains;
2) paroxysmal pain;
3) short-term pain from chemical irritants;
4) constant aching pain;
5) pain on percussion.
6. According to the ICD-C-3 classification, caries is distinguished:
1) medium;
2) deep;
3) enamel caries;
4) superficial;
5) rapidly progressive caries.
7. The color of carious spots is characterized by:
1) the duration of the course of caries;
2) the degree of caries activity;
3) the depth of damage to the hard tissues of the tooth;
4) the degree of involvement in the process of dentin;
5) the transition of enamel caries to dentine caries.
8. The cavity with dentine caries is located within:
1) dental pulp;
2) dentine;
3) enamel and dentine;
4) enamel;
5) periodontium.
9. With dentin caries, probing the cavity:
1) painful in all areas;
2) painful in the area of the bottom of the cavity;
3) painless in all areas;
4) painful at one point;
5) painful in the area of the enamel-dentine junction.
10. To determine the intensity of caries use:
2) an assessment of the prevalence of caries;
RIGHT ANSWERS
1 - 4; 2 - 3; 3 - 4; 4 - 1; 5 - 3; 6 - 3; 7 - 2; 8 - 3; 9 - 5; 10 - 4.