Periodontitis is an inflammation of the periodontium, characterized by a violation of the integrity of the ligaments that hold the tooth in the alveolus, the cortical plate of the bone surrounding the tooth, and bone resorption from small sizes to the formation of large cysts.

Classification

Classification by clinical course

Acute periodontitis . Depending on the nature of the exudate, acute serous and acute purulent are distinguished. But this distinction is not always possible, moreover, the transition of the serous form to the purulent one occurs quite quickly and depends on certain conditions.

Chronic periodontitis. It is divided on the basis of the nature and degree of damage to periodontal tissues and bone. Allocate chronic fibrous periodontitis , chronic granulating and chronic granulomatous periodontitis .

Chronic periodontitis in the acute stage. According to the clinical course, it is similar to acute forms, but has its own characteristics, for example, the presence of destructive changes in the bone tissue.

Origin

Infectious periodontitis . It develops due to the penetration of bacteria and their toxins into periodontal tissues with the subsequent development of inflammation in them.

Traumatic periodontitis . Caused as a result of exposure to the periodontal traumatic factor. This can be a severe single injury, such as a blow or a bruised tooth. And there may be a long-term, low-intensity microtrauma, for example, an overestimated filling, a “straight” bite, overload of teeth, or bad habits.

Medical periodontitis . It occurs due to the penetration of potent chemicals, such as arsenic paste, formalin, phenol, etc.

Classification of periodontitis ICD-10

Acute apical periodontitis NOS

K04.5 Chronic apical periodontitis

Apical granuloma

dental

dentoalveolar

dental abscess

Dentoalveolar abscess

K04.8 Root cyst

apical (periodontal)

periapical

K04.80 Apical and lateral

K04.81 Residual

Classification of periodontitis

Periodontitis (periodontitis) - inflammation of the tissues located in the periodontal gap (periodontitis), - can be infectious, traumatic and drug-induced.

Infectious periodontitis occurs with the introduction of autoinfection located in the oral cavity. The root sheath at the top of the tooth is more often affected, less often - the marginal periodontium.

Traumatic periodontitis develops as a result of both a single (hit, bruise) and chronic injury (violation of occlusion when the height of the tooth is overestimated by an artificial crown, filling; in the presence of bad habits - holding nails in the teeth, biting threads, husking seeds, cracking nuts, etc.). Drug-induced periodontitis can occur in the treatment of pulpitis, when potent medicinal substances are used in the treatment of the canal, and also due to an allergic reaction of the periodontium to drugs. In clinical practice, infectious apical periodontitis is the most common.

According to the clinical picture and pathoanatomical changes, inflammatory periodontal lesions can be divided into the following groups (according to I.G. Lukomsky): I. Acute periodontitis 1. Serous (limited and diffuse) 2. Purulent (limited and diffuse)

II. Chronic periodontitis 1. Granulating 2. Granulomatous 3. Fibrous

III. Chronic periodontitis in the acute stage.

WHO classification of periodontitis (ICD-10)

K04 Diseases of the periapical tissues

K04.4 Acute apical periodontitis of pulpal origin

Acute apical periodontitis NOS

K04.5 Chronic apical periodontitis t

Apical granuloma

K04.6 Periapical abscess with fistula

dental

dentoalveolar

periodontal abscess of pulpal origin.

K04.60 Having communication [fistula] with maxillary sinus

K04.61 Communicating [fistula] with nasal cavity

K04.62 Having a communication [fistula] with the oral cavity

K04.63 Having communication [fistula] with skin

K04.69 Periapical abscess with fistula, unspecified

K04.7 Periapical abscess without fistula

dental abscess

Dentoalveolar abscess

Periodontal abscess of pulpal origin

Periapical abscess without fistula

K04.8 Root cyst

apical (periodontal)

periapical

K04.80 Apical and lateral

K04.81 Residual

K04.82 Inflammatory paradental

K04.89 Root cyst, unspecified

K04.9 Other and unspecified diseases of periapical tissues

Acute periodontitis

Acute periodontitis - acute periodontal inflammation.

Etiology. Acute purulent periodontitis develops under the influence of mixed flora, where streptococci(mostly non-hemolytic, as well as green and hemolytic), sometimes staphylococci and pneumococci. Possible rod-shaped forms (gram-positive and gram-negative), anaerobic infection, which is represented by an obligate anaerobic infection, non-fermenting gram-negative bacteria, veillonella, lactobacilli, yeast-like fungi. With untreated forms of apical periodontitis, microbial associations include 3-7 species. Pure cultures are rarely isolated. With marginal periodontitis, in addition to the listed microbes, a large number of spirochetes, actinomycetes, including pigment-forming ones. Pathogenesis. An acute inflammatory process in the periodontium primarily occurs as a result of the penetration of infection through a hole in the apex of the tooth, less often through a pathological periodontal pocket. The defeat of the apical part of the periodontium is possible with inflammatory changes in the pulp, its necrosis, when the abundant microflora of the tooth canal spreads into the periodontium through the apical opening of the root. Sometimes the putrefactive contents of the root canal are pushed into the periodontium during chewing, under the pressure of food.

Marginal, or marginal, periodontitis develops as a result of the penetration of infection through the gingival pocket in case of injury, ingestion of medicinal substances, including arsenic paste, on the gum. Microbes that have penetrated into the periodontal gap multiply, form endotoxins and cause inflammation in periodontal tissues.

Of great importance in the development of the primary acute process in periodontium are some local features: the absence of outflow from the pulp chamber and canal (the presence of an unopened pulp chamber, fillings), microtrauma during active chewing load on a tooth with an affected pulp.

Common causes also play a role: hypothermia, past infections, etc., but most often the primary effect of microbes and their toxins is compensated by various non-specific and specific reactions of periodontal tissues and the body as a whole. Then there is no acute infectious-inflammatory process. Repeated, sometimes prolonged exposure to microbes and their toxins leads to sensitization, antibody-dependent and cellular reactions develop. BUT antibody-dependent reactions develop as a result of immunocomplex and IgE conditioned processes. Cellular responses reflect a delayed-type hypersensitivity reaction..

The mechanism of immune reactions, on the one hand, is due to a violation of phagocytosis, the complement system and an increase in polymorphonuclear leukocytes; on the other hand, by the multiplication of lymphocytes and the release of lymphokines from them, causing the destruction of periodontal tissues and resorption of the nearby bone.

Various cellular reactions develop in the periodontium: chronic fibrous, granulating or granulomatous periodontitis. Violation of protective reactions and repeated exposure to microbes can cause the development of an acute inflammatory process in the periodontium, which in essence is an exacerbation of chronic periodontitis. Clinically, they are often the first symptoms of inflammation. The development of pronounced vascular reactions in a rather closed periodontal space, an adequate protective response of the body, as a rule, contribute to inflammation with a normergic inflammatory reaction.

The compensatory nature of the response of periodontal tissues in the primary acute process and exacerbation of the chronic is limited by the development of an abscess in the periodontium. It can be emptied through the root canal, gingival pocket when opening the periapical lesion or extracting a tooth. In some cases, under certain general and local pathogenetic conditions, a purulent focus is the cause of complications of an odontogenic infection, when purulent diseases develop in the periosteum, bone, and perimaxillary soft tissues.

Pathological anatomy. In an acute process in the periodontium, the main phenomena of inflammation appear - alteration, exudation and proliferation.

Acute periodontitis is characterized by the development of two phases - intoxication and a pronounced exudative process.

In the phase of intoxication, various cells migrate - macrophages, mononuclear cells, granulocytes, etc. - into the zone of accumulation of microbes. In the phase of the exudative process, inflammation increases, microabscesses form, periodontal tissues melt and a limited abscess forms. At microscopic examination in the initial stage of acute periodontitis, one can see hyperemia, edema and a slight leukocyte infiltration of the periodontal area in the circumference of the root apex. During this period, perivascular lymphohistiocytic infiltrates containing single polynuclear cells are found. With the further increase of inflammatory phenomena, leukocyte infiltration intensifies, capturing more significant areas of the periodontium. Individual purulent foci are formed - microabscesses, periodontal tissues are melted. Microabscesses are interconnected, forming an abscess. When a tooth is removed, only separate preserved areas of sharply hyperemic periodontium are revealed, and the rest of the root is exposed and covered with pus.

An acute purulent process in the periodontium causes changes in the tissues surrounding it (the bone tissue of the walls of the alveolus, the periosteum of the alveolar process, the perimaxillary soft tissues, the tissues of the regional lymph nodes). First of all, the bone tissue of the alveoli changes. In the bone marrow spaces adjacent to the periodontium and located over a considerable distance, bone marrow edema and varying degrees of pronounced, sometimes diffuse, infiltration by neutrophilic leukocytes are noted. In the region of the cortical plate of the alveolus, lacunae appear, filled with osteoclasts, with a predominance of resorption (Fig. 7.1, a). In the walls of the hole and mainly in the area of ​​its bottom, a restructuring of the bone tissue is observed. The predominant resorption of the bone leads to the expansion of the holes in the walls of the hole and the opening of the bone marrow cavities towards the periodontium. There is no necrosis of bone beams (Fig. 7.1, b). Thus, the restriction of the periodontium from the bone of the alveoli is violated. In the periosteum covering the alveolar process, and sometimes the body of the jaw, in the adjacent soft tissues - the gums, perimaxillary tissues - signs of reactive inflammation are recorded in the form of hyperemia, edema, and inflammatory changes - also in the lymph node or 2-3 nodes, respectively, to the affected periodontium of the tooth . They show inflammatory infiltration. In acute periodontitis, the focus of inflammation in the form of an abscess is mainly localized in the periodontal gap. Inflammatory changes in the bone of the alveoli and other tissues are reactive, perifocal in nature. And it is impossible to interpret reactive inflammatory changes, especially in the bone adjacent to the affected periodontium, as its true inflammation.

Clinical picture . In acute periodontitis, the patient indicates pain in the causative tooth, aggravated by pressure on it, chewing, and also by tapping (percussion) on its chewing or cutting surface. The sensation of "growth", elongation of the tooth is characteristic. With prolonged pressure on the tooth, the pain subsides somewhat. In the future, pain intensifies, becomes continuous or with short light intervals. They often pulsate.

Thermal exposure, the adoption by the patient of a horizontal position, touching the tooth, and biting increase pain. The pain spreads along the branches of the trigeminal nerve. The general condition of the patient is satisfactory. On external examination, there are usually no changes. Observe the increase and soreness of the lymph node or nodes associated with the affected tooth. In some patients, there may be an unsharply pronounced collateral edema of the perimaxillary soft tissues adjacent to this tooth. His percussion is painful both in the vertical and in the horizontal direction.

The mucous membrane of the gums, the alveolar process, and sometimes the transitional fold in the projection of the tooth root is hyperemic and edematous. Palpation of the alveolar process along the root, especially corresponding to the opening of the apex of the tooth, is painful. Sometimes, when the instrument is pressed on the soft tissues of the vestibule of the mouth along the root and the transitional fold, an impression remains, indicating their swelling.

Diagnostics Temperature irritants, electrodontometry data indicate the absence of pulp reaction due to its necrosis. On the radiograph in the acute process of pathological changes in the periodontium, it is possible not to reveal or to detect the expansion of the periodontal gap, the fuzziness of the cortical plasty of the alveolus. With exacerbation of the chronic process, changes occur that are characteristic of granulating, granulomatous, rarely fibrous periodontitis. As a rule, there are no blood changes, but some patients may have leukocytosis (up to 9-10 9 /l), moderate neutrophilia due to stab and segmented leukocytes; ESR is often within the normal range.

Differential Diagnosis . Acute periodontitis is differentiated from acute pulpitis, periostitis, osteomyelitis of the jaw, suppuration of the root cyst, acute odontogenic sinusitis.

Unlike pulpitis in acute periodontitis, the pain is constant, with diffuse inflammation of the pulp - paroxysmal. In acute periodontitis, in contrast to acute pulpitis, inflammatory changes are observed in the gum adjacent to the tooth, percussion is more painful. In addition, the data of electroodontometry help the diagnosis.

Differential diagnosis of acute periodontitis and acute purulent periostitis of the jaw is based on more pronounced complaints, a febrile reaction, the presence of collateral inflammatory edema of the perimaxillary soft tissues and diffuse infiltration along the transitional fold of the jaw with the formation of a subperiosteal abscess.

Percussion of the tooth with periostitis of the jaw is not painful, in contrast to acute periodontitis. According to the same, more pronounced general and local symptoms, a differential diagnosis of acute periodontitis and acute osteomyelitis of the jaw is carried out. Acute osteomyelitis of the jaw is characterized by inflammatory changes in the adjacent soft tissues on both sides of the alveolar process and the body of the jaw. In acute periodontitis, percussion is sharply painful in the area of ​​one tooth, in osteomyelitis - several teeth. Moreover, the tooth, which was the source of the disease, reacts to percussion less than neighboring intact teeth. Laboratory data - leukocytosis, ESR, etc. - allow us to distinguish between these diseases.

Purulent periodontitis should be differentiated from suppuration of the periradicular cyst. The presence of a limited protrusion of the alveolar process, sometimes the absence of bone tissue in the center, displacement of the teeth, in contrast to acute periodontitis, characterize a festering periradicular cyst. On the radiograph of the cyst, an area of ​​bone resorption of a round or oval shape is found.

Acute purulent periodontitis must be differentiated from acute odontogenic inflammation of the maxillary sinus, in which pain can develop in one or more adjacent teeth. However, congestion of the corresponding half of the nose, purulent discharge from the nasal passage, headache, general malaise are characteristic of acute inflammation of the maxillary sinus. Violation of the transparency of the maxillary sinus, detected on the radiograph, allows you to clarify the diagnosis.

Treatment. Therapy of acute apical periodontitis or exacerbation of chronic periodontitis is aimed at stopping the inflammatory process in the periodontium and preventing the spread of purulent exudate into the surrounding tissues - the periosteum, maxillary soft tissues, bone. Treatment is predominantly conservative. Conservative treatment is more effective with infiltration or conduction anesthesia with 1-2% solutions of lidocaine, trimecaine, ultracaine.

Blockade contributes to a more rapid subsidence of inflammatory phenomena - the introduction of the type of infiltration anesthesia 5-10 ml of 0.25-0.5% anesthetic solution (lidocaine, trimecaine, ultracaine) with lincomycin into the vestibule of the mouth along the alveolar process, respectively, the affected and 2-3 adjacent teeth. The decongestant effect is provided by the introduction of the transitional fold of the homeopathic remedy "Traumeel" in the amount of 2 ml or external dressings with the ointment of this drug.

It must be borne in mind that without the outflow of exudate from the periodontium (through the canal of the tooth), blockades are ineffective, often ineffective. The latter can be combined with an incision along the transitional fold to the bone, with perforation with a burr of the anterior wall of the bone, corresponding to the near-apical section of the root. This is also shown with unsuccessful conservative therapy and an increase in inflammation, when it is not possible to remove a tooth due to some circumstances. With the ineffectiveness of therapeutic measures and an increase in inflammation, the tooth should be removed. Tooth extraction is indicated in case of its significant destruction, obstruction of the canal or canals, presence of foreign bodies in the canal. As a rule, tooth extraction leads to a rapid subsidence and subsequent disappearance of inflammatory phenomena. This can be combined with an incision along the transitional fold to the bone in the region of the root of a tooth affected by acute periodontitis. After tooth extraction during the primary acute process, curettage of the hole is not recommended, but it should only be washed with a solution of dioxidine, chlorhexidine and its derivatives, gramicidin. After tooth extraction, pain may increase, body temperature may rise, which is often due to the trauma of the intervention. However, after 1-2 days, these phenomena, especially with appropriate anti-inflammatory drug therapy, disappear.

To prevent complications after tooth extraction, antistaphylococcal plasma can be introduced into the dental alveolus, washed with streptococcal or staphylococcal bacteriophage, enzymes, chlorhexidine, gramicidin, an iodoform swab, a sponge with gentamicin can be left in the mouth. The general treatment of acute or exacerbation of chronic periodontitis consists in the appointment of pyrazolone preparations inside - analgin, amidopyrine (0.25-0.5 g each), phenacetin (0.25-0.5 g each), acetylsalicylic acid (0.25-0.5 g each). 0.5 g). These drugs have analgesic, anti-inflammatory and desensitizing properties. Individual patients, according to indications, are prescribed sulfanilamide preparations (streptocid, sulfadimesin - 0.5-1 g every 4 hours or sulfadimethoxine, sulfapiridazine - 1-2 g per day). However, the microflora, as a rule, is resistant to sulfanilamide preparations. In this regard, it is more expedient to prescribe 2-3 pyrozolone drugs (acetylsalicylic acid, analgin, amidopyrine), 1/4 tablet each, 3 times a day. This combination of drugs gives an anti-inflammatory, desensitizing and analgesic effect. In debilitated patients burdened with other diseases, especially the cardiovascular system, connective tissue, kidney diseases, antibiotics are treated - erythromycin, kanamycin, oletethrin (250,000 IU 4-6 times a day), lincomycin, indomethacin, voltaren (0, 25 g) 3-4 times a day. Foreign experts after the extraction of a tooth due to an acute process necessarily recommend antibiotic treatment, considering such therapy also as a prevention of endocarditis, myocarditis. After tooth extraction in acute periodontitis, in order to stop the development of inflammatory phenomena, it is advisable to apply cold (an ice pack on the area of ​​soft tissues corresponding to the tooth for 1-2-3 hours). Further, warm rinses, sollux are prescribed, and when inflammation subsides, other physical methods of treatment are prescribed: UHF, fluctuorization, electrophoresis of diphenhydramine, calcium chloride, proteolytic enzymes, exposure to helium-neon and infrared lasers.

Exodus. With proper and timely conservative treatment, in most cases of acute and exacerbation of chronic periodontitis, recovery occurs. (Insufficient treatment of acute periodontitis leads to the development of a chronic process in the periodontium.) acute periostitis, osteomyelitis of the jaw, abscess, phlegmon, lymphadenitis, inflammation of the maxillary sinus may develop.

Prevention is based on the sanitation of the oral cavity, timely and correct treatment of pathological odontogenic foci, functional unloading of teeth with the help of orthopedic methods of treatment, as well as on hygiene and health measures.

Project

Chronic periodontitis

2. Protocol code: P-T-St-012

Code (codes) according to ICD-10: K04

4. Definition: Chronic periodontitis is a chronic inflammatory disease of periodontal tissues.

5. Classification:

5.1. Classification of periodontitis according to Kolesov et al. (1991):

1. Chronic periodontitis:

Fibrous;

Granulating

Granulomatous

2. Aggravated chronic periodontitis

6. Risk factors:

1. Acute or chronic inflammation of the pulp

2. Overdose or prolongation of the exposure of the action of devitalizing agents in the treatment of pulpitis

3. Periodontal trauma during pulp extirpation or root canal treatment

4. Removal of filling material beyond the apex of the root in the treatment of pulpitis

5. The use of strong antiseptics

6. Pushing the infected contents of the root canal beyond the root apex

7. Allergic reaction of periodontium to products of bacterial origin and medicines

8. Mechanical overload of the tooth (orthodontic intervention, overbite on a filling or crown).

7. Primary prevention:

A system of social, medical, hygienic and educational measures aimed at preventing diseases by eliminating the causes and conditions for their occurrence and development, as well as increasing the body's resistance to the effects of adverse factors in the natural, industrial and domestic environment.

8. Diagnostic criteria:

8.1. Complaints and anamnesis:

Complaints usually do not happen, the disease is asymptomatic. May occur as an outcome of acute periodontitis and as a result of the cure of other forms of periodontitis, may be the outcome of previously treated pulpitis, may occur as a result of overload or traumatic articulation.

May be asymptomatic. It usually arises from acute or may be one of the stages in the development of chronic inflammation. There may be slight pain (feeling of heaviness, bursting, awkwardness), slight pain when biting on an aching tooth. From the anamnesis, it can be found that these pain sensations are periodically repeated, there may be a fistula, a purulent discharge may be released from the fistula.

More often subjective and objective data are absent. Sometimes it can give symptoms of chronic granulating periodontitis.

Of the chronic forms, granulating and granulomatous periodontitis is more often exacerbated, fibrous - less often. Constant aching pain, soft tissue swelling, tooth mobility. There may be malaise, headache, poor sleep, fever.

8.2. Physical examination:

Chronic fibrous periodontitis. Percussion of the tooth is painless, there are no changes in the gingival mucosa in the area of ​​the diseased tooth.

Chronic granulating periodontitis. You can detect hyperemia of the gums in the causative tooth. There is a symptom of vasoporesis. On palpation of the gums, unpleasant or painful sensations occur. Percussion is painful. Often there is an increase and soreness of regional lymph nodes.

Chronic granulomatous periodontitis. More often subjective and objective data are absent.

Exacerbation of chronic periodontitis. Collateral edema of soft tissues, enlargement and soreness of regional lymph nodes, tooth mobility, painful palpation along the transitional fold in the area of ​​the diseased tooth.

8.3. Laboratory research: not held

8.4. Instrumental research:

– Sounding;

- percussion;

– X-ray methods of research

Chronic fibrous periodontitis. On the radiograph, you can detect the deformation of the periodontal gap in the form of its expansion at the root apex. There is no resorption of the bone wall of the alveolus and cementum of the tooth.

Chronic granulating periodontitis. On the radiograph, bone rarefaction in the region of the root apex with fuzzy contours or an uneven broken line that limits the granulation tissue from the bone.

Chronic granulomatous periodontitis. The radiograph reveals a small focus of rarefaction with clearly demarcated edges of a rounded or oval shape about 0.5 cm in diameter.

Exacerbation of chronic periodontitis. On the radiograph, the form of inflammation preceding the exacerbation is determined. The clarity of the boundaries of rarefaction of bone tissue decreases during exacerbation of chronic fibrous and granulomatous periodontitis. Chronic granulating periodontitis in the acute stage is manifested by a greater blurring of the pattern.

8.5. Indications for expert advice:

With multiple damage to the teeth by a carious process - a consultation with a dental surgeon, endocrinologist, therapist, otorhinolaryngologist, rheumatologist, gastroenterologist, nutritionist.

8.6. Differential Diagnosis:

Chronic periodontitis is differentiated with medium caries, deep caries, chronic gangrenous pulpitis.

9. List of basic and additional diagnostic measures:

Main:

– collection of anamnesis and complaints;

– external examination of the maxillofacial area;

- definition of bite;

– probing of the tooth;

- percussion of the tooth;

– thermal diagnostics of the tooth;

Additional:

- X-ray methods of research.

10. Treatment tactics: Foci of inflammation in the periodontium are a source of sensitization of the body, so the ongoing therapeutic measures should actively influence the focus of infection, preventing sensitization of the body.

The main principles of the treatment of periodontitis is the careful and careful mechanical treatment of infected root canals, treatment of the apical focus of inflammation until the exudation stops, followed by filling the canal.

The following treatments are used:

1. Instrumental method (including drug treatment);

2. Physiotherapeutic method (intracanal UHF, diathermocoagulation method, iontophoresis, electrophoresis, root canal depophoresis, laser, etc.);

3. Method of partial endodontic intervention (resorcinol-formalin method);

4. Surgical methods of treatment - root tip resection, hemisection, tooth replantation, coronoseparation.

10.1. Treatment goals: Stopping the pathological process, preventing sensitization of the body, restoring the anatomical shape and function of the tooth, preventing the development of complications, restoring the aesthetics of the dentition.

10.2. Non-drug treatment:

Oral hygiene education,

Professional teeth cleaning (by indications),

Opening of the cavity of the tooth

Mechanical treatment of the root canal,

Grinding fillings

The operation of resection of the apex of the tooth root according to indications,

Tooth replantation surgery according to indications,

Operation hemisection according to indications

Operation coronoseparation according to indications

10.3. Medical treatment(medicines registered in the Republic of Kazakhstan) :

Local anesthesia (anesthetics),

General anesthesia (according to indications) - (anesthetics),

Medical treatment of carious cavity,

root canal treatment,

Antiseptics (hydrogen peroxide, chlorphyllipt, chlorhexidine, etc.),

Enzyme preparations (trypsin, chymotrypsin, etc.),

Preparations containing iodine (iodinol, potassium iodide, etc.),

Analgesic and non-steroidal anti-inflammatory drugs,

Antimicrobials (antibiotics, sulfonamides, antihistamines, etc.),

Formaldehyde-containing preparations,

preparations based on calcium hydroxide,

Root canal filling

Retrograde root canal filling according to indications

Filling of the carious cavity (glass ionomer cements, composite filling materials (chemical and light curing)),

Root canal electrophoresis

Root canal depophoresis

Diathermocoagulation of the gingival papilla, canal contents

10.4. Indications for hospitalization: No

10.5. Preventive actions:

Hygienic education and training in oral hygiene;

The use of fluoride-containing toothpastes (with a deficiency of fluoride in water);

Rational nutrition (fortification, consumption of vegetables and fruits and dairy products, restriction of carbohydrate foods);

Sanitation of the oral cavity;

Carrying out remineralizing therapy;

Repeated annual examinations depending on the degree of activity of the carious process;

Preventive sealing of fissures and blind pits (fissuritis, etc.),

10.6. Further management, principles of clinical examination: Not held

11. List of basic and additional medicines:

Periodontal inflammation for many years has been of great and genuine interest to researchers, including in terms of systematization of this disease. It must be said that the classification of periodontitis in a variant that would suit everyone and would not raise questions or complaints has not actually been created at this point in time.

Important! This disease, along with periodontitis and periodontal disease, is one of the causes of early tooth loss, as it affects the periodontal tissues that firmly hold the tooth in the hole - that is, the ligamentous apparatus itself.

General information about the disease

Periodontium is a connective tissue that fills the entire area located between the tooth (more precisely, its root) and the bone bed. The inflammatory process that occurs in this space is called periodontitis. There are vessels and nerves in the periodontium, the purpose of which is to nourish the tooth with all the substances it needs (yes, not only the pulp does this), so its role is difficult to overestimate. Its main functions are to reduce and evenly distribute the load that falls on the bone tissue during the intake and chewing of food.

The development of the disease can be caused by various reasons, but the most likely and common include the following:

• infectious tissue damage: periodontitis in this case can be a complication if it is ignored for a long time (this is the most common cause) or be associated with inflammation of adjacent tissues in other diseases, for example, sinusitis or osteomyelitis,
• consequences of a certain treatment: during the treatment of various inflammatory processes, in particular pulpitis, a variety of medicines are used, which, if they enter the tissues, can cause irritation and allergic reactions,

Important! When it comes to the treatment of pulpitis, it is very important to consult a professional doctor. He must send you for x-rays without fail, you need to do this more than once. Pictures are obtained during the treatment process, monitoring the quality of work and eliminating possible errors.

• primary disease: if you start or pulpitis, then tooth decay occurs, and sources of inflammation can penetrate into the periodontium,
• poor quality: the doctor may make a mistake and seal the canals poorly, thereby provoking the penetration of the infection inside. Poorly done work can cause an inflammatory process in the area that was not affected at all during the treatment. Also, for example, the banal breaking off of the instrument and its untimely removal from the canals of the tooth can cause the appearance of the disease,
• weakened immunity: it also happens that the problem manifests itself after viral infections, colds or during periods of stress, hormonal changes. Even simple hypothermia can increase the risk of getting a problem.

Disease classification

There are a large number of different options for systematizing the disease. But despite this fact, all of them, along with advantages, have certain disadvantages. As for Russia, the methods of WHO and some individual representatives of the medical profession deserve the greatest respect here. Among the latter, Lukomsky's variant stands out clearly.

For example, the World Health Organization version has many advantages, but its use is hampered by the imperfect diagnostic methods used in practice. Be sure to read about this type of classification in full detail below.

In Russian dentistry, a classification that focuses on the forms of the disease and its exacerbations is still popular.

So, periodontitis can be both ordinary and purulent, chronic and acute, drug-induced, infectious and traumatic. Most often, it occurs at the top of the tooth root and is called "apical", much less often, patients are tormented by the marginal form of the disease, which first affects the gum or mucous membrane.

Apical or apical periodontitis

Clinical manifestations of the apical form of the disease are found in patients in most cases, that is, apical periodontitis is one of the most common forms.

The disease got this name because of its localization, since the tip of the tooth root is affected, and if no measures are taken, then periodontal disease also occurs. The course of the disease can take place in different ways, and depending on this factor, either acute or chronic forms of periodontitis are distinguished, as well as either infectious or non-infectious nature of the disease. At the same time, the symptoms of the acute form are pronounced, in particular:

• throbbing pain, which is sharp and intense in nature,
• increased pain after any mechanical impact on the tooth: in the process of eating, chewing food, closing the jaws, during daily oral hygiene with a brush,
• radiating pain to other areas, such as the neck, ear or eye,
• swelling of the soft tissues of the mucosa on the affected side,
• tooth mobility,
• redness or blueness of the gums associated with circulatory disorders: the symptom is quite alarming, and untimely treatment can lead to tooth loss,
• bleeding gums: it can disturb even during hours of relative rest and at night,
• swollen lymph nodes,
• increase in body temperature: in this case it is insignificant,
• headache and general weakness.

The process of inflammation is characterized by the fact that periods of exacerbation are replaced by remission. This is very dangerous, as some people lose their vigilance as a result and are in no hurry to seek qualified help.

As for the vivid symptoms, it manifests itself precisely in the stage of exacerbation and may indicate the development of a serous and even purulent process. When it occurs, you feel:

• pain while eating
• the appearance of fistulas on the gums, as well as purulent discharge,
• unpleasant pungent odor from the mouth,
• swelling of the soft tissues of the face.

Disease in the chronic stage

The transition of the disease to the chronic stage usually occurs in the absence of proper treatment, however, in some cases, a chronic disease develops initially. Symptoms with this scenario are rather weak, these include darkening of the enamel and mild pain in the tooth when pressure is applied to it.

There are three types of chronic stage of periodontitis:

1. : foci of inflammation are characterized by blurring, the gum becomes red, there is a slight pain (it occurs arbitrarily, mainly due to temperature irritants) and slight discomfort, an unpleasant odor is felt from the mouth of a sick person, a fistula with purulent discharge may form. This form is characterized by increased activity and very quickly contributes to the destruction of bone tissue, which is gradually replaced by loose granulation,
2. : a granuloma develops around the tissues, which is a cavity, the shell of which consists of fibrous tissue, and inside it is filled with granulations. The focus has a rounded shape, its edges are outlined clearly and clearly, with complications, a periradicular cyst may form. They talk about a granuloma when the formation does not exceed 0.5 centimeters in diameter, and about a cyst when a dense sac with pus reaches a size of 1 or more centimeters. In the presence of a granuloma near the root of the tooth, the patient experiences practically no discomfort and anxiety, therefore, destructive processes can occur imperceptibly for the time being, especially if a person ignores annual preventive examinations,
3. : this stage is characterized by loss of sensitivity and pain, the pulp becomes necrotic, which leads to the appearance of a fetid odor from the mouth and indicates the development of a gangrenous process. The upper part of the tooth root expands, the periodontal gap is deformed, the tooth itself becomes mobile. Diagnosis is much more complicated, since there are no complaints of discomfort and pain, the problem can only be noticed with the help of an x-ray.

Important! Recently, with such serious lesions as periodontitis, doctors advise patients not to undergo X-rays, but computed tomography. This diagnostic method allows you to more accurately determine the nature of the problem, as well as the condition of the tissues surrounding the tooth. The accuracy of diagnostic data allows for the most effective treatment.

Chronic form in the acute stage

A chronic disease can worsen with some frequency. While there is a remission, the person does not feel any discomfort. However, the following symptoms may indicate the onset of an exacerbation:

• swelling of tissues in the area of ​​​​inflammation, and not only the gums, but also parts of the face,
• the appearance of fistulas with pus,
• the appearance of acute pain (although it may not be),
• fever and swollen lymph nodes.

Ignoring an exacerbation can lead to serious troubles and complications, to intoxication of the whole organism, so a visit to a doctor is mandatory.

Types of disease, based on the causes of development

Due to its formation (etiology), periodontitis has a different pathogenesis (i.e., the causes of formation) and is divided into the following types:

1. infectious: this form is associated with the action of toxins that secrete harmful microorganisms that managed to penetrate into periodontal tissues and provoked the process of inflammation. The most striking example of this is pulpitis not cured in time,
2. : occurs as a result of the impact of traumatic factors on periodontal tissues. For example, it can be various bruises resulting from blows, accidents, falls, fights. The reason is the occupation of traumatic sports. Often the disease occurs in children due to a mobile lifestyle and poor self-control. In addition, a lesion of this form can also occur with constant overload of the teeth, when a prosthesis, bridge or even a filling was installed poorly,
3. drug: the appearance of this form is facilitated by the action of a chemical, for example, arsenic paste. The problem can also appear as a result of long-term antibiotic treatment. Periodontitis can also be caused by poor-quality cleaning of the canals, as a result of which the remaining organic material becomes the cause of pus in the root of the tooth. It is also possible that during the filling it was not possible to fill the entire cavity, and pathogenic bacteria penetrate into the remaining free space, which leads to inflammation of the tissues. Here we can talk about the occurrence of an allergy in the patient to the components of various drugs and medicines.

Types of periodontitis, based on origin (etiology)

Due to its formation (etiology), periodontitis is divided into:

1. Infectious. This form of the disease is associated with the action of toxins that secrete harmful microorganisms that managed to penetrate into the bone tissue and provoked the process of inflammation.
2. . It occurs as a result of the impact of traumatic factors on periodontal tissues, for example, various bruises resulting from blows.
3. Medical. The appearance of this form is facilitated by the action of a chemical, for example, arsenic paste.
4. Iatrogenic. It is caused by poor-quality cleaning of the canals, as a result of which the remaining organic material becomes the cause of pus in the root of the tooth. It is also possible that during the filling it was not possible to fill the entire cavity, and pathogenic bacteria penetrate into the remaining free space, which leads to inflammation of the tissues.

Classification according to Lukomsky

This version of the classification is very popular in our country - it involves the following division:

1. acute periodontitis, which may have either form,
2. chronic, subdivided into fibrous, granulating and granulomatous forms, respectively.

Classification according to ICD-10 (WHO)

The classification of periodontitis from the World Health Organization (WHO) is based on a comprehensive approach to this topic, since it includes not only the chronic form and acute manifestation of the disease, but also the typical, most common types of complications. Periodontitis in the ICD-10 is placed in section K04, that is, in the one that is devoted to diseases of the apical tissues:

• K04.4: Acute apical periodontitis of a tooth of pulpal origin. This option is one of the classic ones, while the cause of the disease and its manifestations are indicated clearly and clearly. For the dentist, the first task is to relieve the severity of inflammation and eliminate the source of infection with conservative methods of treatment,
• K04.5: Chronic apical periodontitis. The focus of infection is the apical granuloma, which can grow to a very large size, in which case surgery and surgery are applicable,
• K04.6: Periapical abscess with fistula. In turn, it is subdivided into dental, dentoalveolar and periodontal abscesses of pulpal origin. Fistulas can communicate with the oral and nasal cavities, skin and maxillary sinus, depending on this factor, they are classified according to
• K04.7: Periapical abscess without fistula. It can present as a dental, periodontal, and dentoalveolar abscess, as well as a periapical variant without a fistula,
• K04.8: A radicular cyst, which may be lateral or apical and requires a more serious approach to treatment, including surgical intervention. The conservative option is based on the drainage of the cyst cavity and the elimination of the microflora that supports its growth.

How is the treatment carried out

It is important to tune in to the fact that the treatment process will take a fairly long period of time. In this case, the doctor will have to visit more than once. The most important thing that the main manipulations will be aimed at is to eliminate the inflammatory process and try to save the tooth. This can be done through therapeutic methods. It is also worth paying special attention to oral care at home, taking medications prescribed by a doctor.

Important! If left untreated, it is fraught with complications. And we are talking here not only about the formation of cysts and fistulas, but also about osteomyelitis, sepsis or blood poisoning.

First of all, due to the fact that the disease most often occurs as a result of untreated pulpitis, it is with him that treatment should begin. The doctor without fail performs depulpation or removal of the nerve, then lays the drug, designed to eliminate the inflammatory process, including from the tissues around the root. From above, the medicines are closed with a temporary filling (if the process is purulent or sharp, the tooth is left open). In particularly severe cases, it may be necessary to incise the gums and install a drain. Then, the doctor will monitor the condition of the tissues by means of X-rays, and after their restoration, he will install a permanent filling.

How to prevent the development of pathology

On a note! The main factor contributing to the prevention of the occurrence of the disease is proper attention to oral hygiene and timely visits to the dentist. Annual preventive examinations will help to detect the problem in time and proceed with its immediate elimination.

It should be remembered that any pain when eating, injury or prolonged action of medications become a reason for a mandatory visit to the dentist. Naturally, the rule of preventive examination, which should be performed at least once every six months, is not canceled. The sooner the disease is detected, the less losses will be its treatment.

Pay special attention to the prevention of the disease in your children. After all, it is dangerous and can directly affect the formation of a permanent bite in the absence of measures for the treatment of milk teeth.

Related videos

Periodontitis (periodontitis)- inflammation of the tissues located in the periodontal gap (periodontitis), - can be infectious, traumatic and drug-induced.

Infectious periodontitis occurs when an autoinfection is introduced into the oral cavity. The root sheath at the top of the tooth is more often affected, less often - the marginal periodontium.

Traumatic periodontitis develops as a result of both a single (blow, bruise) and chronic injury (violation of occlusion when the height of the tooth is overestimated by an artificial crown, filling; in the presence of bad habits - holding nails in the teeth, biting threads, husking seeds, cracking nuts, etc. ). Drug-induced periodontitis can occur in the treatment of pulpitis, when potent medicinal substances are used in the treatment of the canal, and also due to an allergic reaction of the periodontium to drugs. In clinical practice, infectious apical periodontitis is the most common.

According to the clinical picture and pathoanatomical changes, inflammatory periodontal lesions can be divided into the following groups (according to I.G. Lukomsky):

I. Acute periodontitis

1. Serous (limited and diffuse)

2. Purulent (limited and spilled)

II. Chronic periodontitis

1. Granulating

2. Granulomatous

3. Fibrous

III. Chronic periodontitis in the acute stage.

WHO classification of periodontitis (ICD-10)

K04 Diseases of the periapical tissues

K04.4 Acute apical periodontitis of pulpal origin

• Acute apical periodontitis NOS

K04.5 Chronic apical periodontitis t

• Apical granuloma

K04.6 Periapical abscess with fistula

• dental
• dentoalveolar
• periodontal abscess of pulpal origin.

K04.60 Having communication [fistula] with maxillary sinus

K04.61 Communicating [fistula] with nasal cavity

K04.62 Having a communication [fistula] with the oral cavity

K04.63 Having communication [fistula] with skin

K04.69 Periapical abscess with fistula, unspecified

K04.7 Periapical abscess without fistula

• dental abscess
• Dentoalveolar abscess
• Periodontal abscess of pulpal origin
• Periapical abscess without fistula

K04.8 Root cyst

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Chronic apical periodontitis (K04.5)

Dentistry

general information

Short description

Recommended
Expert Council
RSE on REM "Republican Center
health development"
Ministry of Health
and social development
Republic of Kazakhstan
dated October 15, 2015
Protocol No. 12

Protocol name: Chronic periodontitis

Chronic periodontitis- chronic inflammatory disease of periodontal tissues.

Protocol code:

ICD-10 code(s):
K04.5 Chronic apical periodontitis

Abbreviations used in the protocol:
MMSI - Moscow Medical Dental Institute
EOD - electroodontodiagnostics
EOM - electroodontometry
EDTA - ethylenediaminetetraacetate
GIC - glass ionomer cement

Date of development/revision of the protocol: 2015

Protocol Users: dentist-therapist, general dentist, dentist.

Evaluation of the degree of evidence of the given recommendations.

Table - 1. Evidence level scale:

BUT	High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias whose results can be generalized to an appropriate population.
AT	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with not high (+) risk of bias, the results of which can be extended to the appropriate population.
With	Cohort or case-control or controlled trial without randomization with low risk of bias (+). Results that can be generalized to an appropriate population or RCTs with very low or low risk of bias (++ or +) that cannot be directly generalized to an appropriate population.
D	Description of a case series or uncontrolled study or expert opinion.
GPP	Best Pharmaceutical Practice.

Classification

Clinical classification of periodontitis (MMSI, 1987) :

1. Acute apical periodontitis:
a) phase of intoxication;
b) exudation phase: serous, purulent

2. Chronic apical periodontitis:
a) fibrous;
b) granulating;
c) granulomatous;

3. Chronic apical periodontitis in the acute stage:
a) chronic apical fibrous periodontitis in the acute stage;
b) chronic apical granulating periodontitis in the acute stage;
c) chronic apical granulomatous periodontitis in the acute stage.

Clinical picture

Symptoms, course

Diagnostic Criteria for Making a Diagnosis[ 2, 3, 4, 5, 7 ]

Complaints and anamnesis[ 2, 3, 4, 5, 7 ] :

Chronic apical periodontitis characterized by poor symptoms.

Table - 2. Survey data

Diagnosis	Complaints	Anamnesis
Chronic fibrous periodontitis
Chronic granulating periodontitis	on unpleasant sensations, a feeling of heaviness, fullness, awkwardness in the tooth, there may be a slight pain when biting on an aching tooth. Sometimes the patient may not complain.	earlier, the tooth hurt, a fistula periodically appears with a purulent discharge, which disappears after a while.
Chronic granulomatous periodontitis	It is asymptomatic, patients may complain about the presence of a carious cavity and food getting stuck in it, discomfort when eating hard food.	the tooth was previously sick, or treatment was carried out.
	to constant aching pain, aggravated by biting on a tooth, “a feeling of a grown tooth”.	the tooth was previously sick, or treatment was carried out.

Physical examination:

Table - 3

Diagnosis	Inspection	sounding	Percussion	Palpation
	the face is symmetrical, the crown is changed in color, has a grayish tint, a deep carious cavity communicates with the tooth cavity. The mucous membrane in the projection of the root apex is pale pink.	painless	painless, during comparative percussion, the patient notes slight soreness	painless
	the face is symmetrical, the crown is changed in color, has a grayish tint, a deep carious cavity communicating with the tooth cavity. The mucous membrane in the projection of the root apex is pale pink. A fistula with purulent discharge, or a scar from it, can be detected on the gum.	probing painless	Percussion painless,	painless positive symptom of vasoparesis
	the face is symmetrical, the crown is changed in color, has a grayish tint, a deep carious cavity communicating with the tooth cavity. The mucous membrane in the projection of the root apex is pale pink.	probing painless	percussion is painless, but there may be discomfort during comparative percussion.	painless
	facial asymmetry due to collateral soft tissue edema on the side of the causative tooth. The crown is changed in color, has a grayish tint, a deep carious cavity communicating with the tooth cavity, a putrid odor from the tooth. Possible tooth mobility. The mucous membrane is edematous, hyperemic	painless	percussion painful	gingival mucosa and transitional folds in the area of ​​the causative tooth are painful. Positive symptom of vasoparesis.

Diagnostics

The list of basic and additional diagnostic measures:

Basic (mandatory) and additional diagnostic examinations performed at the outpatient level:

1. collection of complaints and anamnesis
2. general physical examination (external examination and examination of the oral cavity itself, probing the carious cavity, percussion of the tooth, palpation of the gums and transitional folds)
3. determination of the reaction of the tooth to thermal stimuli
4. EDI
5. radiography of the tooth.

The minimum list of examinations that must be carried out when referring to planned hospitalization: no

Basic (mandatory) diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out): no

Diagnostic measures carried out at the ambulance stageemergency care: No

Laboratory studies (according to indications): no.

Instrumental research:

Table - 4

Diagnosis	Rreaction of the tooth to a thermal stimulus	EOD, µA	Radiography
Chronic fibrous periodontitis.	no pain	over 100 µA	expansion of the periodontal gap in the region of the root apex.
Chronic granulating periodontitis.	no pain	over 100 µA	the focus of rarefaction of bone tissue is determined without clear boundaries in the form of tongues of flame.
Chronic granulomatous periodontitis.	no pain	over 100 µA	a focus of rarefaction of bone tissue at the apex of the root with clear contours of a rounded or oval shape.
Exacerbation of chronic periodontitis.	no pain	over 100 µA	corresponds to one of the forms of chronic periodontitis

Indications for expert advice: according to indications - consultation of a dental surgeon for periostotomy.

Differential Diagnosis

differential diagnosis.

Chronic forms of periodontitis are differentiated:
- between themselves,
- with chronic gangrenous pulpitis,
- with medium caries,
- with deep slowly progressive caries.

Chronic periodontitis in the acute stage is differentiated from acute periodontitis in the exudation phase, periostitis and acute osteomyelitis.

Table - 5. Differential diagnostic signs of chronic periodontitis

sign

Chronic periodontitis

Chronic gangrenous pulpitis

Medium caries

Deep caries slowly progressing

fibrous

granulomatous

granulating

Complaints

There may be a feeling of heaviness in the tooth

Sometimes a feeling of heaviness in the tooth

Feeling of heaviness, awkwardness, bursting in the tooth

Prolonged pain from hot

Pain from chemical irritants

Short-term pain from thermal stimuli

Inspection

The crown of the tooth is changed in color. Carious cavity communicates with the cavity of the tooth

Carious cavity within mantle dentin

Carious cavity within the peripulpal dentin

The presence of a fistula with purulent discharge

Tooth probing

painless

Soreness in the mouths of the canals

Pain at the dentin-enamel junction

Soreness on the bottom

Tooth percussion

Painless

Status of regional lymph nodes

Painless, not enlarged

Reaction to temperature stimuli

No pain

Prolonged pain from hot

There may be short term pain

Transient pain

Data radiography

Moderate expansion of the periodontal fissure

Rarefaction of bone tissue at the root apex with clear contours

Rarefaction of bone tissue at the root apex with fuzzy contours

No changes

EDI data

Over 100 uA

80-90 uA

2-6 uA

10-12 uA

General state

Not violated

Table - 6 Differential diagnostic signs of chronic periodontitis in the acute stage

signs	Diagnosis
	Acute periodontitis in the phase of exudation	Chronic periodontitis in the acute stage			Periostitis	Acute purulent osteomyelitis
Complaints	to constant aching pain, aggravated by biting on the causative tooth, "the feeling of a grown tooth."				Constant, aching pain in the jaw	On an unpleasant smell, sharp pain in the entire jaw
Anamnesis	toothache for the first time	the causative tooth was previously sick, or treatment was carried out.
				after the appearance of edema, the pain decreased
Visual inspection	there is asymmetry of the face due to collateral soft tissue edema on the side of the causative tooth
Tooth mobility	causative tooth mobility		motionless					mobility of the causative and adjacent teeth
carious cavity	does not communicate with the cavity of the tooth	communicates with the cavity of the tooth
sounding	painless
Percussion	Sharply painful				Several teeth slightly painful		slightly painful
Palpation	painful				Painful along the transitional fold in the area of ​​​​several teeth		Painful, "sleeve-like" infiltrate
Status of regional lymph nodes	Enlarged, painful on palpation
Reaction to a thermal stimulus	no pain
EOM, µA	Over 100 uA
Radiography	no changes	X-ray picture corresponds to one of the forms of chronic periodontitis
General state	suffering
	headache, sleep disturbance, appetite				subfebrile temperature	Chills, fever

Treatment abroad

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Treatment

Treatment goals:

stop the development of the pathological process;
Prevention of development of complications;
restoration of the anatomical shape and function of the tooth;
Avoid sensitization of the body.

Treatment tactics[ 6, 7, 8, 9, 10, 11, 12, 13 ] :

Treatment is carried out on an outpatient basis.
The following treatments are used:
1. Conservative method;
2. Surgical methods of treatment (according to indications - periostotomy).
According to the indications, premedication is carried out.

Table - 7. Treatment of chronic forms of periodontitis.

Table - 8 Treatment of chronic periodontitis in the acute stage.

visits	Treatment
First	Anesthesia, preparation of the carious cavity, opening of the tooth cavity, evacuation of pulp decay from the root canal, instrumentation of the canal, opening of the apical foramen, when an outflow of exudate occurs, the tooth is left open, recommendations are given. If necessary, consult a dental surgeon.
Second	Antiseptic treatment of the root canal, temporary obturation of the root canal with the imposition of a temporary filling.
Third	removal of a temporary dressing, repeated antiseptic treatment of the root canal, permanent obturation of the root canal, x-ray control, imposition of a permanent filling*.

*The number of visits depends on the choice of filling material for root canal obturation.

One visit treatment.
Indications:
- the presence of a fistulous passage in a single-rooted tooth,
- when performing a periostotomy in a single-rooted tooth.
Methodology: anesthesia, preparation of the carious cavity, opening of the tooth cavity, evacuation of the decay of the pulp from the root canal, instrumental, chemical and antiseptic treatment of the root canal, permanent obturation of the root canal, X-ray control, imposition of a permanent filling.

Medical treatment:

Medical treatment provided on an outpatient basis:

Table - 9

Purpose	Group affiliation	Name of the medicinal product or product/ INN	Dosage, method of application	Single dose, frequency and duration of use
For pain relief Choose from the proposed:	Local anesthetics	Articaine + epinephrine	1:100 000, 1:200 000, 1.7 ml injection anesthesia	1:100 000, 1:200 000 1.7 ml, once
		Articaine + epinephrine	4% 1.7 ml, injectable pain relief	1.7 ml, once
		Lidocaine / lidocainum	2% solution, 5.0 ml injection anesthesia	1.7 ml, once
For antiseptic treatment Choose from the proposed:	Chlorine-containing preparations	Sodium hypochlorite	3% solution, carious cavity and root canal treatment	once 2-10ml
		Chlorhexidine bigluconate/ Chlorhexidine	0.05% solution 100 ml, treatment of carious cavity and root canals	once 2-10ml
	Iodine-containing preparations	Iodinol/ Iodinolum	1% solution 100 ml, intracanal	once 2-3ml
For endo dressings Choose from the proposed:	Phenol derivatives	Cresofen	Solution 13 ml, endobandage	once 1ml
		Cresodent	Solution 13 ml, endobandage	once 1ml
For chemical treatment of root canals Select from the options:	EDTA-based preparations	Channel plus	Gel 5g intracanal
		MD gel cream	Gel 5g, intracanal	One time required quantity
		RC PREP	Gel 10g intracanal	One time required quantity
For temporary obturation of root canals Choose from the proposed:	Temporary filling materials for root canals	Remedy abscess	Powder 15 mg, liquid 15 ml, intracanal
		Iodent	Paste 25 mg, intracanal	One time required quantity
		Demeclocycline + Triamcinolone	paste 5 g intracanal	One time required quantity
		Aqueous suspension of calcium hydroxide	Powder 100g, distilled water 5ml intracanal	Once 0.05 ml of distilled water mixed with the powder to a paste-like consistency
Permanent filling materials for root canals	eugenol-containing	endophile	Powder 15g, liquid 15 ml intracanal	Mix 2-3 drops of the liquid once with the powder to a paste-like consistency.
		Endomethasone	Powder 15g, liquid 15ml intracanal	Mix 2-3 drops of the liquid once with the powder to a paste-like consistency.
	based on epoxy resins	AN plus	Paste A 4 mg Paste B 4 mg intracanal	once 1:1
		AN-26	Powder 8g, paste 7.5g intracanal	One time 1:1
	calcium-containing	Sialapex	Basic paste 12g Catalyst 18g intracanal	once 1:1
	based on resorcinol-formalin	Resident	Powder 20g, healing liquid 10ml, curing liquid 10ml intracanal	Liquids 1:1 and mix with powder to a paste-like consistency
To apply an insulating gasket Choose from the options:	glassiono volumetric cements for filling materials of light and chemical curing	Ketak molar	Powder A3 - 12.5g, liquid 8.5ml. insulating gasket
		Cavitan plus	Powder 15g, liquid 15ml	Mix 1 drop of liquid once with 1 scoop of powder to a paste-like consistency.
		Ionosil	paste 4g, paste 2.5g	One time required quantity
	Zinc-phosphate cements for filling materials of chemical curing	Adhesor	Powder 80g, liquid 55g insulating gasket	once 2.30 g of powder per 0.5 ml of liquid, mix
for applying a permanent filling composite filling materials Choose from the proposed:	light curing	Filtec Z 550	4.0g seal	once Medium caries - 1.5g, Deep caries - 2.5g,
		Charisma	4.0g seal	once Medium caries - 1.5g, Deep caries - 2.5g, pulpitis, periodontitis - 6.5g
		Filtek Z 250	4.0g seal	once Medium caries - 1.5g, Deep caries - 2.5g, pulpitis, periodontitis - 6.5g
		Filtec ultimat	4.0g seal	once Medium caries - 1.5g, Deep caries - 2.5g, pulpitis, periodontitis - 6.5g
	Chemical curing	Charisma	Base paste 12g catalyst 12g seal	once 1:1
		Evikrol	Powder 40g, 10g, 10g, 10g, liquid 28g, seal	Mix 1 drop of liquid once with 1 scoop of powder to a paste-like consistency.
Adhesive system for light-curing composite fillings	Choose from the proposed:	Syngle Bond 2	liquid 6g into the carious cavity	once 1 drop
		Prime & Bond NT	liquid 4.5 ml into the carious cavity	once 1 drop
	For conditioning enamel and dentin	h gel	gel 5g into the carious cavity	once Required amount
To apply a temporary filling Choose from the proposed:	Temporary filling materials	artificial dentine	Powder 80g, liquid - distilled water into the carious cavity	Mix 3-4 drops of liquid once with the required amount of powder to a paste-like consistency.
		Dentin-paste MD-TEMP	Pasta 40g into the carious cavity	One time required quantity
For finishing fillings Choose from the proposed:	Abrasive pastes	Depural neo	Pasta 75g for polishing fillings	One time required quantity
		super polish	Pasta 45g for polishing fillings	One time required quantity

Other types of treatment:

Other types of treatment provided at the outpatient level:
Physiotherapy treatment (electrophoresis).

Other types provided at the stationary level: No

Other types of treatment provided at the stage of emergency medical care: No

Surgical intervention:

Surgical intervention provided on an outpatient basis: periostotomy

Surgical intervention provided in a hospital: No

Treatment effectiveness indicators.
· satisfactory condition;
absence of pain
high-quality obturation of root canals;
restoration of the anatomical shape and function of the tooth.

Drugs (active substances) used in the treatment

Hospitalization

Indications for hospitalization: No

Prevention

Preventive actions:
training in oral hygiene;
professional oral hygiene;
timely sanitation of the oral cavity (treatment of caries and pulpitis of the teeth);
fluoridation of drinking water;
The use of fluoride-containing toothpastes (with a deficiency of fluoride in drinking water);
carrying out remineralizing therapy;
preventive sealing of fissures and blind fossae;
Comprehensive prevention of major dental diseases;
normalization of the mode and nature of nutrition;
rational prosthetics and orthodontic treatment;
dental education.

Further management: observation through 1; 3; 6 months.

Information

Sources and literature

1. Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015
   1. List of used literature: 1. Order of the Ministry of Health of the Republic of Kazakhstan No. 473 dated 10.10.2006. "On approval of the Instructions for the development and improvement of clinical guidelines and protocols for the diagnosis and treatment of diseases." 2. Therapeutic dentistry: Textbook for medical students / Ed. E.V. Borovsky. - M.: "Medical Information Agency", 2011.-798s. 3. Therapeutic dentistry: Textbook / Ed. Yu.M.Maksimovsky. - M.: Medicine, 2002. -640s. 4. Nikolaev A.I., Tsepov L.M. Practical Therapeutic Dentistry: Textbook - M.: MEDpress-inform, 2008. - 960 p. 5. Periodontitis. Clinic, diagnosis, treatment: Textbook. Zazulevskaya L.Ya., Baibulova K.K. etc. - Almaty: Verena, 2007. -160 p. 6. Nikolaev A.I., Tsepov L.M. Phantom course of therapeutic dentistry. Textbook. Moscow: MEDpress-inform. 2014. -430 p. 7. Antanyan A.A. Effective endodontics. Moscow. 2015. 127 p. 8. Martin Trope. Guide to endodontics for general dentists. - 2005. - 70 p. 9. Lutskaya I.K., Martov V.Yu. Medicines in dentistry. - M.: Med.lit., 2007. -384s. 10. Stephen Cohen, Richard Burns. Endodontics.-S-P.- 2000.- 693s. 11. Muravyannikova Zh.G.// Fundamentals of dental physiotherapy. Rostov-on-Don.-2003 12. Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. Journal of Endodontics (JOE) 2004;30(1):5 13. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod 2008;34:1171-6. 14. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol J Endod 2004;196-2004. 15. Friedlander LT, Cullinan MP, Love RM. Dental stem cells and their potential role in apexogenesis and apexification. Int Endod J 2009;42:955-62.

Information

List of protocol developers with qualification data:
1. Yessembayeva Saule Serikovna - Doctor of Medical Sciences, Professor, Director of the Institute of Dentistry of the Kazakh National Medical University named after S.D. Asfendiyarov;
2. Bayakhmetova Aliya Aldashevna - Doctor of Medical Sciences, Professor, Head of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after SD Asfendiyarov;
3. Sagatbayeva Anar Dzhambulovna - Candidate of Medical Sciences, Associate Professor of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after S.D. Asfendiyarov;
4. Smagulova Elmira Niyazovna - Candidate of Medical Sciences, Assistant of the Department of Therapeutic Dentistry of the Institute of Dentistry of the Kazakh National Medical University named after SD Asfendiyarov;
5. Rayhan Yesenzhanovna Tuleutaeva - Candidate of Medical Sciences, Acting Associate Professor of the Department of Pharmacology and Evidence-Based Medicine of the Semey State Medical University.

Indication of no conflict of interest: No

Reviewers:
1. Zhanalina Bakhyt Sekerbekovna - Doctor of Medical Sciences, Professor of RSE on REM West Kazakhstan State Medical University. M. Ospanova, Head of the Department of Surgical Dentistry and Pediatric Dentistry;
2. Mazur Irina Petrovna - Doctor of Medical Sciences, Professor of the National Medical Academy of Postgraduate Education named after P.L. Shupika, Professor of the Department of Dentistry of the Institute of Dentistry.

Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new methods of diagnosis and / or treatment with a higher level of evidence appear.

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" cannot and should not replace an in-person consultation with a doctor. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
• The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
• The MedElement website and mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are exclusively information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
• The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.