Enamel caries: symptoms, treatment and prevention. Method of deep fluorination. Features of the superficial form of the disease

Initial caries (spot stage)
clinical picture. With initial caries, there may be complaints of a feeling of soreness. The affected tooth does not respond to a cold stimulus, as well as to the action of chemical agents (sour, sweet).

Enamel demineralization on examination, it is manifested by a change in its normal color in a limited area and the appearance of matte, white, light brown, dark brown spots with a black tint. The process begins with the loss of enamel gloss in a limited area. It usually occurs at the neck of the tooth near the gum.

The surface of the spot is smooth, the tip of the probe glides over it. The spot is stained with methylene blue solution. The tooth pulp responds to a current of 2-6 μA. During transillumination, it is detected regardless of location, size and pigmentation. Under the influence of ultraviolet rays in the area of ​​​​the carious spot, quenching of luminescence is observed, which is characteristic of the hard tissues of the tooth.

Differential diagnosis. Obvious differences have spots in caries and endemic fluorosis. This applies to both chalky and pigmented carious spots. The carious spot is usually single, the fluorous spots are multiple. With fluorosis, the spots are pearly white, against the background of dense enamel - milky, are localized on the so-called "immune areas" - on the labial, lingual surfaces, closer to the tubercles and cutting edges of the teeth, strictly symmetrically on the teeth of the same name on the right and left sides and have the same shape and color. Carious spots are usually located on the proximal surfaces of the crown of the tooth, in the area of ​​fissures and necks of the teeth. Even if they formed on symmetrical teeth, they differ both in shape and location on the tooth.

Carious spots are usually detected in people prone to caries. Such stains are combined with other stages of dental caries, and for fluorosis, a pronounced resistance to caries is typical. In contrast to caries, fluorous spots are especially often found on incisors and canines, teeth that are resistant to caries. Diagnosis is helped by staining the teeth with a solution of methylene blue: paint over only the carious stain.

It is necessary to carry out differential diagnosis initial caries with enamel hypoplasia.

With hypoplasia, vitreous spots are visible white color against the background of thinned enamel. The spots are located in the form of "chains" encircling the crown of the tooth. Such chains are single, but can be located several times. different levels tooth crowns. Identical in shape, spotted lesions are localized on symmetrical teeth. Unlike carious spots, hypoplastic ones do not stain with methylene blue and other dyes. Hypoplasia is formed even before the eruption of the tooth, its size and color do not change during the development of the tooth.

Treatment. A white or light brown spot is a manifestation of progressive enamel demineralization. As shown by experimental and clinical observations, such changes may disappear due to the entry of mineral components from the oral fluid into the focus of demineralization. This process is called enamel remineralization.

The ability of dental tissues to restore in initial stages caries, which is provided by the main mineral substance of the tooth - a crystal of hydroxyapatite, which changes its chemical structure. With the loss of part of the calcium and phosphorus ions, under favorable conditions, hydroxyapatite can be restored to its original state by diffusion and adsorption of these elements from saliva. In this case, a new formation of a hydroxyapatite crystal from calcium and phosphate ions adsorbed by dental tissues can also occur.

Remineralization is possible only with a certain degree of damage to dental tissues. The damage limit is determined by the preservation of the protein matrix. If the protein matrix is ​​preserved, then in its inherent properties it is able to combine with calcium phosphate ions. Subsequently, hydroxyapatite crystals form on it.

At initial caries(white spot stage), with partial loss of mineral substances by enamel (demineralization), free microspaces are formed, but the protein matrix capable of remineralization is preserved.

The increased permeability of the enamel in the white spot stage causes the penetration of calcium ions of phosphates, fluorides from saliva or artificial remineralizing solutions into the demineralization area with the formation of hydroxyapatite crystals in it by filling the microspaces of the carious focus in the enamel.

However, it should be noted that the permeability of different parts of the tooth enamel is not the same due to its heterogeneous structure. But the cervical region, fissures, pits and, of course, defects in tooth enamel have greater permeability. The least permeable is the surface layer of enamel, the middle layers are much larger. The permeability is greatly influenced by the concentration and temperature of the remineralizing solution, as well as the ability of the hydroxyapatite crystal to ion exchange and adsorb other substances.

The penetration of substances into the enamel occurs in 3 stages: 1) the movement of ions from the solution to the hydrated layer of the crystal; 2) from the hydrate layer to the crystal surface; 3) from the surface of the hydroxyapatite crystal to various scrap crystal lattice- intracrystalline exchange [Newman W., 1961]. If the first stage lasts minutes, then the third - tens of days.

Pellicle, soft plaque and dental plaque prevent the essential macro and microelements from entering the enamel, impede the remineralization of tooth enamel. All patients, regardless of age, need to conduct a thorough professional oral hygiene before application remineralizing therapy: remove plaque, grind and polish all surfaces of teeth, fillings, orthopedic structures with brushes with abrasive pastes, rubber bands, strips until the patient feels smooth teeth ( language test). The quality of professional hygiene is determined by the dentist using a dental angle probe, a cotton swab or flagellum, which should slide over the surface of the teeth. Only professional oral hygiene will make it possible to achieve a dynamic balance of the processes of demineralization and remineralization, to activate the process of remineralization and mineralization.

The dynamic balance of re and demineralization processes in the oral cavity ensures the homeostasis of dental tissues. Violation of this balance towards the prevalence of the demineralization process and a decrease in the intensity of remineralization processes are considered as an important link in the chain pathogenetic mechanisms development of caries.

It is known that fluorine, when directly exposed to tooth enamel, helps to restore its structure. It has been proven that not only during the period of enamelogenesis, but also after the eruption of the tooth, fluorapatite resistant to the action of aggressive factors of the oral cavity is formed in the surface layers of the enamel. It has been established that fluorine contributes to the acceleration of calcium precipitation in the enamel in the form of fluorapatite, which is characterized by a very high stability [Ovrutsky GD, Leontiev VK, 1986].

Remineralizing therapy of dental caries is carried out by various methods, as a result of which the surface layer of the affected enamel is restored.

Currently, a number of preparations have been created, which include calcium, phosphorus, fluorine ions, which cause remineralization of tooth enamel. The most widespread are 10% calcium gluconate solution, 2% sodium fluoride solution, 3% remodent, fluorine-containing varnishes and gels.

To this day, the Leus-Borovsky enamel restoration technique remains popular.

The surfaces of the teeth are thoroughly cleaned mechanically from plaque with a brush and toothpaste. Then treated with 0.5-1% hydrogen peroxide solution and dried with a stream of air. Next, cotton swabs moistened with a 10% solution of calcium gluconate are applied to the site of the changed enamel for 20 minutes; Swabs are changed every 5 minutes. This is followed by application of 2-4% sodium fluoride solution for 5 minutes. After the procedure is completed, it is not recommended to eat for 2 hours. The course of remineralizing therapy consists of 15-20 applications, which are carried out daily and every other day. The effectiveness of treatment is determined by the disappearance of and. reduction in the size of the focus of demineralization. For a more objective assessment of treatment, the method of staining areas with a 2% solution of methylene blue can be used. At the same time, as the surface layer of the affected enamel remineralizes, the intensity of its staining will decrease. At the end of the course of treatment, it is recommended to use fluoride varnish, which is applied to thoroughly dried tooth surfaces with a brush, single dose no more than 1 ml, always in a heated form.

As a result of the treatment White spot can completely disappear, the natural luster of the enamel is restored. The nature of the restoration of the focus depends entirely on the depth of changes in the area of ​​the pathological process. With the initial changes, the effect of the treatment is immediately noticeable. With more pronounced changes, which is clinically characterized by a significant area of ​​damage, and morphologically - by the destruction of the organic matrix, complete remineralization cannot be achieved.

VC. Leontiev suggested using 1-2% sodium fluoride gel on 3% agar for applications. After professional cleaning of the teeth, the gel heated on the spirit lamp is applied with a brush to the dried teeth. After 1-2 minutes, it solidifies in the form of a thin film. The course of treatment is 5-7 applications. The effectiveness of this method is significant. After one course of treatment, the spots are reduced by 2-4 times. A year later, they may increase slightly again, but after a second course of treatment they decrease by 4-5 times compared with the initial state.

AT last years Remodent was proposed for remineralizing therapy. The dry preparation of Remodent contains calcium 4.35%; magnesium 0.15%; potassium 0.2%; sodium 16%; chlorine 30%; organic matter 44.5%, etc.; is produced in the form of a white powder, from which 1-2-3% solutions are prepared.

A feature of the remodent used in the treatment of initial caries is that there is practically no fluorine in its composition, and the anti-caries effect is primarily associated with the replacement of calcium and phosphate vacant sites in hydroxyapatite crystals and the formation of new crystals. R.P. Rastinya successfully applied 3% Remodent solution for applications. At acute forms caries, complete disappearance of spots was noted in 63%, stabilization of the process - in 24% of cases.

Remodent treatment is carried out as follows: the surfaces of the teeth are thoroughly mechanically cleaned of plaque with a brush, then treated with a 0.5% hydrogen peroxide solution, dried with an air stream. Next, cotton swabs moistened with a remineralizing solution for 20–25 minutes are applied to the areas of altered enamel, the swabs are changed every 4–5 minutes. The course of treatment is 15-20 applications.

VC. Leontiev and V.G. Suntsov developed a method for treating initial caries with a calcium phosphate-containing gel with a pH of 6.5-7.5 and 5.5. Prepare gels based on calcium chloride and sodium hydrogen phosphate. Neutral gel is intended for the treatment of initial caries. Exceptions are spots large sizes with sharply disturbed permeability and a softening area in the center. Such spots are treated with an acidic (pH=5.5) gel. acid environment gel leads to the elimination of the affected tissues in the center of the stain, which are no longer capable of remineralization, while the other part of the stain, which can still be mineralized, being sufficiently exposed to the mineral components of the gel, is restored. The specified gel contains calcium and phosphate ions in the same ratio as these elements are in saliva (1:4). At the same time, the amount of calcium and phosphate in the gel is 100 times higher than that in saliva. The state of the gel prevents the interaction of calcium with phosphate and precipitation.

The treatment is carried out as follows: the surfaces of the teeth are mechanically cleaned of plaque with a brush or professional oral hygiene is carried out, then the teeth are treated with a 0.5% hydrogen peroxide solution, dried with a stream of air. The gel is applied with a brush to all surfaces of the teeth, dried for 2 minutes. The course of treatment is 10 procedures.

Gels can be used as toothpastes for the third evening brushing of teeth for 20-30 days (Fluodent, Elmex, Fluocal) or in the form of applications, the course of treatment is 15-20 procedures.

Treatment is carried out as follows: the surfaces of the teeth are mechanically cleaned of plaque with a brush with toothpaste or professional oral hygiene is carried out, then all surfaces of the teeth are dried with a warm air jet or cotton swabs. The teeth are isolated from the oral fluid with dry cotton rollers, then a gel is applied to all surfaces with a brush, which is held for 15-20 minutes. The course of treatment is 15-20 procedures. It is convenient to apply the gel using a disposable polyurethane or wax template when the gel thin layer is applied to the bottom of the template, which is carefully placed on the teeth and held for 15-20 minutes. This method treatment even with hypersalivation allows the patient to feel comfortable.

To optimize and intensify remineralizing therapy, it is advisable to educate the patient on rational oral hygiene with subsequent control in order to consolidate the skills of proper brushing. For self-control, the feeling of smoothness of the teeth, which the patient receives after professional oral hygiene, can serve. It is the feeling of smoothness of teeth at home that determines the time, technique and quality of brushing for the patient, and most importantly, it is an effective motivation to perform a hygiene ritual.

At home, as a rule, it is advisable for children and pregnant women with decompensated and subcompensated forms of caries to use a magnetic toothbrush, 2 times a day: in the morning after breakfast and in the evening before bedtime, for 3-4 minutes. A magnetic toothbrush speeds up the process of cleaning the teeth, gives a high quality of hygiene and a long-lasting feeling of smoothness of the teeth due to the detachment of microorganisms from the surface of the enamel, helps to reduce swelling, redness and bleeding of the gums. A magnetic toothbrush can be used for therapeutic and prophylactic purposes by patients with inflammatory periodontal diseases, dental caries (at the stages of oral cavity sanitation), with chronic and acute diseases of the oral mucosa [Danilevsky N.F., 1993; Lukinykh L.M., 1996].

A high remineralizing effect is given by a 12-day course of products consistently used in the form of applications:
. calcium gluconate gruel - 7 days,
. fluorine-containing gel - 5 days (elgifluor, elugel, sensigel, elgydium, elmex, fluodent, fluocal).
The last visit to the dentist ends with the coating of all surfaces of the teeth with fluorine-containing varnish (fluorine varnish, bifluoride12).
Yu.M. Maksimovsky proposed a ten-day course of remineralizing therapy, consistently using various remineralizing agents in the form of applications:
. 3% remodent solution - 2 days,
. calcium glycerophosphate gruel - 4 days,
. 1% sodium fluoride solution - 3 days,
. fluoride varnish - 1 time, at the end of the course of treatment.

Important integral part The treatment of the focus of demineralization is strict adherence to the rules of oral care, the purpose of which is to prevent the formation and long-term existence of plaque at the site of the former demineralization site. In addition, it is necessary to convince the patient to follow the nature of the diet: reduce the intake of carbohydrates and eliminate them in between meals.

Brown and black spots characterize the stage of stabilization of the carious process. Pigmented spots are asymptomatic. In addition to a cosmetic defect and the patient's suspicion of the presence of a carious cavity, there are no complaints.

Of interest are the data of R.G. Sinitsin, explaining the cause of pigmentation of the carious cavity. He established the possibility of accumulation of tyrosine in enamel and dentine and its transformation into a pigment - melanin. This process occurs with an apparently intact outer layer of enamel, although it is noted that in the center of the stain there is a decrease in microhardness and an increase in permeability, in particular, for radioactive calcium.

Clinical and experimental studies showed that remineralizing therapy with such changes is ineffective. As a rule, such lesions proceed for a long time and can turn into carious cavities with a violation of the dentin-enamel connection after a few years. With minor foci of pigmentation of the tooth enamel, a dynamic observation is carried out. In the presence of an extensive area of ​​pigmentation, it is possible to prepare the hard tissues of the tooth and seal without waiting for the formation of a cavity. In most cases, grinding of the pigmented area is indicated, followed by remineralizing therapy.
General etiopathogenetic therapy of dental caries is prescribed individually, based on the intensity of the lesion and the nature of the course of the pathological process.

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

Dental caries (K02)

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

DENTAL CARIES

Dental caries is a pathological process that manifests itself after teething, in which demineralization and softening of the hard tissues of the tooth occur, followed by the formation of a defect in the form of a cavity. .

Protocol name: Dental caries

Protocol code:

ICD-10 code(s):
K02.0 Enamel caries. "White (chalky) spot" stage [initial caries]
K02.I Dentinal caries
K02.2 Cement caries
K02.3 Suspended dental caries
K02.8 Other dental caries
K02.9 Dental caries, unspecified

Abbreviations used in the protocol:
MBC -international classification disease

Date of development/revision of the protocol: 2015

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

Evaluation of the degree of evidence of the given recommendations

Table - 1. Evidence level scale

Classification

Clinical classification: . .

Topographic classification of caries:
Spot stage
· superficial caries;
average caries;
deep caries.

By clinical course:
fast flowing;
Slow-flowing
· stabilized.

Clinical picture

Symptoms, course

Diagnostic criteria for making a diagnosis

Complaints and anamnesis [2, 3, 4, 6.11, 12]

Table - 2. Data collection of complaints and anamnesis

Physical examination:

Table - 3. Data from the physical examination of caries in the stain stage

Table - 4. Physical examination data of superficial caries

Diagnostics

List of diagnostic measures:

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

1. Collection of complaints and anamnesis
2. General physical examination (External examination of the face (skin, facial symmetry, skin color, condition lymph nodes color, shape of teeth, size of teeth, integrity of hard tissues of teeth, mobility of teeth, percussion
3. Probing
4. Vital staining
5. Transillumination
6. X-ray of the tooth intraoral
7. Thermal diagnostics

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 taken at the stage of emergency care: No

Laboratory research: not held

Instrumental research:

Table - 7. Data instrumental research

Indications for consultation of narrow specialists: not required.

Differential Diagnosis

Differential diagnosis of enamel caries in the stage of white (chalky) spots (initial caries) (k02

0) - should be differentiated from the initial stages of fluorosis and enamel hypoplasia.

Table - 8. Data on the differential diagnosis of caries in the stain stage

It must be differentiated from medium caries, wedge-shaped defect, dental erosion and some forms of fluorosis(chalky-mottled and erosive).

Table - 9. Data of differential diagnosis of superficial caries

Differential diagnosis of dentin caries (to 02.1) (medium caries)- should be differentiated from superficial and deep caries, chronic apical periodontitis, wedge-shaped defect.

Table - 10. Data of differential diagnosis of medium caries

Differential diagnosis of initial pulpitis(pulp hyperemia) (k04.00) (deep caries)
- it is necessary to differentiate from medium caries, from chronic forms of pulpitis (chronic simple pulpitis), from acute partial pulpitis.

Table - 11. Data of differential diagnosis of deep caries

Medical tourism

Get treatment in Korea, Israel, Germany, USA

Medical tourism

Get advice on medical tourism

Treatment

Treatment goals:

stop the pathological process;


restoration of the aesthetics of the dentition.

Treatment tactics:
When preparing carious cavities, it is recommended to be guided by the following principles:
medical validity and expediency;
sparing attitude to unaffected tooth tissues;
Painlessness of all procedures;
· visual control and convenience of work;
preservation of the integrity of adjacent teeth and tissues of the oral cavity;
Rationality and manufacturability of manipulations;
creating conditions for aesthetic restoration of the tooth;
Ergonomics.

Treatment plan for a patient with dental caries:

The general principles of treatment of patients with dental caries include several stages:
1. Prior to the preparation of the carious cavity, it is necessary to eliminate as much as possible the cariogenic situation in the oral cavity, microbial plaque, factors that cause the process of demineralization and tooth decay
2. Teaching the patient oral hygiene recommendations for the choice of hygiene items and means, professional hygiene, recommendations for diet correction.
3. A tooth affected by caries is being treated.
4. With caries of the white spot stage, remineralizing therapy is performed.
5. When caries has stopped, fluoridation of teeth is carried out.
6. If there is a carious cavity, the carious cavity is prepared and prepared for filling.
7. Restoring the anatomical shape and function of the tooth with filling materials.
8. Measures are being taken to prevent complications after treatment.
9. Recommendations are given to the patient about the timing of re-treatment and the prevention of dental diseases.
10. The treatment is recorded in the card separately for each tooth, form 43-y. In the treatment, materials and medicines are used that have permission for use on the territory of the Republic of Kazakhstan

Treatment of a patient with enamel caries in the stage of a white (chalky) spot (initial caries) (k02.0)

Table - 12. Data on the treatment of caries in the stain stage

Treatment of a patient with caries of enamel m (k02.0) (superficial caries)

Table - 13. Data on the treatment of superficial caries

Treatment of a patient with dentine caries (k02.1) (medium caries)

Table - 14. Data on the treatment of medium caries

Treatment of a patient with initial pulpitis (pulp hyperemia) (k04.00) (deep caries)

Table - 15. Data on the treatment of deep caries

Non-drug treatment: Mode III. Table number 15.

Medical treatment:

Medical treatment provided on an outpatient basis:

Table - 16. Data on dosage forms and filling materials used in the treatment of caries

Other types of treatment provided at the outpatient level:

according to indication physiotherapy according to indications (supragingival electrophoresis)

Treatment effectiveness indicators:
· satisfactory condition;
· recovery anatomically shaped and function of the tooth;
Prevention of development of complications;
restoration of the aesthetics of teeth and dentition.

Drugs ( active ingredients) used in the treatment

Hospitalization

Indications for hospitalization, indicating the type of hospitalization: No

Prevention

Preventive actions:

Primary Prevention:
basis primary prevention of dental caries is the use of methods and means aimed at eliminating risk factors and causes of the disease. As a result of preventive measures, the initial stages of a carious lesion may stabilize or undergo regression.

Methods of primary prevention:
dental education of the population
individual oral hygiene.
endogenous use of fluorides.
topical application of remineralizing agents.
sealing fissures of teeth.

Further management: are not carried out.

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", 2014. 3. Therapeutic dentistry. Diseases of the teeth: textbook: in 3 hours / ed. E. A. Volkov, O. O. Yanushevich. - M. : GEOTAR-Media, 2013. - Part 1. - 168 p. : ill. 4. Diagnostics in therapeutic dentistry: Tutorial/ T.L. Redinova, N.R. Dmitrakova, A.S. Yapeev and others - Rostov n / D .: Phoenix, 2006. -144p. 5. Clinical materials science in dentistry: textbook / T. L. Usevich. - Rostov n / D .: Phoenix, 2007. - 312 p. 6. Muravyannikova Zh.G. Dental diseases and their prevention. - Rostov n / a: Phoenix, 2007. -446s. 7. Dental composite filling materials / E.N. Ivanova, I.A. Kuznetsov. - Rostov n / D .: Phoenix, 2006. -96s. 8. Fejerskov O, Nyvad B, Kidd EA: Pathology of dental caries; in Fejerskov O, Kidd EAM (eds): Dental caries: The disease and its clinical management. Oxford, Blackwell Munksgaard, 2008, vol 2, pp 20-48. 9. Allen E Minimal interventiondentistry and older patients. Part1: Risk assessment and caries prevention./ Allen E, da Mata C, McKenna G, Burke F.//Dent Update.2014, Vol.41, No.5, P. 406-408 10. Amaechi BT Evaluation of fluorescence imaging with reflectance enhancement technology for early caries detection./ Amaechi BT, Ramalingam K.//Am J Dent. 2014, Vol.27, No.2, P.111-116. 11. Ari T The Performance of ICDASII using low-powered magnification with light-emitting diode headlight and alternating current impedance spectroscopy device for detection of occlusal caries on primary molars / Ari T, Ari N.// ISRN Dent. 2013, Vol.14 12. Bennett T, Amaechi// Journal of applied physics 2009, P.105 13. Iain A. Pretty Caries detection and diagnosis: Novel technologies/ Journal of dentistry 2006, No. 34, P.727-739 Vol. 3, No. 2, P.34-41. 15. Sinanoglu A. Diagnosis of occlusal caries using laser fluorescence versus conventional methods in permanent posterior teeth: a clinical study./ Sinanoglu A, Ozturk E, Ozel E.// Photomed Laser Surg. 2014 Vol. 32, No. 3, P.130-137.

Information

List of protocol developers with qualification data:
1. Yessembayeva Saule Serikovna - doctor medical sciences, Professor, Director of the Institute of Dentistry of the Kazakh National Medical University named after Sanzhar Dzhaparovich Asfendiyarov;
2. Abdikarimov Serikkali Zholdasbayevich - Candidate of Medical Sciences, Associate Professor of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after Sanzhar Dzhaparovich Asfendiyarov;
3. Urazbayeva Bakitgul Mirzashovna - Assistant of the Department of Therapeutic Dentistry of the Kazakh National Medical University named after Sanzhar Dzhaparovich Asfendiyarov;
4. Raykhan Yesenzhanovna Tuleutaeva - Candidate of Medical Sciences, Acting Associate Professor of the Department of Pharmacology and Evidence-Based Medicine of the State medical university Semey.

Indication of no conflict of interest: No

Reviewers:
1. Margvelashvili VV - Doctor of Medical Sciences, Professor of Tbilisi State University, Head of the Department of Dentistry and Maxillofacial Surgery;
2. Zhanarina Bakhyt Sekerbekovna - Doctor of Medical Sciences, Professor
RSE on REM WKSMU named after M. Ospanov, head of the Department of Surgical Dentistry.

Indication of the conditions for the revision of the protocols: revision of the protocol after 3 years or when new methods of diagnosis or treatment with a higher level of evidence become available.

Mobile application "Doctor.kz"

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website cannot and should not replace an in-person medical consultation. Be sure to contact medical institutions if you have any diseases or symptoms that bother you.
• Choice medicines 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 state of the patient's body.
• The MedElement website is an information and reference resource only. 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.

Most people firmly believe that the right toothpaste, all kinds of improved toothbrushes, rinses, etc., will reliably and almost guaranteed to protect them from caries. Moreover, serious mistakes are often made when choosing hygiene products or there is an overestimation of their capabilities.

Enamel caries often develops contrary to these beliefs, and there are certain prerequisites for that ...

Provoking factors: microbial exposure

Usually enamel caries is gradually formed under the thickness of plaque covering the tooth for a long time. Numerous microorganisms feed on carbohydrate residues in the layers of plaque.

Gram-positive bacteria - streptococci - play a decisive role in the formation of a carious stain on tooth enamel. At the same time, anaerobic bacteria Streptococcus mutans are considered the most important “destroyers” of the enamel mineral structure. Due to the enzymatic processing of carbohydrates (for example, sugar), they form organic acids that wash out mineral components from enamel (compounds of calcium, phosphorus and fluorine).

It is interesting

Elements of early diagnosis

In most cases, the patient cannot recognize enamel caries in the early stages, since the clinic of this pathology is poorly expressed. When a white or pigmented spot appears, many attribute it to plaque or tartar, not understanding the seriousness of the problem.

The color of the affected enamel can be different, depending on the characteristics of the regularly eaten food and the presence of certain dyes in it.

Only a dentist has the opportunity to carry out a set of simple diagnostic measures aimed at establishing a hidden carious focus. Already at the first stages of examination of the teeth and their probing, it is possible to determine the nature of the lesion:

1. When smooth areas of enamel are detected on chalky-white and pigmented spots during the probe passing over its surface, it is difficult to immediately speak of the presence of caries. The second stage is important - staining doubtful areas with special dyes (more on this below).
2. The presence of a rough surface when the dental probe is guided along the suspicious zone immediately defines this phenomenon as a defect or initial “softening”. In another way, it is enamel caries in the stage of superficial destruction.

In the photo below, enamel caries is presented as the initial stage of the lesion with the characteristic features of this particular stage:

Dentist's opinion

1. 0.1% methylene red solution;
2. Carmine;
3. Kongoroth;
4. Tropeolin;
5. Silver nitrate solution.

Luminescent diagnosis of enamel caries is a rare diagnostic method that has not been widely used in dental clinics. It is based on the phenomena of fluorescence of healthy tooth tissues under the influence of ultraviolet rays.

Special lamps, for example, OLD, illuminate the teeth in a dark room at a distance of about 20 cm. At the same time, healthy enamel tissues give light of a bluish or light green tint, and areas with enamel caries do not emit it. The method is quite effective, but has a high attachment to complex expensive equipment.

Clinical picture: indistinctness of symptoms

Blade caries enamel in most cases is not bright. Spotted forms of caries may not cause any painful reactions from irritants at all, only in exceptional cases discomfort and a feeling of “setting the teeth” are possible when carious lesions are located in the area of ​​​​sensitive necks of the teeth.

Since enamel caries is, in addition to stains, superficial disturbances in the transmission of enamel, certain symptoms are associated with this in some cases:

1. Reaction to temperature influences (cold, hot);
2. Reaction to mechanical stimuli (when eating hard food);
3. Reaction to chemical factors (sweet, salty, sour).

In most cases, all these symptoms are mild and quickly subside when the cause is eliminated.

Caries damage to the enamel of contact surfaces in the tooth gaps is the most insidious variant of the development of pathology. Due to long latency destructive process in the gap between the teeth, there is a possibility of late detection of the focus and its transition to the stage of dentin caries - a more serious form of the pathological process.

The enamel caries clinic can also manifest itself in the aesthetic imperfection of the tooth (or teeth), causing a certain psychological discomfort to a person.

On the last month pregnancy, my dentist suddenly found a white border next to my gum on almost every front tooth. I noticed this already a month ago, it began to worry me a lot, because it became even impossible to smile normally. The doctor said that I have caries in the stain stage and that it will not go away on its own: either treatment with fluoride-containing agents is needed, or the tooth is already drilled, but it depends on what will be observed after the first option. Somehow I don’t really want to walk with two-color teeth, I don’t know what to do now. I would like to try the option with fluorine, where you just need to cover the enamel with varnish. The dentist also said that it would not be possible to quickly get a normal color, and that the fluoridation course would last more than one visit. I will save my teeth.

The relevance of the treatment of enamel caries without a drill

General rules in the treatment of enamel caries include:

1. Thorough oral hygiene with the use of fluoride-containing pastes;
2. Compliance with the diet;
3. Remineralizing therapy;
4. The use of sealants;
5. The use of special preparations of fluorine;
6. Tooth preparation followed by filling.

From this list, everything should be distinguished, except for the last item, which is characteristic of a violation of the integrity of the enamel with the formation of roughness or a small cavity. Here, the preparation with a drill is inevitable.

If caries is in the stain stage, remineralizing therapy with gels, fluoride varnishes, sodium fluoride solutions, etc. can be used.

To speed up the restoration of the enamel structure, dentists also use "Enamel-Sealing Liquid", which consists of two liquids. When alternately applied to the enamel, the pores are filled with crystals of fluorine-containing compounds of calcium, magnesium and copper. They remain in the pores from 4-6 months to 2 years, constantly releasing fluoride ions.

Treatment of caries in the stain stage at home

It is important to consult with your dentist before treatment, as home remedies can delay professional care, potentially leading to the next stage of caries. The preferred option - when home therapy is used as an auxiliary - to enhance the effect of the treatment of enamel caries, for example, in the clinic.

So, self-treatment of caries in the stain stage is possible only after consulting a dentist and with his permission. Usually these are small areas of enamel demineralization, the treatment of which does not cause difficulties.

Let's take a look at some common tools that can be used in this case.

Tooth gels that provide enamel restoration:

• Tooth Mousse - gel from the extract of milk casein, which includes calcium and phosphorus compounds;
• R.O.C.S. Medical Minerals is a special remineralizing gel containing magnesium, calcium and fluoride. When applied to the teeth, these components restore the mineral structure of the enamel.

Separately, fluorine-containing pastes with high content fluorides, which also provide a good restorative effect on enamel caries:

The importance of preventive measures

Generally speaking, for the occurrence of caries, it is enough to have only 2 factors in the oral cavity: the presence of carbohydrate residues and the presence a large number cariogenic bacteria. With the formation of plaque and tartar on the surface of the teeth, enamel caries is almost inevitable.

It is important to understand that proper hygiene oral cavity, and limiting the intake of easily fermentable carbohydrates can reduce the risk of developing enamel caries by 3-5 times or more.

Here are some simple ways to prevent tooth decay:

1. Regular brushing of teeth at least 3 times a day. The standard and understandable method of brushing your teeth involves cleaning all surfaces with brushes and flosses (dental floss). It is best to use toothpastes containing fluoride, and flosses also impregnated with fluoride compounds. Not less than importance has brushing teeth only after eating, and not before, as previously thought.
2. The use of fluoride rinses strengthens enamel and prevents destructive action organic acids secreted by bacteria. The antiseptic substances contained in such rinses reduce the number of bacteria themselves.
3. Limit snacking between main meals. This is an important point, since non-compliance with it and frequent use eating during the day, especially sweet, delays self-cleaning of teeth for a long period. And this is enough for the development of enamel caries.
4. Visit the dentist once every 6 months to preventive examination or professional oral hygiene: removal of plaque and calculus from all surfaces of the teeth (especially in between) and, if necessary, deep fluoridation of the enamel with special gels.

Save your teeth and be healthy!

How can caries be cured without using a drill, that is, without drilling teeth

Interesting facts about caries and other dental problems

A carious lesion, accompanied only by the destruction of the enamel, is a superficial caries. In this case, the enamel demineralizes and destructs, and a stain appears on the surface of the tooth, which causes further destruction.

What is this ailment?

Superficial caries is the demineralization and destruction of hard dental tissues, when a carious defect affects the enamel.

The main symptom of the disease is pain from exposure to mechanical, chemical and thermal stimuli, which is of a short-term nature.

The disease can be detected during examination, as well as through probing, transillumination and radiography.

Shallow caries in children can be cured by remineralizing therapy, adults most often need to remove the affected enamel tissue and apply a filling material.

Features of the disease

When caries affects the enamel, it demineralizes. In this case, a cavity defect occurs, the dentin is not affected.

The initial forms are more often present in children and adolescents, while the medium and deep forms are more likely to affect adult patients.

For Russians, the disease in question is the most common among dental ailments, which affects 65-95% of the country's inhabitants.

Factors provocateurs

The enamel structure is mineral. It withstands loads well, but is easily destroyed when exposed to acids.

The main provocateurs of superficial caries are harmful microorganisms(streptococci) living in the oral cavity. The products of their vital activity are toxins and acids that affect the enamel. At the same time, calcium and other minerals are washed out of the enamel, which leads to the appearance of a focus of caries.

In addition, the following factors can provoke the development of the disease:

1. Lack of vitamins and minerals (primarily calcium and fluorine), excessive consumption of foods containing carbohydrates.
2. Poor oral hygiene, due to which plaque from bacteria accumulates on the teeth.
3. Availability chronic diseases that disrupt mineral metabolism in the body.
4. disturbed biochemical composition saliva.
5. Incorrect bite and anomalies of the dental organs.
6. The presence of fillings and orthodontic structures in the mouth.

Development of the disease

The development of superficial caries begins where the enamel has undergone demineralization and the disease has appeared in the stain stage. For this reason, tissues lose their resistance to destruction, their sensitivity and permeability increase. Due to this defect, plaque accumulates, which gradually becomes saturated with salts and transforms into dental plaque. Under this plaque, harmful bacteria actively secrete harmful acids. Also, it is more difficult to neutralize the acid under the plaque and the destruction of the enamel spreads rapidly.

That is, superficial caries is no longer reversible; as a stain stage, it cannot be eliminated by enamel remineralization procedures. Treatment is already taking place with the use of boron. If left untreated, the carious lesion will progress, affecting more and more deep tissue tooth.

Symptoms

The earliest stage of caries is characterized only by the appearance of spots on the enamel. And when the disease is already moving into the cavity of the tooth, rather vivid symptoms appear, such as discomfort, pain when eating and drinking.

The affected area of ​​the tooth reacts strongly to the effects of sweet, salty and sour. The tooth is also irritated by heat, cold, and mechanical stress. At the same time, it forms sharp pain which passes quickly. Sometimes pain is not felt at all.

The patient feels the greatest discomfort when eating, the particles of which are then clogged into the existing cavity. At the same time, the gums of the damaged tooth may become inflamed, and bleeding is also possible.

On a note: The most important symptom of the disease is the deformed surface of the tooth enamel, which gradually collapses more and more and allows caries to pass to the next layers of the tooth.

Superficial caries on milk teeth

In children, tooth decay can occur at two or three years of age. The course of the disease occurs much faster than in adults, because mineralization is not completed in milk teeth, and their walls are quite thin.

The main symptoms of primary caries in children are:

• tooth reaction when eating sweet and sour foods;
• destruction (destruction) of enamel.

It is especially important for children to visit the dentist regularly in order to identify and treat caries in time.

Related videos

clinical picture. With initial caries, there may be complaints of a feeling of soreness. The affected tooth does not respond to a cold stimulus, as well as to the action of chemical agents (sour, sweet). Enamel demineralization on examination is manifested by a change in its normal color in a limited area and the appearance of matte, white, light brown, dark brown spots with a black tint. The process begins with the loss of enamel gloss in a limited area. It usually occurs at the neck of the tooth near the gum. The surface of the spot is smooth, the tip of the probe glides over it. The spot is stained with methylene blue solution. The tooth pulp responds to a current of 2-6 μA. During transillumination, it is detected regardless of location, size and pigmentation. Under the influence of ultraviolet rays in the area of ​​​​the carious spot, quenching of luminescence is observed, which is characteristic of the hard tissues of the tooth.

Differential diagnosis of initial caries. Obvious differences have spots in caries and endemic fluorosis. This applies to both chalky and pigmented carious spots. Carious spot is usually single, fluorous spots are multiple. With fluorosis, the spots are pearly white, against the background of dense enamel - milky in color, are localized in the so-called "immune areas" - on the labial, lingual surfaces, closer to the tubercles and cutting edges of the teeth, strictly symmetrically on the teeth of the same name on the right and left sides and have the same shape and coloration. Carious spots are usually located on the proximal surfaces tooth crowns, areas of fissures and necks of teeth. Even if they formed on symmetrical teeth, they differ both in shape and location on the tooth. Carious spots are usually detected in people prone to caries. Such stains are combined with other stages of dental caries, and for fluorosis, a pronounced resistance to caries is typical. Unlike caries, fluorotic spots are especially often found on incisors and canines, teeth that are resistant to caries. Diagnosis is helped by staining the teeth with a solution of methylene blue: only the carious stain is stained. It is necessary to carry out differential diagnosis of initial caries and enamel hypoplasia. With hypoplasia, vitreous white spots are visible against the background of thinned enamel. The spots are located in the form of "chains" encircling the crown of the tooth. Such chains are single, but can be located several at different levels of the tooth crown. Identical in shape, spotted lesions are localized on symmetrical teeth. Unlike carious spots, hypoplastic ones do not stain with methylene blue and other dyes. Hypoplasia is formed even before the eruption of the tooth, its size and color do not change during the development of the tooth.

Treatment of caries in the stain stage. A white or light brown spot is a manifestation of progressive enamel demineralization. As experimental and clinical observations have shown, such changes can disappear due to the entry of mineral components from the oral fluid into the focus of demineralization. This process is called enamel remineralization. The ability of dental tissues to restore in the initial stages of caries has been proven, which is provided by the main mineral substance of the tooth - a hydroxyapatite crystal that changes its chemical structure. With the loss of part of the calcium and phosphorus ions, under favorable conditions, hydroxyapatite can be restored to its original state by diffusion and adsorption of these elements from saliva. At the same time, new formation of hydroxyapatite crystals from calcium and phosphate ions adsorbed by dental tissues can also occur. Remineralization is possible only with a certain degree of damage to dental tissues. The damage limit is determined by the preservation of the protein matrix. If the protein matrix is ​​preserved, then, due to its inherent properties, it is able to combine with calcium and phosphate ions. Subsequently, hydroxyapatite crystals form on it. With initial caries (white spot stage), with partial loss of mineral substances by enamel (demineralization), free microspaces are formed, but the protein matrix capable of remineralization is preserved. The increased permeability of the enamel in the white spot stage causes the penetration of calcium ions, phosphates, fluorides from saliva or artificial remineralizing solutions into the demineralization area with the formation of hydroxyapatite crystals in it and filling the microspaces of the carious focus in the enamel. However, it should be noted that the permeability of different parts of the tooth enamel is not the same due to its heterogeneous structure. The cervical region, fissures, pits and, of course, defects in tooth enamel have the highest permeability. The least permeable is the surface layer of enamel, the middle layers are much larger. The permeability is greatly influenced by the concentration and temperature of the remineralizing solution, as well as the ability of the hydroxyapatite crystal to ion exchange and adsorb other substances. The penetration of substances into the enamel occurs in 3 stages:

1. movement of ions from the solution to the hydrated layer of the crystal;
2. from the hydrate layer to the crystal surface;
3. from the surface of the hydroxyapatite crystal to different layers of the crystal lattice - intracrystalline exchange.

If the first stage lasts minutes, then the third - tens of days. Pellicle, soft plaque and dental plaque prevent the necessary macro- and microelements from entering the enamel, impede the remineralization of tooth enamel. All patients, regardless of age, need to conduct a thorough professional oral hygiene before application remineralizing therapy: remove plaque, grind and polish all surfaces of teeth, fillings, orthopedic structures with brushes with abrasive pastes, rubber bands, strips until the patient feels smooth teeth ( language test). The dentist determines the quality of professional hygiene with the help of a dental angle probe, a cotton swab or a flagellum, which should slide over the surface of the teeth. Only professional oral hygiene will make it possible to achieve a dynamic balance of de- and remineralization processes, to activate the process of remineralization and mineralization. The dynamic balance of the processes of re- and demineralization in the oral cavity ensures the homeostasis of dental tissues. Violation of this balance towards the prevalence of the demineralization process and a decrease in the intensity of remineralization processes are considered as an important link in the chain of pathogenetic mechanisms of caries development. It is known that fluorine, when directly exposed to tooth enamel, helps to restore its structure. It has been proven that not only during the period of enamelogenesis, but also after the eruption of the tooth, fluorapatite resistant to the action of aggressive factors of the oral cavity is formed in the surface layers of the enamel. It has been established that fluorine accelerates the deposition of calcium in the enamel in the form of fluorapatite, which is characterized by a very high stability. Remineralizing therapy of dental caries is carried out by various methods, as a result of which the surface layer of the affected enamel is restored. Currently, a number of preparations have been created, which include calcium, phosphorus, fluorine ions, which cause remineralization of tooth enamel. The most widespread are 10% calcium glucanate solution, 2% sodium fluoride solution, 3% remodent, fluorine-containing varnishes and gels. To this day, the Leus-Borovsky enamel restoration technique remains popular: The surfaces of the teeth are thoroughly mechanically cleaned of plaque with a brush and toothpaste. Then it is treated with a 0.5-1% hydrogen peroxide solution and dried with an air stream. Next, cotton swabs moistened with a 10% solution of calcium gluconate are applied to the site of the changed enamel for 20 minutes; Swabs are changed every 5 minutes. This is followed by application of 2-4% sodium fluoride solution for 5 minutes. After the procedure is completed, it is not recommended to eat for 2 hours.

Well remineralizing therapy consists of 15-20 applications, which are carried out daily or every other day. The effectiveness of treatment is determined by the disappearance or reduction in the size of the focus of demineralization. For a more objective assessment of treatment, the method of staining the area with a 2% solution of methylene blue can be used. At the same time, as the surface layer of the affected enamel remineralizes, the intensity of its staining will decrease. At the end of the course of treatment, it is recommended to use fluoride varnish, which is applied to thoroughly dried surfaces of the teeth with a brush, a single dose of not more than 1 ml, always in a heated form. As a result of the treatment, the white spot can completely disappear, and the natural luster of the enamel is restored. The nature of the restoration of the focus depends entirely on the depth of changes in the area of ​​the pathological process. With the initial changes, the effect of the treatment is immediately noticeable. With more pronounced changes, which are clinically characterized by a significant area of ​​damage, and morphologically - by the destruction of the organic matrix, complete remineralization cannot be achieved. VC. Leontiev suggested using 1-2% sodium fluoride gel on 3% agar for applications. After professional cleaning of the teeth, the gel heated on the spirit lamp is applied with a brush to the dried teeth. After 1-2 minutes, it solidifies in the form of a thin film. The course of treatment - 5-7 applications. The effectiveness of this method is significant. After one course of treatment, the spots are reduced by 2-4 times. A year later, they may increase slightly again, but after a second course of treatment they decrease by 4-5 times compared to the initial state.

In recent years, Remodent has been proposed for remineralizing therapy. The dry preparation of Remodent contains calcium 4.35%; magnesium 0.15%: potassium 0.2%; sodium 16%; chlorine 30%; organic matter 44.5%, etc.; is produced in the form of a white powder, from which 1-2-3% solutions are prepared. A feature of the remodent used in the treatment of initial caries is that there is practically no fluorine in its composition, and the anti-caries effect is primarily associated with the replacement of calcium and phosphate vacant sites in hydroxyapatite crystals and the formation of new crystals. R.P. Rastinya successfully applied 3% Remodent solution for applications. In acute forms of caries, the complete disappearance of spots was noted in 63%, the stabilization of the process - in 24% of cases. Remodent treatment is carried out as follows: the surfaces of the teeth are thoroughly mechanically cleaned of plaque with a brush, then treated with a 0.5% hydrogen peroxide solution, dried with an air stream. Next, cotton swabs moistened with a remineralizing solution for 20-25 minutes are applied to the areas of the changed enamel, the swabs are changed every 4-5 minutes. The course of treatment is 15-20 applications. VK Leontiev and VG Suntsov developed a method for treating initial caries with calcium phosphate-containing gel with pH=6.5-7.5 and 5.5. Prepare gels based on calcium chloride and sodium hydrogen phosphate. Neutral gel is intended for the treatment of initial caries. The exceptions are large spots with sharply disturbed permeability and a softening area in the center. Such spots are treated with an acidic (pH=5.5) gel. The acidic environment of the gel leads to the elimination of the affected tissues in the center of the stain, which are no longer able to remineralize, while the other part of the stain, which can still be mineralized, being sufficiently exposed to the mineral components of the gel, is restored. The specified gel contains calcium and phosphate ions in the same ratio as these elements are in saliva (1:4). At the same time, the amount of calcium and phosphate in the gel is 100 times higher than that in saliva. The state of the gel prevents the interaction of calcium with phosphate and precipitation. The treatment is carried out as follows: the surfaces of the teeth are mechanically cleaned of plaque with a brush or professional oral hygiene is carried out, then the teeth are treated with a 0.5% hydrogen peroxide solution, dried with a stream of air. The gel is applied with a brush to all surfaces of the teeth, dried for 1-2 minutes. The course of treatment is 10 procedures.

Gels can be used as toothpastes for the third evening brushing of teeth for 20-30 days (Fluodent, Elmex, Fluo-Kal) or as applications, the course of treatment is 15-20 procedures. The treatment is carried out as follows: the surfaces of the teeth are mechanically cleaned of plaque with a brush with toothpaste or professional oral hygiene is carried out, then all surfaces of the teeth are dried with a warm air jet or cotton swabs. The teeth are isolated from the oral fluid with dry cotton rollers, then a gel is applied to all surfaces with a brush, which is held for 15-20 minutes. The course of treatment is 15-20 procedures. It is convenient to apply the gel using a disposable polyurethane or wax template, when the gel is applied in a thin layer to the bottom of the template, which is carefully placed on the teeth and held for 15-20 minutes. This method of treatment even with hypersalivation allows the patient to feel comfortable. To optimize and intensify remineralizing therapy, it is advisable to educate the patient on rational oral hygiene with subsequent control in order to consolidate the skills of proper brushing. For self-control, the feeling of smoothness of the teeth, which the patient receives after professional oral hygiene, can serve. It is the feeling of smoothness of teeth at home that determines the time, technique and quality of brushing for the patient, and most importantly, it is an effective motivation to perform a hygiene ritual. At home, as a rule, it is advisable for children and pregnant women with decompensated and subcompensated forms of caries to use a magnetic toothbrush 2 times a day, in the morning after breakfast and in the evening before bedtime, for 3-4 minutes. A magnetic toothbrush speeds up the process of cleaning the teeth, gives a high quality of hygiene and a long-lasting feeling of smoothness of the teeth due to the detachment of microorganisms from the surface of the enamel, helps to reduce swelling, redness and bleeding of the gums. A magnetic toothbrush can be used for therapeutic and prophylactic purposes by patients with inflammatory periodontal diseases, dental caries (at the stages of oral cavity sanitation), with chronic and acute diseases of the oral mucosa. A high remineralizing effect is given by a 12-day course of products consistently used in the form of applications:

• calcium gluconate gruel - 7 days,
• fluorine-containing gel - 5 days (zlgifluor, elugel, sensigel, elgydium, elmex, fluodent, fluocal). The last visit to the dentist ends with the coating of all surfaces of the teeth with fluorine-containing varnish (fluorine varnish, bifluoride-12). Yu.M. Maksimovsky proposed a ten-day course of remineralizing therapy, consistently using various remineralizing agents in the form of applications:
• 3% remodent solution - 2 days,
• slurries of calcium glycerophosphate - 4 days,
• 1% sodium fluoride solution - 3 days,
• fluoride varnish - 1 time, at the end of the course of treatment.

An important component of the treatment of the focus of demineralization is strict adherence to the rules of oral care, the purpose of which is to prevent the formation and long-term existence of plaque at the site of the former demineralization site. In addition, it is necessary to convince the patient to follow the nature of the diet: reduce the intake of carbohydrates and eliminate them in between meals. Brown and black spots characterize the stage of stabilization of the carious process. Pigmented spots are asymptomatic. In addition to a cosmetic defect and the patient's suspicion of the presence of a carious cavity, there are no complaints. Of interest are the data of R.G. Sinitsin, explaining the cause of pigmentation of the carious cavity. He established the possibility of accumulation of tyrosine in enamel and dentine and its transformation into a pigment - melanin. This process occurs with an apparently intact outer layer of enamel, although it is noted that in the center of the stain there is a decrease in microhardness and an increase in permeability, in particular, for radioactive calcium. Clinical and experimental studies have shown that remineralizing therapy with such changes is ineffective. As a rule, such lesions proceed for a long time and can turn into carious cavities with a violation of the dentin-enamel connection after a few years. With minor foci of pigmentation of the tooth enamel, a dynamic observation is carried out. In the presence of an extensive area of ​​pigmentation, it is possible to prepare the hard tissues of the tooth and seal without waiting for the formation of a cavity. In most cases, grinding of the pigmented area is indicated, followed by remineralizing therapy. General etiopathogenetic therapy of dental caries is prescribed individually, based on the intensity of the lesion and the nature of the course of the pathological process.