practical skills

MINISTRY OF HEALTH OF UKRAINE IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY

PRACTICAL SKILLS

FOR STATE CERTIFICATION OF THE SPECIALTY “DENTISTRY”

Ivano-Frankivsk 2015 1

UDC: 371.315 + 371.322 + 616.314 LBC 56.6 я 73 Р 15 The manual contains a set of practical skills that meets industry standards of education developed and approved by the Ministry of Health and Ministry of Education of Ukraine for specialty “Dentistry”. A manual for students of foreign nationals in the specialty “Dentistry” dental faculties, practical dentists. Practical skills for state certification of the specialty “Dentistry”/ Ozhogan Z.R., BulbukO.I., et al., – Ivano-Frankivsk: Publisher IFNMU, 2015. – 176 p. Authors: Prosthetic Dentistry: Ozhogan Z.R., Kyrylyuk M.I., BulbukO.I., Buherchuk O.V., Mizyuk L.V., Zayats A.R., Sydorenko L.P., Klymiuk Yu.V., Kumgyr I.R., Biben A.V. Pediatric Dentistry: Melnuchyk G.M., Bazalytska A.V., Oktysyuk U.V., Bilyschuk M.V., Mudrik- Goncharuk N.P., Khomyk M.I. Surgery Dentistry: Pyuryk V.P., Prots G.B., Nechyporchuk G.P., Perminov O.B., Tarnavska L.L., Derkach L.Z., Kogut V.L. Therapeutic dentistry: Herelyuk V.I., Neiko N.V., Kukurudz N.I., Ozhogan I.A., Kurbatova S.S., Melnuk N.S., Pavelko N.M., Ilkiv M.M., Kobrin O.P., Melnuk S.S., Plavjuk L.Y., Stashkiv A.I., Chaykivskuj R.V., Shutak K.V.; Authors: Ozhogan Z.R., Bulbuk O.I. Approved by the Academic Council of the Ivano-Frankivsk National Medical University (protocol №4 of 30 March 2015) Approved on first methodic ciclecomissionfrom dental disciplines IvanoFrankivsk Medical University (protocol №6 of 25 March 2015)

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TABLE OF CONTENTS Section 1. THERAPEUTICAL DENTISTRY ……………5 Section 2. PEDIATRIC DENTISTRY …………………...73 Section 3. PROSTHETIC DENTISTRY ………………...111 Section 4. DENTAL SURGERY ………………………....152 Literature .............................................................................175

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Foreword Organization and procedure of state certification in the specialty “Dentistry” in Ivano-Frankivsk National Medical University carried out in accordance with the Laws of Ukraine “On Higher Education”, “On Education”, Regulation “On organization of educational process in higher education”, approved by the Ministry of Education and Science of Ukraine, the Ministry of Education and Science of Ukraine “On introduction of credit-modular system learning process” public education and industry standards and regulations of Ukraine for Education, Regulation of IvanoFrankivsk National Medical University. The final state certification of graduates conducted in IvanoFrankivsk National Medical University and specialties in the direction of Decree of the Cabinet of Ministers of Ukraine and completed degreegranting form for education and training. In accordance with industry standards for higher education standard form state certification of graduates in the specialty “Dentistry” in Ivano-Frankivsk National Medical University is a standardized test and practically-oriented state exam. Practically oriented state exam verifies readiness to graduate to perform real object of future professional activity (human) or model of the object (phantom dummy, situational problem, etc.) production functions that cannot be estimated by standardized testing. The purpose of practically-oriented state test is to evaluate the quality of graduate solution of typical problems and demonstrate relevant skills and abilities in conditions that are close to reality. The test is conducted directly “by the bed (chair) patient” and in specially equipped classrooms and evaluates the ability of each graduate collect complaints and medical history, conduct physical examination of patients draft survey to assess the results of laboratory and instrumental studies, establish and substantiate previous clinical diagnosis, determine treatment strategy, examine efficiency. The guide includes algorithms of practical skills and abilities are based on the list in typical tasks and skills that are brought to practicallyoriented state exam.

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SECTION 1

THERAPEUTICAL DENTISTRY 1. Observation of stomatological patient. 2. Preparation of the carious cavities 2.1. Burs choosing for step-by step preparation of the carious cavity. 2.2. Class I carious’ cavity preparation in a case of simultaneous decay of occlusal and buccal surfaces. 2.3.Class II carious’ cavity preparation in a case of closely situation of adjacent teeth. 2.4. Class III carious’ cavity preparation in a case of free access to cavity. 2.5. Class IV carious’ cavity preparation. 2.6.Creation of additional area at Class IV carious cavity preparation in a case of expressed attrition of cutting edge. 2.7. Creation of additional area at Class IV carious cavity. 2.8. Class V carious cavity preparation (cervical wall of cavity on the level of gingiva). 2.9. Smoothing of Class I – II carious cavities enamel edges when composite is permanent filling material 2.10. Smoothing of Class III – IV carious cavities enamel edges when composite is permanent filling material 2.11. Smoothing of Class V carious cavities enamel edges when composite is permanent filling material 2.12. Smoothing of carious cavities enamel edges when amalgam is permanent filling material. 19 2.13. Class II carious’ cavity preparation using tunnel technique 2.14. Adhesive technique of carious cavity preparation (on example of Class I) 3. Filling of the carious cavities. 3.1. Class I carious cavity filling by amalgam. 3.2. Applying of medical liner on a base of calcium hydroxide (indirect covering of the pulp).

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3.3. Applying of isolating liner (Zinc-Phosphate cement) using as permanent filling material self-curing composite. 3.4. Enamel etching. 3.5. Using of enamel adhesive. 3.6. Total etching. 3.7. Using of IV generation adhesive system. 3.8. Using of V generation adhesive system. 3.9. Applying and layer-by-layer polymerization of light-curing composite filling material. 3.10. Applying of medical varnishes. 3.11. Applying of medical gels. 3.12. Final treatment of light-curing fillings. 3.12.1. Counturing. 3.12.2. Grinding. 3.12. 3. Polishing. 3.13. Final treatment of amalgams. 3.14. Applying and removing of temporary fillings. 3.15. Applying and removing of medical liners. 3.16. Class I small carious cavities filling by floweble composite. 3.17. Class V small carious cavities and small abfractions filling by floweble composite. 3.18. Grinding of light-curing composites by IDENTOFLEX system. 3.19. Polishing of light-curing composites by IDENTOFLEX system. 4. Endodontics. 4.1.Trepanation of crown (incisor or canine), when the tooth is intact. 4.2. Trepanation of crown (premolar), when the tooth is intact. 4.3. Trepanation of crown (upper molar), when the tooth is intact. 4.4. Trepanation of crown (lower molar), when the tooth is intact. 4.5. Trepanation of tooth crown (premolar), when carious cavity is on the contact surface (Class II). 4.6. Trepanation of tooth crown (molar), when carious cavities are on the both contacy surfaces. 4.7. Trepanation of tooth crown (incisor or canine), when carious cavity is on the cervical area. 4.8. Resection of the pulp chamber roof. 4.9. Applying of the devitalizing paste. 4.10. The pulp amputation in permanent tooth (pulpotomy). 4.11. Extarpation of the pulp in permanent tooth.

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4.12. The root canal depth measuring. 4.13. Medicamentous treatment of the root canal. 4.14. “Step-back” technique. 4.15. «Step-down» technique. 4.16. Instrumental treatment (shaping) of curved root canals. 4.17. Impregnation of the root canals. 4.18. Intradental electrophoresis. 4.19. “Central-cone” technique of the root canal filling. 4.20. “Cold lateral condensation of gutta-percha” technique of root canals filling. 4.21. X-ray measuring of the root canals depth. 4.22. Indication of the root canals treatment quality. 4.23. Temporary filling of the root canals. 4.24. Desobturation of the root canal filled with gutta-percha. 5. Methodology of the teeth hard tissues, periodontal tissues and oral mucosa membrane condition evaluation. 5.1. The vital coloration of the tooth hard tissues. 5.1.а. Detection of the tooth hard tissues condition. 5.2. ERT (enamel resistance test). 5.3. СRT (color reaction time). 5.4. Clinical estimation of the enamel remineralization speed. 5.5. Green-Vermillion index 5.6. РМА index. 5.7. Shiller-Pisarev-test 5.8. Formalin-test. 5.9. PI index 5.10. CPITN index 5.11. Examination of the OOM. 5.12. Cytological examination. 5.13. Vital coloration by hematoxylin. 5.14. Nikolsky’s symptom. 5.15. Morphological examination of the OMM 5.16. Pulp-testing. 5.17. Benzidine-test. 5.18. Rotter-test (lingual modification). 5.19. Cytological examination of periodontal pockets composition. 5.20. Bacterioscopic examination of periodontal pockets composition.

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6. The techniques of periodontal tissues and oral mucosa membrane diseases treatment 6.1. Rinsing. 6.2. Bathes. 6.3. Irrigations. 6.3.1. Irrigations with irrigator. 6.3.2. Irrigations with syringe. 6.4. Gingival applications of solutions. 6.5. Gingival applications of ointments. 6.6. Installation of the solutions. 6.7. Installation of the ointments. 6.8. Applying of medical hardening dressings. 6.9. Applying of isolating dressings. 6.10. Coagulation of hyperthrophed interdental papillae. 6.11. Curettage of periodontal pockets. 6.12. Splintage with Glas Span system. 6. 13. Applications on oral mucosa membrane. 6.14. Lubrication of the oral mucosa membrane. 6.15. Aerozol-therapy. 6.16. Medicamentouse and surgical treatment of erosions, aphthes, ulcers, fissures. 6.17. Medicamentouse treatment of hyperkeratosis area. 6.18. Removing of dental deposites by mechanical technique. 1. Observation of stomatological patient. With the aim to take diagnosis and to choose an adequate treatment a dentist has to thoroughly observe a patient. The observation start with questioning, which is consists of complaints of a patient, anamnesis of disease and history of life. A doctor carries out observation of dento-facial area in some sequence, using basic and additional methods of examination, after questioning.

BASIC METHODS OF EXAMINATION QUESTIONING A patient questioning –– first and very important stage of patient examination. Correct questioning allows foreknowing a diagnosis, which has to be improved by objective examinations.

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Complaints. Questioning starts with complaints of patient. It is possible to ask questions, but it will be better request patient to tell, what ails him (her) at the moment. A doctor directs account in needeble course during conversation. Patients visit dentist complaining on pain with some special features most often. A pain symptom at injury of tooth hard tissues, pulp tissue and periodontal ligament. When you ask patient it is necessary to pay attention on features which characterized pain: The character of pain appearance: - a pain can be „spontaneous” – shown up without external irritants (typical for pulpitis and periodontal ligament inflammation), or „causal” – shown up under the influence of external mechanical, chemical and thermal irritants (typical for tooth erosion, caries decay, pulpitis). A character of irritant, which causes a pain, indicates on peculiarity of pathological process and simplify it diagnostics. For instance, if pain appear after “hot” and becomes slight or completely disappear at “cold” contact – one might think about acute purulent pulpitis. Defined contents of food may cause painfull sensations also: pain after sweet, sour or bitter shown up in a case of caries decay. Mechanical workload on tooth leads to pain increasing at inflammatory process in periodontal ligament. Localization and prevalence of pain: - a pain can be “localized” (in separate tooth, or in separate group of teeth), also “non-localized” (a pain acquires indefinite diffuse localization gradually or at once), a pain can irradiate (spread) in direction of trigeminal nerv radicles. Duration of pain: - transitory (pain after irritants in a case of caries, enamel erosion, tooth hard tissues hypersensitivity, which immediately disappear after irritant removing), and prolonged ( pain, which shown up after irritants and does not disappear after they stop; characteristically for pulpitis). - spontaneous pain may appear like pain-attack (typical for pulpitis). Pain-attack can be transitory (several minutes), or prolonged. There are painless periods (intermission) between attacks or periods of pain relaxation (remission). Some times spontaneous pain can be permanent (typical for acute or exacerbate apical periodontitis). Time of pain appearance: - in a case of pulpitis spontaneous pain-attack show-up at night firstly;

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it is typically intensification of pain at night-time (patients which are suffer because neuralgia have pain at day-time only). Besides of pain complaints, patients with hard tissues diseases have esthetic defects (non-carious lesions, initial and superficial caries). Discomforteble sensations, slight pain at biting appear in a case of chronic apical periodontitis. Complaints of patients with periodontal tissues pathology. As usually they complaints on: - bleeding of the gum (during teeth brushing, some times – spontaneous, without any reasons); - pain in gingiva (slight – at chronic process, intensive – in a case of acute and exacerbate; throbbing [pulsing] pain in gingiva appear at case of periodontal abscess); - discoloration of gingiva (bright hyperemia is typical for acute and exacerbate inflammatory processes, cyanotic shade – for chronic, pale gingiva characterized dystrophic processes); - dental deposites (debris, supra- and subgingival tooth tartar [calculus]); - gingival pyorrhea (develops at deep periodontal and bone pockets, intencify in a case of generalized periodontitis exacerbation and periodontal abscesses); - hyperaesthesia of teeth (as a result of gum recession and exposure of the roots of teeth); - halitosis (as a result of dental deposites, periodontal pyorrhea, bad oral hygiene); - teeth mobility (as a result of interdental septas resorption); - change of separate teeth disposition, apearence of diastema and trema (as a result of interdental septas resorption, traumatic occlusion); - change of bite [occlusion] (as a result of significant interdental septas resorption, significant traumatic occlusion); - dysfunction of biting and speaking (as a result of significant interdental septas resorption, significant traumatic occlusion); - general weakness, headache, fever (in a case of acute and exacerbate course of disease); - enlargement of limph nodes (in a case of acute and exacerbate course of disease, periodontal abscesses). It should be noted, that it is typically for periodontal tissues diseases on initial stages – no complaints, or symptoms of diseases insignificant, on that

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patients do not pay attention. Complaints of patient with OMM and red border of lips diseases Typically, patients with pathology of the oral mucosa and red border of lips complain on: - pain in different areas of OMM and red border of lips (arises in the case of inflammatory, allergic processes, at infectious diseases, traumatic lesions, precancer and cancer process); - atypical view of OMM and red border of lips, appearance of rash (primary and secondary lesions development); - burning sensations, itching (arises in the case of inflammatory, allergic processes, at infectious diseases, frequently – in a case of candidosis); - xerostomia (arises as result of diseases, which leads to major and minor salivary glands disorders: atrophic candidosis, lichen ruber planus, lupus erythematosus, diffuse scleroderma, rheumatoid arthritis, diabetes mellitus, etc); - feeling of the mucous membrane “tightness” (at disorders of OMM keratinization, scar involution changes); - gustatory deviations (arise as a result of OMM injury under the influence of micro-currents, at mercurial, lead stomatitis, candidosis, etc.); - halitosis (arise in a case of OMM diseases, which accompanied by necrotic mucosal changes, pyorrhea and pyogenic debris: ulcerativenecrotizing gingivo-stomatitis of Vincent, gangrenous stomatitis, erythema multiforme,etc.); - general weakness, headache, fever (at viral and another infection diseases of OMM, toxic-allergic process); - enlargement of limph nodes (it is typical for infection diseases like AIDS, syphilis, tuberculosis; malignant tumors). Lesions of OMM and red border of lips can be independent, or manifest together with injures of skin, pathology of internal organs and systems. It should be noted, that some diseases of OMM have asymptomatic course and detect during stomatological screening. That concern especially precancer and cancer diseases.

ANAMNESIS OF DISEASE (CASE HISTORY) After complaints it is necessary to take history of disease; make analysis of separate symptoms appearance time, interrelation of disease signs and dynamic of disease in general.

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It needs to carefully question the patient about: - the earliest known manifestations of the disease; - when, on patient opinion, the disease started; - what feuteres of disease course: changing kind of pain, have there been earlier similar manifestations; - how often the patient goes to the dentist? - regular and quality conducted oral hygiene? - taking into account a possible genetic predisposition to certain diseases, it is necessary to find out from the patient, there have been cases of such diseases at his relatives and parents; - if the symptoms of disease were observed by patient before, learn about which diagnosis had been taking, kind of treatment as well as it has been effective. Studing of disease dynamic consists of: - information about patients health condition; - information about patients working capacity before disease; - duration of the illness and peculiarities of initial period; - sequence of the different manifestations of the disease development. Find out, if there were periods of improvement or deterioration, what patients explanations. Physicians should interest not only the facts and symptoms, but the patient’s attitude to these facts. The disease may be exacerbation of chronic or consequence of another disease, suffering even in early childhood. If the patient has documentation of conducted examination and treatment: - extract out the medical history; - skiagraphs; - laboratory tests; - results of special methods of examination; - consultation with other specialists - dentist should be familiar with them. Also clarifies the possible relation of the disease with other diseases, surgery, trauma, etc.. Properly collected and analyzed by a dentist case history provides information about the nature of the disease, the relationship to the pathology of other organs and systems, volume and effectiveness of treatment before.

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ANAMNESIS OF LIFE Anamnesis of life – next stage of patient subjective examination, which gives the opportunity to establish the possible causes of the disease, to conduct differential diagnostics correct, and gives a general idea of the features of the patient organism, which is important for choice of treatment and prevention of disease complications. Collect anamnesis of life using next schema: 1. The disease, traumas, surgery (pay particular attention if the patient is suffering from tuberculosis, sexually transmitted diseases. The doctor should not be limited by statement of illness fact, should also clarify their course characteristics and the presence of complications). 2. General biographical information (where he was born, is not lagging behind in physical development of his (her) peers). 3. Heredity. Family History (health of family members; close relatives, cause of death; the presence of inherited diseases). 4. Conditions of the patient life (poor social - living conditions can influence the development of the disease). 5. Ocupation (information about working conditions and their impact on patient; identification of occupational hazards make it possible to establish the cause of the disease). 6. Character of nutrition (unbalanced diet, deficiency in the diet of vitamins, minerals, proteins, unsaturated fatty acids, carbohydrates prevalence and others factors create conditions, may be causing or aggravating the course of many diseases). 7. Allergological anamnesis (presence of allergic history should be considered when applying medicines and anesthesia). 8. Harmful habits (smoking, alcohol and drug - may be causing or aggravating the course of many diseases). Full history of life as well as data of patient complaints and history of disease enable the physician to take a preliminary diagnosis of the disease, predict its course and possible complications.

PATIENT OBSERVATION After determining complaints, history of illness and life begin to inspection a patient. Observation includes the following steps: А. Extraoral observation. Б. Intraoral observation: а) soft tissues; b) teeth and periodontal tissues.

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Extraoral observation carries out at daylight [natural] illumination. Dentist has to put on gloves and mask. Pay attention on the general condition of patient, configuration of the face (aedema, asymmetry and disproportion), color of skin and lips red border, lesions. Configuration of the face can change at inflammatory process of dentofacial area, tumors, traumas, some endocrine diseases. At hyperfunction of thyreoid gland (exophthalmic [toxic] goiter) it is observed exophtalm and enlargement of thyreoid gland, for example. At nephritis, cardio-vascular diseases – configuration of the face can change as a result of swilling. Aedema of the face may observe at allergic conditions (Quincke’s edema). Configuration of the face changing, aedema or swilling, color of the skin, pigmentations, conditions of the hair and nails help for dentist to take differentiated diagnostics often. Changes of skin and lips red border color can show up as palish, which appear in a case of anemia and kidneys diseases. However, a skin in a case of kidneys anemia is warm, but at hurt diseases - cold. In a case of myxedema skin is pale and wrinkled, epidermis consolidated, etc.. Redness of skin appears at polycythemia (an abnormally increased concentration of hemoglobin in the blood, through either reduction of plasma volume or increase in red cell numbers. It may be a primary disease of unknown cause, or a secondary condition linked to respiratory or circulatory disorder or cancer) and accompanied by vasodilatation. Redness of the face is also observed in alcoholism, due to moderate polycythemia and partial vasodilatation. Color of a face, red border of lips, OMM may be with cyanotic shade. Cyanosis is divided into true and false. True - appears when the blood stored a significant percentage of reduced hemoglobin, as well as longterm administration of drugs (sulfonamides, phenacetin, analgesics). True cyanosis is observed in congenital and acquired heart defects, case of pulmonary disease (emphysema, bronchiectasis, etc.). False cyanosis occurs due to deposition in the skin and mucous membrane derivatives of silver and gold (some schemas of syphilis treatment). Yellowish skin (icteritiousness) varying intensity are observed in the case of liver disease, with anemia (hemolytic and pernicious), chronic enterocolitis, prolonged septic conditions, in patients with cancer pathology, etc. Pigmented mask or hyperpigmentation around the eyes in the

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form of glasses, observed mainly in women and often runs in families. Hyperpigmentation may occur in patients with cirrhosis and thyrotoxicosis (Grave’s disease). Pigmentation of the skin is often observed in pregnant women. In the case of iron deficiency anemia, Addison’s disease, hemochromatosis, Hodgkin’s disease, ovarian dysfunction, avitaminosis B 12, PP, B1, etc.. often found considerable skin pigmentation. Often pigmentation caused by excessive melanin content, and in certain diseases such as hemochromatosis - hemosiderin, chronic porphyria, porphyrin, etc. Examining the skin of face and neck, note presence of lesions (primary, secondary). If any, as well as patient complaints to the appearance of lesions in the mouth, inspect the skin of the body. After extraoral examination determined the elasticity of skin, evaluating the content of fluid in the tissues and blood supply status. For this purpose, take a skin in folds with two fingers (thumb and index), and then release it, in case of normal condition the skin should crack down completely. Further determine the condition of lymph nodes. One should pay attention to: - size; - mobility; - painfulness; - matted together and with the underlying tissues lymph nodes. At palpation of submandibular, ear and posterior neck lymph nodes use such technique: with one hand tilted head of the patient to the chest, and the second consecutively palpate lymph nodes with three fingers. Submental lymph nodes palpate in the same position with your index finger. Cheek, nasolabial, mandibular lymph nodes palpate bimanually: fingers of one hand from the side of the mouth, another hand - outside. Parotid lymph nodes palpate by two - three fingers in the projection of the mandible branch or bimanually on the front edge of the parotid salivary glands.

INTRA-ORAL EXAMINATION The patient is in a sitting position. Removable dentures must be removed. Intra-oral examination start taking RED BORDER AND CORNERS OF THE MOUTH in position closed and open mouth. Determines their color, gloss, consistence. Normally, the red border of lips pink and soft consistency, moderate shiny. There are sebaceous glands in the commissural area of

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mouth (pay attention to the color, the presence of lesions, seals in this area). There are tuberous surface which detects on mucosal part of the lips (that are small salivary glands, localized in lamina propria). That is possible to see punctures – excretory ducts of small salivary glands. Next, carry out examination of the oral cavity VESTIBULE: define the limits of frenulums and folds of mucous, leading lip and cheek forward and up in half-open mouth. Normally frenulum of the upper and lower lip ends on the mucous membrane of the alveolar process, before reaching the gingival margin 5-7 mm. Other end connects to the aponeurosis of musculus orbicularis oris (to note abnormalities in the frenulum attachment, presence of diastemas, the condition of periodontal tissues in the area of abnormally localized bands). There are lateral buccal-gingival folds from the vestibular side in the area of premolars both upper and lower jaw (note height of their attachment, mobility, connection with gingival papillae). Pay attention to the transitional fold (the place of alveolar process’s mobile mucosa transition to the cheek mucosa). It is upper (for maxilla) and lower (for mandible) limit of oral cavities vestibule vault. The vault has a different volume (it is narrow in the front section and expanded in distal direction), with an open mouth due to muscle contraction decreases the vertical size of the vault. Notes the condition of the mouth vestibule mucous membrane (color, consistency, moisture, condition of minor salivary glands, lesions preasence). Determine the depth of the vestibule (measure the distance from the edge of gum to the bottom of vestibule by graded instrument). Vestibule of mouth is shallow if its depth is less than 5mm, medium – 8 – 10 mm, more than 10 mm – deep. Then proceed to inspection of CHEEKS. Using two mirrors, inspect mucous membrane first right, then left cheek from the corner of the mouth to the tonsils. When opening the mouth mucosa is smooth, and at closing of jaws becomes folded. Notes the color, moisture, turgor of mucosa (if any lesions - point this out); pay attention to the condition of the excretory ducts of the parotid salivary glands, which open on the second upper molars. Do not take for abnormalities glands of Fordyce (sebaceous glands, located along the line closing of teeth, as a pale yellow nodules with a diameter of 1-2 mm, which does not rise above the level of mucosa). Examination of GINGIVA. First, examine the buccal and labial surfaces (maxilla - right to left, mandible - left to right). Then examine the lingual and palatal surface of the gums in the same way. Mark the color, consistency, bleeding, gingival sulcus depth, dento-gingival attachment status, condition and outlines of interdental papillae. Normal, clinically healthy gums pale

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pink, moderately moist, palpation painless, elastic consistency. The gingiva tightly cover necks of the teeth, gingival papilla occupied interdental spaces in the cervical area of the teeth, forming “scallops”. Dento-gingival sulcus localized between external surface of tooth crown and internal surface of gingival margine; it depth is about 1 – 1.5 mm, normally, and reach dentogingival junction. If inflammation have noted: character of iflammation (catarrhal, hypertrophic, ulcerative); course (acute, chronic, exacerbate); prevalence (localized, generalized); degree of inflammation. When observed attachment lost and formation of periodontal pockets, necessary to measure its depth with a calibrated periodontal probe (spend at least 4 measurements on each side of the tooth: mesially and distally on the vestibular surface and similarly – on oral; analyzing the values, take into account the maximum depth of the pocket). Determine the presence and nature of the exudate in pockets at the same time. Checks for swelling, fistula, tumor formations. Examination of the ORAL CAVITY PROPER. Primarily carried observation, focusing on color, moisture of mucosa (if there is discoloration, signs of inflammation, lesions indicate that). EXAMINATION OF THE TONGUE. There are tip, body and root of the tongue, upper (back), lower and the side surface of the tongue. There is lymphoid tissue in the form of follicles on the back third of the tongue (lingual tonsil). On the surface of the tongue (especially distal) minor salivary glands ducts open. Lamina propria of mucosal membrane together with epithelium forms the buds (papillae) of the tongue: - filiform (the most numerous, are located over the entire surface of the tongue); - fungiform (as red dots located at the tip of the tongue, to a lesser extent, on the back); - foliaceous (located at the edges of the tongue in the distal, forming small protube-rances that should not be taken for pathology); - circumvallate (located on the border of the root of the tongue and the body as a Roman numeral V). On the lateral surface of the tongue is more or less pronounced vascular venous plexus, which can be mistakenly taken for pathology. Examining the tongue, pay attention to size (note the possible deviations from the norm: macro-, mikroglossia, swelling of the tongue), the presence of

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debris and changes in topography, color of mucosa, consistency and mobility of the tongue. Note the lesions. The bottom surface of the tongue mucosa is more mobile and in the middle part passes to frenulum of the tongue and lines the bottom of the oral cavity. Bottom’s of the oral cavity examination. The mucous membrane that lines the bottom of the oral cavity, forming several folds. Frenulum the tongue is a vertical tuck that connects the lower surface of the tongue with the oral part of the gums. On either side from the tongue’s frenulum submandibular and sublingual salivary glands duct opens; formation on which it opens called caruncula sublingualis (bilateral roll). Feature of oral cavity floor’s mucosa is presence of well-developed submucosal layer with the underlying muscle and adipose tissue, resulting in significant mucosa mobility. That is necessary to note: - color; - vascular [vessel] pattern; - pliability of the mucosa; - attachment of the frenulum of the tongue; - limitation of movements of the tongue; - gingival retraction in case of short frenulum; - condition of major salivary glands ducts (sublingual and submental). Next conduct examination of the soft and hard palate. The mucous membrane of the hard palate tightly connected to the periosteum almost throughout (alveolar area, palatal suture), in specified areas mucosa immobile. In the anterior of hard palate is a small amount of adipose tissue, which makes it a vertical pliability. In the distal third of the palate is well defined submucosa (place of neurovascular bundles out through foramen palatinum minor et major), so specified section has some mobility. That is necessary to determine: condition (intensity, position, color, soreness) of incisal papilla; transversal palatal folds; palatal suture; palatal torus. At the same time determine the height of the palate vault, which depends on the vertical size of the alveolar process (this figure changes at partial or complete adentia) and development of jaws. At the narrow upper jaw - palate vault is high, etc. There are palatal blind holes at both sides of the median palatine suture

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on the border between hard and soft palate. The pale-pink mucosa of hard palate transit to pink-red of soft one along the lines of these holes location (determine color, moisture, lesions of soft palate). That detects contouring of tonsils behind plica pterigo-palatinum (pay attention to their size, color of mucous, signs of inflammation and lesions).

EXAMINATION OF TEETH Determine the status of dental hard tissues, using instruments: dental mirror, explorer, pincer. Visually determine the color, size of teeth, carious or uncurious decay. Spend probing of teeth to determine their integrity, consistency, defects and the sensitivity of hard tissue. With one hand, take a mirror, the other probe and inspect the state of dental hard tissues, showing carious cavities. With the explorer determine depth, size of the cavity, the degree of softening of enamel and dentin. Then hold percussion of teeth to determine the state of the apical periodontium: at first carry out vertical percussion (cutting edge of incisors and canines, oclussal surface of premolars and molars) after that horizontal one by pincer or explorer holder. Details of the patient’s feelings, conducting comparative percussion in adjacent (intact) teeth. Determine mobility of teeth in the vestibulo-oral, mesio-distal and vertical directions with dental pincer. 2. Preparation of the carious cavities. 2.1 Burs choosing for step-by step preparation of the carious cavity. Goal: a reasonable choice of burs ensures accurate carrying out of carious cavity different stages preparation. Equipment: steel, carbide and diamond burs of different shapes and sizes for turbine and contra-angle handpieces. Methodology of conducting: 1. Choose the turbine dimond burs (cylindrical or round-shaped) for opening of carious cavity. Sizes of the burs must comply with the size of the carious cavity orifice, or be a little smaller. 2. Choose the turbine cylindrical burs (for removing of enamel – diamond, dentine – carbide burs of proper sizes) for expending of carious cavity. 3. Choose the contra-angle carbide or steel round-shaped burs of proper

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sizes for necrectomy. ( Do not use reversed-conical or cylindrical burs and instruments of small sizes, to prevent perforation of the pulp chamber fornix). 4. Choose the contra-angle carbide or steel cylindrical, reversed-conical, wheel-shaped or conical-shaped burs for carious cavity formation. 5.Choose the contra-angle or turbine dimond cylindrical or conicalshaped burs for enamel edges smoothing. 2.2 Class I carious’ cavity preparation in a case of simultaneous decay of occlusal and buccal surfaces. Goal: preparation of the Class I carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Make an opening of the carious cavity on the oclussal and buccal surfaces separately by cylindrical dimond bur, following the movements around the perimeter of orifices or by round-shaped dimond bur, providing movements in direction from inside of carious cavity to outside (HS – high speed mode). 2. Make an expending of carious cavity by cylindrical dimond bur, providing movements on perimeter of cavity (HS – high speed mode). 3. Make a necrectomy by excavator, it size must comply with the size of the carious cavity. Place the working part of excavator parallel to the bottom of carious cavity and make coma-shaped movements from centre to periphery; or using carbide round-shaped bur (MS -medium speed mode). 4. Make a formation of carious cavity on occlusal and buccal surfaces separately by cylindrical or reversed-conical diamond burs, following the principles of biological reasonability and technical rationality. 5. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.3 Class II carious’ cavity preparation in a case of closely situation of adjacent teeth. Goal: preparation of the Class II carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting:

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1.Make notches of enamel by reversed-conical or wheel-shaped dimond bur on the occlusal surface. Place the bur on-the-mitre 450 - 900 to the tooth surface. Preparation carring-out in ultra-fast and high speed mode. 2. Make a trepanation of the occlusal surface hard tissues by roundshaped dimond bur, placed it on-the-mitre 450 to the tooth surface (in ultrafast and high speed mode). 3. Make an expanding of trepanation foramen by cylindrical dimond bur, following the movements around the perimeter of the cavity (in ultrafast and high speed mode). 4 Make a necrectomy by excavator, it size must comply with the size of the carious cavity. Place the working part of excavator parallel to the bottom of carious cavity and make coma-shaped movements from centre to periphery; or using carbide round-shaped bur (MS -medium speed mode). 5. Make a formation of the cavity and additional area by reversedconical or cylindrical dimond bur, following the principles of biological reasonability and technical rationality (high speed mode). 6. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.4 Class III carious’ cavity preparation in a case of free access to cavity Goal: preparation of the Class III carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Make an opening of the carious cavity by cylindrical dimond bur following the movements around the perimeter of orifices or by roundshaped dimond bur, providing movements in direction from inside of carious cavity to outside (HS – high speed mode). 2. Make an expanding of trepanation foramen within the contact surface by cylindrical dimond bur, following the movements around the perimeter of the cavity (in ultra-fast and high speed mode). 3. Make a necrectomy by excavator, it size must comply with the size of the carious cavity. Place the working part of excavator parallel to the bottom of carious cavity and make coma-shaped movements from centre to periphery; or using carbide round-shaped bur (MS -medium speed mode). 4. Make a formation of the cavity by reversed-conical or cylindrical

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dimond bur, following the principles of biological reasonability and technical rationality (high speed mode). 5. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.5 Class IV carious’ cavity preparation. Goal: preparation of the Class IV carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Make an opening of the carious cavity from the oral surface, trying to keep most of the vestibular enamel by cylindrical dimond bur, following the movements around the perimeter of orifices or by round-shaped dimond bur, providing movements in direction from inside of carious cavity to outside (HS – high speed mode) 2. Make an expanding of trepanation foramen by cylindrical dimond bur, following the movements around the perimeter of the cavity (in ultrafast and high speed mode). 3. Make a necrectomy by excavator, it size must comply with the size of the carious cavity. Place the working part of excavator parallel to the bottom of carious cavity and make coma-shaped movements from centre to periphery; or using carbide round-shaped bur (MS -medium speed mode). 4. Make a formation of the cavity by reversed-conical, fissured or wheel-shaped dimond bur, following the principles of biological reasonability and technical rationality (high speed mode). Additional retention points formed in the dentin toward the root. Pay special attention to forming the edges of the cavity and the angle of the cutting edge. 5. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.6 Creation of additional area at Class IV carious cavity preparation in a case of expressed attrition of cutting edge. Goal: formation of the Class IV carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Create a notch along the cutting edge of the tooth using a cylindrical

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or wheel-shaped diamond bur. Place the bur parallel to the cutting edge. 2. Make expanding of the notch by cylindrical dimond bur. Place the bur parallel to cutting edge. Provide the coma-shaped movements to vestibular and oral direction. 3. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.7 Creation of additional area at Class IV carious cavity. Goal: formation of the Class IV carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Make formation of additional area on palatal or lingual surface in the form of a triangle, “ Swallow tail”, oval. 2. Make a formation of additional area by reversed-conical or cylindrical diamond bur, following the backward forward movements from main cavity to the center of palatal or oral surface. Follow the requirements: - between the main and additional cavities angle should be 900; - additional area should be 1 mm deeper of dentin-enamel boundary; - additional area should take no more than 1 \ 3 of palatal or lingual surfaces; - additional area width should match the width of the main cavity. 3. Create the retention points in the form of cuts on the inner surface of additional area by reversed-conical or wheel-shaped bur. 4. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.8 Class V carious cavity preparation (cervical wall of cavity on the level of gingiva). Goal: formation of the Class V carious cavities mastering. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, retraction cord, phantom teeth. Methodology of conducting: 1. Make an opening of the carious cavity by cylindrical dimond bur following the movements around the perimeter of orifices or by roundshaped dimond bur, providing movements in direction from inside of carious cavity to outside (HS – high speed mode).

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2. Push the gingival margin by retraction cord. Make an expanding of trepanation foramen by cylindrical dimond bur, following the movements around the perimeter of the cavity (in ultra-fast and high speed mode). 3. Make a formation of the cavity by reversed-conical or fissured dimond bur, following the principles of biological reasonability and technical rationality (high speed mode). Make an acute angle between bottom and walls of cavity. 4. Make a smoothing of enamel edges, according to requariments of filling material, by conical-shaped diamond bur (HS – high speed mode). 2.9 Smoothing of Class I – II carious cavities enamel edges when composite is permanent filling material. Goal: smoothing of the enamel edges technique mastering, when composites are permanent filling material. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, metallic stripes with abrasive sputtering, phantom teeth. Methodology of conducting: Make smoothing of enamel by conical dimond bur in high-speed range, on-the-mitre 450. Adhesive systems of 4-5 generation, allow to not carryout the enamel smoothing or beveling on the occlusal surface (Class I - II), because of thin layer of composite, till 2 mm develops, which is not resistent to jowing pressure. It is enough to create enamel edge according to enamel prisms direction. 2.10 Smoothing of Class III – IV carious cavities enamel edges when composite is permanent filling material. Goal: develop the skills of correct smoothing of enamel edges of the cavities of different classes, while filling them with composite filling materials. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, metallic stripes with abrasive sputtering, phantom teeth. Methodology of conducting: 1. Make smoothing of enamel edges in Class III – IV carious cavities by flame-shaped turbine bur. Bevel make an angle 450; to increase contact of composite with enamel and improve the aesthetic result, increase bevel area by removing the surface layer of enamel on area that is larger than the defect area (the area of the bevel is directly dependent on the area of hard tissue

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defect). On the palatal side bevels make narrower (1-1.5 mm). If the labial edge of Class III cavity is localized on contact surface, then beveled it in this area by abrasive metal strip. It will allow during preparation not damage the adjacent tooth. 2. Adhesive systems of 4-5 generation, allow to not carry-out the enamel smoothing or beveling. It is enough to create enamel edge according to enamel prisms direction.Adhesive systems of generation III need of enamel beveling on-the-mitr 450. It is not obligatory to create enamel bevel on the oral surface (palatal or lingual), if additional retention is not required. 2.11 Smoothing of Class V carious cavities enamel edges when composite is permanent filling material. Goal: develop the skills of correct smoothing of enamel edges of the cavities of different classes, while filling them with composite filling materials. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Conduct the smoothing of enamel edge by conical diamond bur at a high speed range on-the-mitr 450. The total area of bevel and removed superficial layer should correspond to surface of caries defect. If the cervical wall below the gums, or gum level - bevel on this side is not created. Adhesive systems of 4 – 5 generation, allow to not carry-out the enamel smoothing or beveling. It is enough to create enamel edge according to enamel prisms direction. 2.12 Smoothing of carious cavities enamel edges when amalgam is permanent filling material. Goal: develop the skills of correct smoothing of enamel edges of the cavities of different classes, while filling them with amalgam. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: Conduct the beveling of enamel edge by conical diamond bur at a high speed range on-the-mitr 450, when permanent filling material is amalgam of generation I; when permanent filling material is amalgam of generation II or 0 III, conduct the beveling on-the-mitr 70 .

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2.13. Class II carious’ cavity preparation using tunnel technique. Goal: preparation of the Class II carious cavities mastering using of tunnel technique. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Conduct trepanation of enamel on the chewing surfaces using spherical diamond bur, departing at 2-3,5 mm from the contact surface, performing interrupted tangent movements (high-speed mode). 2. Create a “tunnel” in the dentine toward the cavity, using a spherical diamond bur with a long neck (high-speed mode). 3. After reaching the cavity, conduct necrosectomy using spherical steel bur in the medium speed range. 4. Make a formation of the cavity by reversed-conical dimond bur, following the principles of biological reasonability and technical rationality (high-speed mode). 5. Check the cavity through the interdental space. 2.14 Adhesive technique of carious cavity preparation (on example of Class I) Goal: to master the adhesive preparation technique. Equipment: turbine and contra-angle handpieces, dimond, carbide and steel burs for turbine and contra-angle different shapes and sizes, excavators of different sizes, phantom teeth. Methodology of conducting: 1. Make an opening of the carious cavity by round-shaped dimond bur, providing movements in direction from inside of carious cavity to outside – coma-shaped (HS – high speed mode) 2. Make an expending of carious cavity by cylindrical dimond bur, providing movements on perimeter of cavity (HS – high speed mode). 3. Make a necrectomy by excavator, it size must comply with the size of the carious cavity. Place the working part of excavator parallel to the bottom of carious cavity and make coma-shaped movements from centre to periphery; or using carbide round-shaped bur (MS -medium speed mode). 4. Make a formation of the carious cavity by reversed-conical, pearshaped or spherical-shaped diamond bur, rounding off all sides, corners, and walls of cavity (ultrafast mode).

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5. Make a smoothing of enamel edges, according to requariments of filling material, by cylindrical diamond bur (HS – high speed mode). 3. Filling of the carious cavities. 3.1. Class I carious cavity filling by amalgam. Goal: to master of technique - Class I carious cavity filling by amalgam. Equipment: amalgamator, capsules with amalgam, handle and mechanical amalgamtregger, phantom. Methodology of conducting: 1. Take the capsule with amalgam (№1, 2, 3 – depending on cavity size) and load it in amalgamator. 2. Mix the amalgam in amalgamator, exposition according to requirements of producer. 3. Extract the capsule from amalgamator and open it counterclockwise. 4. Fill the mechanical amalgamtregger with amalgam and carry into carious cavity. 5. Condence the amalgam with amalgamtregger, making movements from central part of carious cavity to periphery. Renew the anatomical structure of the tooth. 3.2. Applying of medical liner on a base of calcium hydroxide (indirect covering of the pulp). Goal: to master the technique of working with medical liner on a base of calcium hydroxide (technique of indirect pulp caping). Equipment: set of self-curing or light-curing liner on a base of calcium hydroxide, plastic spatula, plugger of small size or explorer, phantom. Methodology of conducting: 1. Apply a thin layer of medical liner for nearpulp area or on the deepest place of cavity, pointwise, by plugger number 1 or explorer (odontotropic materials exhibit poor adhesion to dentin, so do not cover the entire bottom) and polymerize it. 2. Avoid getting material on the walls of the cavity, in case of contact - carefully remove. 3. Technique of self-curing liner preparation: squeeze out basic and catalyst paste on mixing notepad in equal amounts and mixed them with a plastic spatula for 15-20 seconds. 4. The prepared paste apply in cavity as described above.

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3.3. Applying of isolating liner (Zinc-Phosphate cement) using as permanent filling material self-curing composite. Goal: to master the technique of isolating liner applying (Zinc-Phosphate cement) when the permanent filling material – self-curing composite. Equipment: Zinc-Phosphate cement, chromium-plated or nickelplated steel spatula, glass plate for mixing, phantom. Methodology of conducting: 1. On a smooth surface of mixing glass, apply a few drops of cement liquid (depending on the amount of needed filling material). 2. Put cement powder at some distance from the liquid with a spatula (dosing spoon) and divide it into four equal parts. 3. Consistently add parts of powder to liquid (and not vice versa) and mix to obtain a homogeneous filling mass. Conduct mixing by chromiumplated or nickel-plated steel spatula. Mixing time - 60-90 sec. Consistency of filling mass – pasty. Consistency a well prepared filling mass for isolating lining shall be such, that when a spatula detachment from filling material, it is not stretched over it, and tear off, forming teeth to 1 mm in height. 4. Apply the cement in to the cavity by several (one, two, three) portions using smoother. Each portion condence by plugger and spread evenly on walls and bottom. The level of isolating liner - till enamel-dentine border. The thickness of liner – 1,0 – 1,5 mm. The isolating liner should not reach enamel. Zinc-Phosphate cement begin to harden in 3-4 minutes after mixing, complete solidification via - 6-10 minutes. If cement is equipped by dosage spoon, then dosing it according to instructions of producer. 3.4. Enamel etching. Goal: to master the technique of enamel etching. Equipment: etching gel, glass plate, microbrush, disposable syringe, phantom. Methodology of conducting: 1. Unscrew the syringe cap with gel for etching and replace it with a cannula. 2. Squeeze out a drop of gel on the glass plate to ensure proper operation of the syringe and prevent “discharging” of gel due to the appearance of air bubbles. 3. Apply gel to the enamel, covering all areas of the bevel, not capturing the dentin.

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Exposure 15-30 sec. (time begins after full cover of enamel edges by gel). 4. Carefully rinse and dry the cavity (15-30 sec washing time). 3.5. Using of enamel adhesive. Goal: to master the technique of work with enamel adhesive. Equipment: enamel fdhesive, plastic cups for adhesive, microbrush, phantom. Methodology of conducting: 1.Drop into the plastic cup basic and catalyst liquid in the ratio 1:1. 2. Mix them with a microbrush for 10-15 seconds. 3. Apply a mixture of pre-prepared surface of enamel, dentin, liner. Exposure 15sec. 4. Evenly spread by a weak jet of air. 5. Wait for 45 seconds 3.6. Total etching Goal: to master the technique of tooth hard tissues total etching. Equipment: etching gel, glass plate, microbrush, disposable syringe, phantom. Methodology of conducting: 1. Unscrew the syringe cap with gel for etching and replace it with a cannula. 2. Squeeze out a drop of gel on the glass plate to ensure proper operation of the syringe and prevent “discharging” of gel due to the appearance of air bubbles. 3. Apply gel to the enamel, covering all areas of the bevel, not capturing the dentin. Exposure 30 sec. (time begins after full cover of enamel edges by gel). 4. Apply the gel on dentin and evenly spread it with a microbrush on the surface (exposure 15sec.). 5. Carefully rinse and dry the cavity (15-30 sec washing time). 3.7. Using of IV generation adhesive system. Goal: master the technique of adhesive system IV generation use. Equipment: adhesive system, plastic cups, microbrush. Methodology of conducting: 1. Apply primer with a microbrush to clean, wet dentin.

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2. Wait 15 sec., then divide it by weak jet of air (2-3 sec.). Prepared surface should be slightly moistened, with no excess liquid. 3. Apply the layer of adhesive to the surface treated by primer, using a new microbrush. 4. Wait 10 sec., and then evenly spread by a weak jet of air. 5. Polymerize 10-20 sec. by ultraviolet light (covered surface should shine). 3.8. Using of V generation adhesive system. Goal: master the technique of adhesive system V generation use. Equipment: adhesive system, plastic cups, microbrush. Methodology of conducting: 1.Apply the first layer of adhesive with a microbrush on pre-prepared surface (enamel and dentin), the exposition - 15sek. Remove excess of adhesive by weak jet of air. 2. Polymerize 20 sec. by ultraviolet light. 3. Apply the second layer of adhesive with a microbrush on preprepared surface (enamel and dentin), the exposition - 15sek. Remove excess of adhesive by weak jet of air. 4. Polymerize 20 sec. by ultraviolet light. Treated dentin surfaces should be shiny, “wet” view. 3.9. Applying and layer-by-layer polymerization of light-curing composite filling material. Goal: to master the technique of layer-by-layer applying and direct polymerization of light-curing composite. Equipment: set of light-curing composite filling material, steel or plastic pluggers and smoothers, photopolymer lamp, phantom. Methodology of conducting: 1. Squeeze out any portion of a composite material from lightproof syringe (turning the piston of syringe- clockwise) on a plastic plate covered with a special transparent red cap. 2. Insert a small portion of the material in the prepared cavity with special plastic or steel modeling instruments. If the composite pre-packed in capsules, squeeze out material directly into the cavity using a special “pistol”. 3. Carefully condensed applied material by plugger, smoother or modeling instrument so that under it not turned out vesicles of air. The condensation should start from the center of portion and to the periphery by

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concentric movements. The one portion of material should ensure formation of a layer not more than 1-2 mm in thickness. Try not to place layers of composite horizontally but obliquely relative to the bottom of cavity (“technique of triangles or Christmas tree”). 4. Spend photopolymerization of composite portion. The exposition 20 – 40 sec. The first lighting (10-20 sec.) should be on hand, to which will be most attached filling material, through, hard tissues (direct polymerization), second lighting (10-20sec.) – perpendicularly (final polymerization). Fill the cavity by portions (layers 1-2 mm). 5. Insert a new portion of composite perpendicular to the previous. Make polymerization. Repeat manipulation to full fill cavity. 3.10. Applying of medical varnishes: Goal: applying of fluorine-containing varnishes carry out for remineralization therapy and increasing of teeth resistency (remineralization therapy, prophylaxis of caries decay). Equipment: fluorine-containing varnish ( “Bifluorid-12”( Voko)); microbrush, plastic or wooden stick, glass plate, phantom, cotton tampons and rolls. Methodology of conducting: 1. Make an isolation of teeth by cotton rolls, dry by cotton tampons and jet of warm air after professional hygiene. 2. Apply several drops of varnish to the smooth surface of glass plate. 3. Apply on all surfaces of teeth fluorine-containing varnish using microbrush, plastic or wooden stick (start from mandible teeth), protect the OMM against varnish. 4. Patient doesn’t close the mouth during 3-4 minutes, for the rapid during of varnish; some times you may use chip-blower. 5. Repeat the procedure 2 – 3 times, for improving of evenly spread of varnish. 6. Recommendations for patient: to not eat 2 hours after procedure; to take only fluid and soft food during one day; to not brush the teeth in the evening. Floorcoverings produce three times at intervals of 2-3 days depending on the activity of caries : at І degree – 2 times per year, at ІІ degree - 4 times per year, ІІІ degree – 6 – 12 times per yer.

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3.11. Applying of medical gels: Goal: applying of fluorine-containing gels carry out for remineralization therapy and increasing of teeth resistency (remineralization therapy, prophylaxis of caries decay).. Equipment: fluorine-containing gels (“Elmex”, 1-2 % sodium fluoride on 3 % agar), microbrush, contra-angle handpiece, cotton rolls. Methodology of conducting: 1. On all surfaces of pre-cleaned, isolated from saliva and dried teeth we applyed thin layer of gel by brush. 2. First, treat the teeth of the mandible, and then - the maxilla. 3. Then rubbing gel with the brush and contra-angle handpiece in the low speed range for 1 - 2 min.,and dry with air jet. 4. The course is about 3-5 applications 2 times per year. 3.12. Final treatment of light-curing fillings 3.12.1. Counturing. Goal: to master of skill: countering of light-curing fillings Equipment: adequate illumination, medical tray with a set of instruments, gloves, mask, the set of diamond heads with red, yellow and white marking, the knife for composite materials, articulating paper, contraangle handpiece, retraction cord. Methodology of conducting: 1. Detect excess of filling material using articulation paper. 2. Remove detected excess of filling material immediately after filling by fine-grained diamond burs of various shapes, depending on the anatomical shape of the tooth, using one by one bur with the red, yellow, white markings and handpiece with water cooling. 3. Quality of passage “filling-tooth” test by probe. Probe should be free to slide on the surface. 4. The remaining material from the oral surface removes by knife for composites in the direction from the enamel to fillings. 5. Remove the material remains on the contact surfaces by thin conical bur. 6. In cervical area counturing of restoration should be careful, not to injure the soft tissue, with this aim used retraction cords. Again, check the filling by occlusion. 3.12.2. Grinding. Goal : to master of skill: grinding of light-curing fillings.

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Equipment: the set of disks and contact-stripes «Soft-Lex» producer 3М, dental flosses, photopolymer lamp, adhesive system. Methodology of conducting: 1. For the grinding use the disks and contact strips «Soft-Lex», 3M. 2. Treatment is start by disc of black color and with yellow finish. 3. While working the surface of filling should regularly moisten and conduct work by shorter intermittent movements. 4. To finish the the contact surfaces use the strips of different dispersion from the dark green, orange-white to light green. Enter a strip in the interdental space in a place free from abrasive, pressed to restoration and make a progressive movements. 5. Quality check of dental flosses. The floss must pass through the contact point with a force and easy to slide on the contact surface. 3.12. 3. Polishing. Goal: to master of skill: polishing of light-curing fillings. Equipment: adequate illumination, mask, gloves, medical tray with a set of instruments, contra-angle handpiece, foam rubber microbrushes, polishing pastes «Enhance» by Dentsplу, photopolymer lamp. Methodology of conducting: 1. Polish of brushes and “cups” with polishing pastes at low revs. 2. Start polishing with paste “Prizma Gloss” for 60 seconds of each surface. 3. Finish by the paste “Prizma Gloss Extra Fine” for 60 seconds of each surface. 4. Regularly moisturize the surface with water. 5. Check the quality of restoration. Polished surface should have a mirror shine and brilliance does not differ from tooth enamel. 3.13. Final treatment of amalgams. Goal: to master of skill: the final treatment of amalgam filling. Equipment: pluggers, smoother, semilunar probe. Burs for grinding and polyshing, steel polishing heads, rubber and felt heads, interdental stripes, microbrushes, pastes. Methodology of conducting: 1. Perform a rough modeling of fillings with a cotton balls, plugger and smoothers (separate spatules), control the occlusion. 2. After removing the wedge and the matrix, remove overhanging edges of fillings by narrow sharp sickle scalers, form the pites and fissures. 3. To finish in 24 hours, using carbide heads, the finishing burs, metal polishers, rubber caps, metal stripes.

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3.14. Applying and removing of temporary fillings. Goal: to master of skill: applying and removing of temporary fillings. Equipment: glass plate, medical tray with a set of instruments, artificial dentine and dentine-paste, distilled water, cotton rolls. Methodology of conducting: 1. Isolate the tooth and dry carious cavity. 2. Mix artificial dentin, insert by one portion in the carious cavity, and condense with a cotton ball. 3. Dentin-paste inserts with smoother by one or more portions and condenses with cotton. 4. Remove by rotary instruments at low-speed range or by ultrasonic device. 3.15. Applying and removing of medical liners Goal: to master of skill: applying and removing of medical liner Equipment: glass plate, medical tray with a set of instruments, medical liner, artificial dentine, distilled water, cotton rolls. Methodology of conducting: 1. Isolate the tooth and dry carious cavity. 2. Apply the medical liner on the bottom of cavity with plugger. 3. Cover the liner by cotton ball. 4. Mix artificial dentin, insert by one portion in the carious cavity, and condense with a cotton ball. 5. Remove by rotary instruments at low-speed range or by ultrasonic device. 3.16. Class I small carious cavities filling by floweble composite. Goal: to master of skill: Class I small carious cavities filling. Equipment: syringe of floweble composite with adapter, dental explorer, plugger and smoother of small sizes, photopolymer lamp, phantom. Methodology of conducting: 1. Attach the adapter to the syringe. 2. Enter the adapter into the prepared carious cavity and apply a small portion of floweble composite material. Thickness of filling material’s layer should not exceed 2 mm. 3. Wait when the material evenly fills the entire cavity, if necessary, dispense the material by probe, plugger or smoother additionally. Control and prevent the formation and inclusion of air bubbles in the material.

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4. Conduct photopolymerization of the material’s input portion (20 – 40 seconds). Lighting can be made perpendicular to the surface of the material entered in. 5. If necessary, insert, and polymerize additional portion of composite material to fully fill the cavity. 3.17. Class V small carious cavities and small abfractions filling by floweble composite. Goal: to master of skill: small cervical carious cavities filling. Equipment: syringe of floweble composite with adapter, dental explorer, plugger and smoother of small sizes, photopolymer lamp, phantom. Methodology of conducting: 1. Attach the adapter to the syringe. 2. Insert a small portion of floweble composite by clicking on the plunger of the syringe on the outer edge of prepared cavity (in the teeth of the mandible) or gingival edge of cavity (in the teeth of upper jaw). 3. Wait when the material evenly fills the entire cavity, if necessary, dispense the material by probe, plugger or smoother additionally. Thickness of filling material’s layer should not exceed 2 mm. 4. Conduct photopolymerization of the material’s input portion (20 – 40 seconds). Lighting can be made perpendicular to the surface of the material entered in. 5. If necessary, insert, and polymerize additional portion of composite material to fully fill the cavity. 3.18. Grinding of light-curing composites by DENTOFLEX system. Goal: to master of skill: grinding technique with different rubber heads (for example: Have producer). Equipment: rubber heads for composites “Identoflex” cup-shaped, flame-shaped, disc-shaped (yellow color). Methodology of conducting: 1. Grind the concave and occlusion surfaces by the flame-shaped rubber polishers. 2. On convex, interdental surfaces, fissures and thin edges – by the cup-shaped. 3. The convex surfaces of front teeth by the disk-shaped polishers. Every surface should work out up to 40 seconds by the rotary heandpiece with a maximum number of revolutions per minute 3000.

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4. The quality of the work check with explorer, and on the contact surfaces by interdental floss, which should easily slide over the surface of the tooth. 3.19. Polishing of light-curing composites by IDENTOFLEX system. Goal: be able to complete the work with composite materials at the stage of polishing. Equipment: polishers for composites Identoflex of gray and white color, cup- and disc-shaped. Methodology of conducting: 1. First, conduct the polishing by polishers of gray color, on all surfaces of fillings in 40 seconds. 2. After that by polishers of white, provide a mirror shine on all surfaces. 3. To work by rotary heandpiece with a maximum number of revolutions per minute 3000. 4. Endodontics: 4.1. Trepanation of crown (incisor or canine), when the tooth is intact. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2.Make an isolation of tooth. 3. Make the notch of tooth enamel in place of trepanation: on lingual surface in the middle of the crown by conical-shaped or reverse-conical diamond burs. 4. Trepanation of the tooth crown perform according to projections of pulp chamber at high speed by spherical-shaped bur close to the cutting edge. During the preparation direction of bur must comply with the axis of tooth, and looks like crossing the tooth cavity in its center. 5. After trepanation expand the hole with spherical or cone-shaped (cylindrical) burs to create better access to the root canal. Trepanation hole should not destroy the integrity of the cutting edge.

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4.2. Trepanation of crown (premolar), when the tooth is intact. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2.Make an isolation of tooth. 3. Make the notch of tooth enamel in place of trepanation: on the oclussal surface in transversal sulcus surface by conical-shaped or reverseconical diamond burs. 4. Trepanation of the tooth crown perform according to projections of pulp chamber at high speed by spherical-shaped bur. 5. Further preparation, conduct from occlusal surface parallel to the longitudinal axis of tooth. The tooth cavity of upper premolar is shaped like an oval, slender in the buccal-palatal direction (from cusp to cusp), so preparation performs from the fissure in the buccal-palatal direction. 4.3. Trepanation of crown (upper molar), when the tooth is intact. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2.Make an isolation of tooth. 3. Make the notch of tooth enamel in the area of medial fissure, which separates buccal-mesial cusp by reverse-conical or conical-shaped diamond burs. 4. Trepanation of the tooth crown perform according to projections of pulp chamber at high speed by spherical-shaped bur. 5. During the preparation must take into account that the first and second molars of the upper jaw with Medio-distal compression of pulp chamber, which is located closer to the medial part of the tooth. Form of access to the cavity of the tooth will look like a triangle (in the first molar - equilateral, and the second molar - a right triangle).

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4.4. Trepanation of crown (lower molar), when the tooth is intact. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2. Make an isolation of tooth. 3. Make a cutting on tooth enamel in the longitudinal sulcus closer to the buccal-medial cusp by reverse-conical or cone-shaped diamond bur. 4. Trepanation of the tooth crown perform according to projections of pulp chamber at high speed by spherical-shaped bur. 5. Further preparation, conduct from in distal direction, parallel to the longitudinal axis of tooth. 6. After trepanation expand aperture by spherical-shaped or coneshaped (cylindrical) bur to create better access to the root canals. In the first lower molars it is marked a significant breadth of one distal root canal or two different distal root canals, that is why, form of access to the cavity of the tooth will looks like a trapezoid. The second and third molars have only one distal root canal, so a form of access to the cavity of the tooth is triangular. 4.5. Trepanation of tooth crown (premolar), when carious cavity is on the contact surface (Class II). Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2. Make an isolation of tooth. 3. Take out the carious cavity on occlusal surface, cutting of enamel roll by round-shaped bur (high-speed range), using of turbine handpiece or contra-angle with raise reduction. 4. Make a futher preparation on occlusal surface to buccal-palatal direction, take in consideration the localization of pulp chamber. 5. Expand already prepared cavity by round-shaped or conical-shaped

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bur, for removing of overhanging enamel edges and creation of better access to root canals. 4.6. Trepanation of tooth crown (molar), when carious cavities are on the both contacy surfaces. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2. Make an isolation of tooth. 3. Make preparation and subsequent filling of the carious cavity on distal surface firstly. 4. Take out the carious cavity from mesial surface on occlusal one, cutting of enamel roll by round-shaped bur (high-speed range), using of turbine handpiece or contra-angle with raise reduction. 5. Make a futher preparation on occlusal surface, take in consideration the localization of pulp chamber. 6. Expand already prepared cavity by round-shaped or conical-shaped bur, for removing of overhanging enamel edges and creation of better access to root canals. 4.7. Trepanation of tooth crown (incisor or canine), when carious cavity is on the cervical area. Goal: be able to create optimal access to pulp chamber for further endodontic treatment. Equipment: turbine handpiece, contra-angle handpiece with raise reduction of speed till 100000 rotations per min., revers-conical, sphericalshaped, conical-shaped diamond and carbide burs. Methodology of conducting: 1. Conduct anesthesia of tooth. 2. Make an isolation of tooth. 3. Make a preparation and filling of the cervical carious cavity under the rules. 4. Make a cutting on tooth enamel in the place of trepanation from the middle of crown’s tongue side by cone-shaped or reversed-conical diamond bur.

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5. Trepanation of the tooth crown perform according to projections of pulp chamber at high speed by spherical bur close to the cutting edge, using the turbine or micromotor handpieces with high reduction rate. While preparation the direction of bur must comply with the axis of the tooth. 6. After trepanation expand the hole by spherical-shaped or conicalshaped (cylindrical) bur to create better access to the root canal. Trepanation hole should not destroy the integrity of the cutting edge. 4.8. Resection of the pulp chamber roof. Goal: be able to create best of all access to the root canals, for prevention of endodontic instrument break off. Equipment: contra-angle handpiece with speed of rotation till 30000 per min, revers-conical, spherical-shaped, conical-shaped diamond and carbide burs, endoburs (hard-steel or diamond – cilindrical, conical-shaped with safe tip (Batt)). Methodology of conducting: 1. Carry out trepanation (perforation) of the pulp chamber roof on 10000 per min rotations by spherical-shaped burs №2, №4. 2. Make resection of the pulp chamber roof by conical-shaped bur following the movements around the perimeter of orifices or by roundshaped dimond bur, providing movements in direction from inside of pulp chamber to outside. 3. Use the endodontic burs with Batt-tip, to prevent perforation of the pulp chamber floor in multyroot teeth. It is consider that the pulp chamber opened and shaped correctly, when gradient junction between prepared carious cavity and pulp chamber has improved; free access to the root canals orifices is present. 4.9. Devitalizing paste application. Goal: be able to impose of devitalizing paste, for the most complete removal of the pulp when contraindications to the use of vital treatments. Equipment: devitalizing paste, sterile cotton balls, filling material for temporary fillings, glass plate, metallic spatula, smoother. Methodology of conducting: Devitalizing paste application carries out by three ways: 1) directly on the open horn of the pulp; 2) near the open horn of the pulp; 3) application of the devitalizing paste on a cotton ball.

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1. When applying the devitalizing paste on the pulp horn, the causal tooth must isolate from the oral liquid. For this purpose, use cotton rolls, saliva ejector and cofferdam. 2. After overlaying of devitalizing paste in cavity, insert a small cotton ball with anesthetic medication to reduce pain, caused by stimulating action of the paste on the pulp. 3. Mix the temporary filling material (water dentin) and apply it in cavity gently using smoother, without pressure to hermetically close and not displace the devitalizing paste. 4.10. Pulp amputation in a permanent tooth (pulpotomy) Goal: removal areas of focal inflammation in coronal pulp and preservation of the radicular pulp viability. Equipment: excavators of different sizes, antiseptic solutions, cotton, phantom tooth. Methodology of conducting: 1. After removal of the pulp chamber roof, slowly promote sharp excavator (carefully selected according to the size of cavity) on the side wall of the cavity, in direction to the root canals orifices; 2. “Row-shaped” or (“scooping”) movements with turning at 90 degrees use for cuts the coronal pulp; - make irrigation of the tooth cavity with warm antiseptic solution during manipulation ( 2% chlorhexidine ); 3. Cult of the pulp covers with treatment or odontothropic paste after vital amputation. 4. Cult of the pulp covers with mummifying or metaplastic paste. 4.11. Extirpation of the pulp in permanent tooth: Goal: surgical removing of the pathologically changed radicular pulp. Equipment: pulp extractors of different sizes, Peeso-reamers, antiseptic solution 2% chlorhexidine), phantom tooth. Methodology of conducting: 1. Make amputation of the pulp in accordance with generally accepted 2. Opening of the root canals orifices by Peeso-reamers. 3. Removing of the orifice pulp by round-shaped burs of proper sizes. 4. Extirpation of the pulp: - In the bath with antiseptic pulp extractor of appropriate size (we select it considering the length of root and root canal diameter) insert to the root

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canal by corkscrew movements to sense light resistance. - Then with little effort “pull up” of pulp extractor to 1 ml back, turn of it 1-2 times around axis, and then extract with the twisted on his pulp. - If the pulp didn’t remove by one cord, the procedure should be repeated. Take each time new pulp extractor. - In single-root teeth, given the lack of a clear separation in coronal and radicular pulp, amputation and extirpation of the pulp hold simultaneously using pulp extractor. 4.12. The root canal depth measuring. Goal: be able determine the length of the root canal for further high quality endodontic treatment. Equipment: table of average data calculated length of the tooth and root, depth gauge (К-reamer, К-file) with rubber stoper, endodontic ruler or endo-block. Methodology of conducting: 1. On the endodontic instrument (depth gauge for example) by rubber stopper and endodontic ruller check the length, which corresponds to calculated length of the tooth (average length of root canal). 2. Enter selected endodontic instrument in root canal to stop feeling. If after instrument’s entering into the channel, stopper reaches the cutting edge or occlusal surface, then the tip of the instrument within the apical foramen. If the stopper does not reach the cutting edge or occlusal surface of the tooth is necessary to keep passing the root canal. 3. If after instrument’s entering into the channel, stopper reaches the cutting edge or occlusal surface, but there is no stop filling, probably, that you have passed apical foramen (wide apical foramen) or root canal length greater than the average data indicated. 4.13. Medicamentous treatment of the root canal. Goal: be able to hold medicamentous treatment of root canal to clean and reduce microbial contamination of pathogenic flora, preventing infection of periapical tissue Equipment: endodontic syringe for 5 ml, endodontic needle for rinsing with lateral port, paper pins, solutions of antiseptics (sodium hypochlorite 5,25 %, chlorhexidine 2%), dental pincer, set of rubberdum, cotton rolls. Methodology of conducting: 1. Draw the antiseptic solution in endodontic syringe.

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2. Connect the endodontic syringe with endodontic needle. 3. Mark on endodontic needle working length of root canal with rubber stoper. 4. Make isolation of tooth with rubberdum or cotton rolls 5. Enter the endodontic needle into the root canal before reaching 2 mm of the working depth. 6. Gently press the plunger of the syringe by the index finger to prevent the withdrawal of antiseptic out of the apex. 7. Avoid falling antiseptic on the mucous membrane. 8. Never use one syringe to various antiseptics. 9. In the same way rinse the root canal with distilled water. 10. Dry the root canal with paper pin of appropriate size 11. Medicament treatment perform to absolute purity (if possible) the root canal. 12. Quality of root canal clean is estimated to cleanliness of rinsing solution after use 4.14. “Step-back” technique. Goal: to master the technique of root canal instrumentation using “step-back” technique. Equipment: К-reamers, К-files for direct root canals (10-40 sizes), to slightly curved - flexikat files, endodontic ruler (or endo-block), GatesGlidden burs, contra-angle handpiece. Methodology of conducting: 1. At the selected files of small sizes (10-25 size ISO) using silicone stoppers, check the working length of root canal, which you have to pass till apical foramen. 2. Start the treatment with small (10 size) K-file by typing it with rotary movements to the whole working length of the canal to the apex. Bring out the file by sawing-shaped movements. 3. Then, the same manipulation conduct with endodontic instrument of next size (15), returning to the previous for removing of dentinal shavings. The following sequence of instruments sizes that is used: 10-15-10-20-1525-20. 4. So, make expending of the root canal for whole working length, till 25 size of instrument as minimum (it is minimal file, which provide for good cleaning and obturation of the root canal’s apical part). 5. Insert K-file 30 in to the root canal after apical part instrumentation

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with K-file 25. The working length of K-file 30 for 1 mm less, then last apical file (25) and make instrumentation of middle part of root canal. 6. With this aim insert each next size of instrument for 1 mm shorter then previous working length. For example, if the working length of cannal 20 mm, 30 size of the file imposed on the length of 19 mm, 35 size - 18 mm, 40 size - 17 mm. After each increase in size of the file you need return to the original size, which completed the formation of the root canal apical part. 7. Coronal and middle part of root canal expand by the appropriate size of burs type Gates-Glidden and Pesso (Largo) reamers N1, 2, 3. Enter the bur into a direct part of the root canal, turn on micromotor and in twisting moment output Gates-drill burr from the root canal, removing all small benches in the root canal. With a significant expanding of root canal the walls strength decreases. 4.15. «Step-down» technique. Goal: to master the technique of root canal instrumentation using “step-down” technique. Equipment: К-reamers, К-files for direct root canals (10-40 sizes), to slightly curved - flexikat files, endodontic ruler (or endo-block), GatesGlidden burs, contra-angle handpiece. Methodology of conducting: 1. The orifice of canal fill with solution of sodium hypochlorite, file N 35 insert in the cannal till stop and fix its length. 2. Than on the same length conduct instrumentation by burs like Gates-Glidden № 1 and continue till №3 as minimum. 3. Once enter the file 30 into cannal till stop, fix it length and make preparation of this part by irreversible movements. 4. Carry out instrumentation of canal to guide the apical area, gradually reducing file sizes. 5. Conduct precise definition of root canal length. 6. Apical part gradually expand to the file 25, using the technique of “step-back”. 7. Smooth the walls by H-files 30-35 4.16. Instrumental treatment (shaping) of curved root canals. Goal: be able to perform instrumental treatment of curved root canals to prevent lateral perforations.

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Equipment: NiTi-files (15-40), flexicat-files (15-40), profiles, endodontic handpiece. Methodology of conducting: 1. After the working length of the tooth have been check, choose a file according to the diameter of root canal and enter the endodontic instrument into the canal until you feeling weak resistance. 2. Rotate the instrument clockwise by 900 for passage into cannel. At the same time goes a partial removal of the nearwalls dentin. 3. Press your finger on the file into apical direction to lock it at that depth; rotate the file for 1200 counter-clockwise (reverse direction). It is important that the pressure on the file was such that made it possible to file rotation on the same level. 4. Then output file with dentin from canal, clearing it and rinse canal. Then conduct instrumentation of cannal for full length, not reaching 1-1.5 mm till apical constriction. 5. The above mentioned instrumentation of the root canals may be repeated by the files with gradually enlargement of their diametr (30 - 45). 4.17. Impregnation of the root canals. Goal: Mummification of the pulp rest in the inpassible root canals. Equipment: solution of formaline, powder of resorcine, metallic spatula, Miller’s broach, papers pins, stomatological pincer, cotton rolls, artificial dentine, glass plate. Methodology of conducting: - isolation of tooth with cotton rolls; - drying of the tooth cavity using cotton rolls and pincer; root canals with paper pins; - several drops of formaline apply on glass plate, add some cristalls of resorcine till saturation and spread well - apply a drop of resorcin-formaline solution on the orifice of the root canal with pincer and systematically incite its with a needle, displacing air bubbles, repeat manipulation for the other canals - cotton ball (ball size must be less than the cavity volume), soaked in resorcin-formaline liquid, introduced into the cavity of the tooth; - close tooth tight with water dentin bandage. If impregnation hold the tooth in the maxilla the patient should placed in a horizontal position. Using a combined method of pulpitis treatment, firstly provide obturation of passible root canals and make impregnation of impassable after that.

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4.18. Intradental electrophoresis. Goal: improve the efficiency of endodontic treatment in the processing of infected, hardly passable (curved) cannals. Equipment: potassium iodide 10 % solution, device for electrophoresis, cotton rolls, dental wax, metallic spatula, matches, alcohol lamp, artificial dentine or dentine-paste. Methodology of conducting: - isolate the tooth from saliva with a cotton rolls, dried with jet of warm air, - put in the prepared cavity cotton ball soaked in a solution of potassium iodide (squeeze), and the active electrode. - tooth cavity sealed with wax (pre-heated over the flame of spirit lamp). - Iodine preparations is injected with a negative pole, the current strength 2.3 mA, duration of procedure 15 - 20 minutes. - remove wax and cotton ball, close the tooth tight with bandage of artificial dentine or dentine paste. 4.19. “Central-cone” technique of the root canal filling. Goal: be able to fill root canal by filling material and pin. Equipment: filling material for root canal (siler), pins (filler - guttapercha pins) paste injector type Lentulo, glass plate (or a paper notebook), spatula. Methodology of conducting: 1. Before the root canal obturation, choose a pin of desired size (it should be size of the last instrument for the apical part of root canal expansion). On that pin mark the working length of root canal. 2. In the prepared, dried canal insert filling material (siler) using paste injector or root broach. After that, enter the pin into canal, which previously dipped in siler, and push it to the top of the root canal with tweezers. 3. Remove the excess of forced out canal filling material, and the base of gutta-percha pin cut by heated excavator. 4. Make a vertical condensation of filling mass in orifice part of canal. 4.20. “Cold lateral condensation of gutta-percha” technique of root canals filling. Goal: be able to fill root canal and its branch by cold lateral condensation of gutta-percha. Equipment: standard gutta-percha pins - cones, gutta-percha custom

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pins, filling material for root canal (siler) spreader of different sizes, pincer, a glass plate (or a paper notebook), spatula, spirit lamp, excavator for cutting pins. Methodology of conducting: 1. Before filling of root canal, incert the spreader to make sure its passableness. It should be up to a distance of about 1-2 mm from the apex of the root. 2. Choosen size of standard gutta-percha pin should be one size larger than the endodontic instrument, which was finished treatment the apical part of root canal. The pin should with little effort inserts and removes root canal. 3. Mix the filling material for root canal (siler) and incert it into the canal with paste injector. The tip of the pin also soak in siler and carefully push the pin to the top of canal. 4. After the main pin, incert the spreader slowly into root canal, carry out condensation of the pin in lateral and apical direction. 5. Incert additional gutta-percha pin in the canal, which was formed after condensation, size of pin should correspond to the size of the last spreader. 6. Conduct the lateral condensation of gutta-percha pin again. This has to be done as long as the root canal will not be filled completely. The spreader creates significant pressure on gutta-percha pins and deformed them, acquiring the shape of canal and gradually filling all microbranchings of root canal. After each additional pin input and output spreader attention must be paid at the main apical pin that its accidentally being pulled from the root canal and not push per apical hole. 7. Remove the excess of forced out canal filling material, and the base of gutta-percha pin cut by heated excavator. This allows for a good view of the root canals orifices, if necessary, enter additional guttapercha pins to complete root canal filling. 4.21. X-ray measuring of the root canals depth. Goal: length of the root canal determine for future quality endodontic treatment Equipment: table of average data calculated length of the tooth and root, K-files with rubber stopper, endodontic ruler. Methodology of conducting: 1. To consider and deliver a preview X-ray image. 2. Choose the file according to the statistical average length of root

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canal (note the length by stopper using dental ruler). 3. Enter the instrument in canal to stop feeling. 4. Make X-ray image with instrument inside of cannal (to specify the location of the tip of the file). 5. Having examined the X-ray image to adjust the length by measuring the distance from the tip to the ruber stoper using dental ruler. 4.22. Evaluation of the root canals treatment quality. Goal: carry out to make Evaluation of the root canals treatment quality. Equipment: Miller’s broach with cotton turunda, paper pins, iodinol solution. Methodology of conducting: 1. After medicamental treatment of root canal, dry it with paper pin of appropriate size, or by a dry cotton turunda on Miller’s broach. 2. Insert iodinol solution in root canal with cotton turundas on Miller’s broach. 3. Control the color of cotton turundas derived from the root canal. If iodinol become colourless (from blue to white), this indicates the presence of degradation products and fluids. 4.23. Temporary filling of the root canal. Goal: to master the skill of root canals temporary obturation when treat of complicated caries. Equipment: filling material for root canals (plastic nonhardening material with medicalproperties), contra-angle handpiece, paste injector, glass plate (or paper pad), spatula (metallic or plastic). Methodology of conducting: 1. Mix the filling material for root canal. 2. In the prepared and dried canal insert filling material with paste injector or Miller’s broach, taking into account the working length of root canal. 3. Conduct a condensation of filling material at the orifice of canal by cotton ball. 4.24. Desobturation of the root canal filled with gutta-percha. Goal: to master the skill of the root canals filled with gutta-percha desobturation. Equipment: heat carrier (for example, heated explorer), Gates-Glidden

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burs, H-files, eucalyptol or chloroform (gutta-percha solvents). Methodology of conducting: 1. Conduct softening and partial removal of gutta-percha from root canal orifice using heated probe. 2. Drill the gutta-percha in the orifice part by Gates-Glidden to a depth of 3 mm. 3. Fill in created space of canal drop of the eucalyptol. 4. After a few minutes remove the softening gutta-percha in small portions using the H-files. 5. Methodology of the teeth hard tissues, periodontal tissues and oral mucosa membrane condition evaluation. 5.1. The vital coloration of the tooth hard tissues: Goal: be able to detect pathological processes of the tooth hard tissues. Equipment: dental mirror, explorer, pincer, cotton rolls, cotton tampons, 2% water solution of methylene blue. Methodology of conducting: 1. Clean the tooth hard tissues for dental deposites and carry out antiseptic application of them. 2. Make an isolation of tooth by cotton rolls. 3. Apply tampon with stain on the tooth surface wich has to be observed. 4. Remove the solution of stain by cotton ball and make evaluation of the tooth’ hard tissues condition on this area. Areas of demineralized enamel and hidden, non-visible lesions became colored in blue. The pigment spots, spots at enamel hypoplasia and fluorosis are not colorated. 5.1.а. Determination of the teeth hard tissues condition. Goal: the condition of teeth hard tissues is determined for diagnostics of caries, uncarious lesions, pulpitis and apical periodontitis. Equipment: stomatological mirror, explorer, pincer, 2 syringes (5.0 ml), glasses with cold and warm water. Methodology of conducting: A. Observation of dentition. 1. Conduct from right to left, beginning from the teeth of maxilla (molars), and then from left to right - teeth of lower jaw. 2. Define visually a color, size of teeth, presence of fillings, carious cavities.

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B. Exploring of teeth hard tissues. 1. Take a dental mirror by one-hand, second - explorer and inspect the status of teeth hard tissues and carious cavities. 2. Define deepness, size of cavity, degree of enamel and dentine softening using explorer. C. Percussion of tooth hard tissues. 1. Carefully knock by pincers or handle of explorer on a cutting edge or masticatory surface of tooth in vertical direction (for determination of the apical periodontum status). 2. Conduct identical procedure, knocking on teeth in horizontal direction(for determination of the marginal periodontum condition). 3. Begin percussion from healthy teeth, not to close sharp pain and to create pre-conditions for comparison of feeling in a healthy and affected tooth. D. To detect tooth reaction for thermal irritants by irrigation of it firstly cold and after that warm water. In a case of carious cavity presence, insert a cotton ball saturated in cold or warm water inside. 5.2. TER-test (test of enamel resistance) Goal: to define the degree of destruction of superficial layers of enamel under act of acid. Equipment: contra-angle handpiece, rubber cups, brushes, polishing discs, flosses, paste for professional oral hygiene, distilled water, cotton tampons, cotton balls, 1N solution of HCl, fluorine varnish, 1% solution of Methylene blue, 10-points scale of blue color tint. Methodology of conducting: 1. Conduct a professional hygiene of oral cavity. 2. Damp crowns of teeth by cotton tampons saturated in distilled water; dry by jet of air and isolate with cotton rolls. 3. Apply drop of 1N solution of HCl on vestibular surface of central maxilla incisor with diameter 1,5 – 2 mm. 4. Wash-out the acid with distilled water after 5 sec., and dry a tooth crown by cotton tampon. 5. Apply a tampon saturated in 1% solution of Methylene blue on tooth surface. 6. Wipe the colorant by dry cotton tampon till intact enamel rich initial color. 7. Evaluate test according 10 points scale.

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8. Apply fluorine varnish on demineralization zone. Evaluation of results according 10-points scale: 1. 1 - 3 points - pale-blue color - high resistence to caries. 2. 4 - 5 points – blue color - middle resistence. 3. 6 - 7 points – intensive blue color - low resistence. 4. 8 points and more – dark blue color – very low resistence to caries. 5.3. СRT-test ( color reaction time) Goal: to define speed of enamel dissolution in acid. Equipment: dental mirror, explorer, pincer, solution of chlorhexidine ( 0,05%), cotton bolls, filter paper disc with diameter 3 mm., 0,02% water solution of cristall violet, micropipet of 1N solution of HCl, contra-angle handpiece, polishing paste with fluorine. Methodology of conducting: 1. Carry out antiseptic treatment of oral cavity by irrigation it of 0,05% solution of chlorhexidine. 2. Remove a dental plaque from vestibular surface of 12 tooth, make isolation and dry by jet of air. 3. Saturate a filter papar disc by 0,02% water solution of cristall violet during 30 sec. 4. After that aplly filter papar disc on enamel of tooth 12 and using micropipette drop 1,5 ml of 1N solution HCl on it. 5. Fix a time from moment of HCl applying till complete transformation of yellow color to violet (in seconds). 6. After testing apply fluorine paste on tooth surface using micro-brush and polish it. CRT > 60 seconds – solubility low, caries resistency - high. СКТ < 60 seconds - solubility high, caries resistency - low. 5.4. Clinical evaluation of enamel remineralization speed (CEERStest). Goal: to define speed of enamel remineralization. Equipment: contra-angle handpiece, rubber cups, brushes, polishing discs, flosses, paste for professional oral hygiene, distilled water, cotton tampons, cotton balls, 1N solution of HCl, fluorine varnish, 2% solution of Methylene blue, 10-points scale of blue color tint. Methodology of conducting: 1. Carry out antiseptic treatment of oral cavity by irrigation it of 0,05%

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solution of chlorhexidine. 2. Remove a dental plaque and soft debris from vestibular tooth, make isolation and dry by jet of air. 3. Aplly 1,5 ml of 1N solution HCl on enamel using micropipette for 60 seconds. 4. Wipe solution of HCl by cotton tampon. 5. Apply cotton boll, saturated in 2% solution of Methylene blue on tooth surface for 1 minute. 6. Remove colorant by dry cotton tampon. 7. Repeat applying of colorant after 1 – 2 – 3 – 4 days. 8. Evaluate test according 10 points scale of blue tint. Criteria of evaluation: a sensitiveness of enamel to the action of acid define in order to the painted area intensity: the least painted stripe is conditionally taken for 10%, and most saturated - for 100%. 5.5. Oral Hygiene Index - (Greene and Vermillion, 1960) Goal: to evaluate oral hygiene condition. Equipment: Lugol’s iodine, cotton bolls, cotton rolls, glass plate, dental mirror. Methodology of conducting: 1. The Oral Hygiene Index is composed of the combined Debris Index and Calculus index. 2. Each of these index is in turn based on 12 numerical determinations representing the amount of debris or calculus found on the buccal and lingual surfaces of each of three segments of each dental arch (The Maxillary and the Mandibular), namely: - The segment distal to the right cuspid (see picture). - The segment distal to the left cuspid. - The segment mesial to the right and left first bicuspids. 3. Each segment is examined for debris or calculus. 4. From each segment one tooth is used for calculating the individual index, for that particular segment. The tooth used for the calculation must have the greatest area covered by either debris or calculus. 5. The method for scoring calculus is the same as that applied to debris, but additional provisions are made for recording subgingival deposits.

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Criteria for classifying debris Scores Criteria 0 No debris or stain present 1 Soft debris covering not more than one third of the tooth surface, or presence of extrinsic stains without other debris regardless of surface area covered 2 Soft debris covering more than one third, but not more than two thirds, of the exposed tooth surface. 3 Soft debris covering more than two thirds of the exposed tooth surface.

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Criteria for classifying calculus Scores Criteria 0 No calculus present 1 Supragingival calculus covering not more than third of the exposed tooth surface. 2 Supragingival calculus covering more than one third but not more than two thirds of the exposed tooth surface or the presence of individual flecks of subgingival calculus around the cervical portion of the tooth or both. 3 Supragingival calculus covering more than two third of the exposed tooth surface or a continuos heavy band of subgingival calculus around the cervical portion of the tooth or both.

6. After the scores for debris and calculus are recorded, the Index values are calculated. For each individual, the debris scores are totaled and divided by the number of segments scored. 7. The same method is used to obtain the calculus index scores. 8. The average individual or group debris and calculus scores are combined and divided by the “two”to obtain Oral Hygiene Index. 9. Till – 0,6 points - oral hygiene is good, 0,7–1,6 – satisfactory; 1,72,5 – unsatisfactory; more than 2,5 – bad. 5.6. РМА index. Goal: index used for recording the prevalence and severity of gingivitis by noting and scoring three areas: the gingival papillae (P), the buccal or labial gingival margin (M), and the attached gingiva (A). Equipment: dental mirror, dental probe. Methodology of conducting: 1. Divide a gingiva on three parts: interdental papillae (P), marginal gingiva (M) and attached gingiva (A). 2. Determine visually the inflammatory process in a gum of each tooth using dental mirror and probe: 1 point – inflammation of interdental papilla; 2 points – inflammation of marginal gingiva; 3 points – inflammation of attached gingiva. 3. Score the index using formula: 100 % 3XZ - the total of maximal points for all examined teeth; Z – amount of teeth, it is evaluate 30 teeth after 15 years old.

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5.7. Schiller-Pisarev’s test. Goal: The test can be used for determining the extent of inflammation and the limits of operative interference in gingivoectomy, curettage of the periodontal canals, for revealing subgingival tooth deposits.This test is an objective mean for evaluating the efficacy of treatment, for differential diagnostics of gingivite severity, for index assessment of periodontium condition. Equipment: iodine, potassium iodine, distilled water, cotton balls, cotton rolls, pincer, glass. Methodology of conducting: 1. Conduct an isolation of the gingiva with cotton rolls in the area of mandible frontal teeth. 2. Apply a several drops of solution on the glass. The composition of solution: Iodi puri - 1,0; Kallii iodidi- 2,0; Aquae destillatae- 40,0. 3. Take a cotton ball by a pincer and saturate it with iodine solution. 4. Apply iodine solution on to the gum. 5. According coloration intensity we distinguish: negative test (yellowish color), slight positive test (light-brown color) and positive test (dark greyish-brown color). 5.8. Formalin test. Goal: by means of Formalin tests find out violation of dento-gingival attachment integrity, presence of it ulcerations. Equipment: solution of formalin, glycerine, distilled water, glass plate, cotton rolls, pincer. Methodology of conducting: 1. Conduct an isolation of the gingiva with cotton rolls in the examed area. 2. Dry of teeth cervicis by air jet. 3. Apply several drops of solution on the glass plate. The composition of solution: 5 ml of 40% formalin, 20 ml of glycerine and 75 ml of distilled water. 4. Incert a drop of above-mentioned solution in to periodontal pocket by a pincer. 5. Short-term, sharp pain tells us about damage of gingiva’ internal wall or punctate attachments lose. 5.9. РІ index (according Russel). Goal: to evaluate condition of periodontal tissues. Equipment: dental mirror, periodontal probe.

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Methodology of conducting: 1. Detect a condition of tooth surrounding tissues for each one with exception of wisdom teeth: 0 points – intact gingiva; 1 point – slight inflammation which does not spread surround of tooth; 2 points – inflammation involves a gingiva surround of tooth, but no attachments lose; 4 – Inflammation surround of tooth, initial stage of interdental septas tips resorption, which diagnosed on sciagram; 6 – inflammation of gingiva with attachment lose, development of periodontal pockets and alveolar bone resorption till 1/2 of tooth’ root length, no deviation of tooth’ functions; 8 – deviation of tooth functions because of mobility, expressed destructive changes in periodontum, resorption of interdental septas more than 1/2 of root length. 2. Calculate the index according formula: PI=

Sum of points Ammount of teeth

3. The figures of PI index: 0 to 0,1 – norm; 0,1 to 1 innitial stage of periodontal tissues disease; 1,5 to 4,0 – midlle and 4,5 – 8 – severe. 5.10. CPITN (The community periodontal index of treatment needs) index. Goal: it used for evaluation of periodontal tissues condition and treatment needs (in exact person or community). Equipment: dental mirror, explorer, periodontal probe. Methodology of conducting: 1. Divide the teeth arches on 6 sextants and exame teeth: 17/16, 11, 26/27, 31, 36/37, 47/46. 2. Detect condition near that tooth (bleeding, dental calculus, periodontal pocket) where pathological changes mostly expressed. 3. For detection of periodontal pockets used periodontal probe. 4. For detection of bleeding and dental calculus used dental mirror and explorer. 5. Conduct probing without pressure, inserting probe till small resistance filling, move it around of tooth.

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Clinical condition No sign of disease Gingival bleeding after gentle probing Supra and / or sub gingival calculus Pathological pocket 4 to 5 mm deep Pathological pocket up to 6 mm or deeper

Score Treatment Needs (TN) 0 No treatment 1 Improvement in personal oral hygiene (TN 1) 2 Imrovment in personal oral hygiene and scaling (TN 2) 3 Same as score 2 plus curettage 4

Same as score 3 and complex treatment (TN 3)

5.11. Investigation of OMM. Goal: routine and consecutive conducting of patient examination helps us to study clinical manifastations of disease in detail, compare separate symptoms and take correct diagnosis. Equipment: adequate illumination (desirable daylight), 2 dental mirrors, 2 gauze napkins, paper napkins, gloves, mask. Methodology of conducting: 1. When examination of OMM carry out it is used stomatoscopy, vital coloration, cytological and morphological inspections. 2. That is necessary to detect clinical manifestations, character of lesions and features of pathological process course. 3. Detect merging of lesions, their localization and phase of development. 4. Define lesions in order to features: Primary lesions: A. Size B. Shape. C. Color.

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D. Phase of development. E. Topography. F. True polymorphism. Secondary lesions A. Size B. Shape. C. Color. D. Phase of development. E. Topography. F. False polymorphism. 5.12. Cytological examination. Goal: for verification of the OMM disease. Equipment: slides, sterile rubber markers, reagents for fixation and coloration. Methodology of conducting: 1. Rinse an oral cavity by normal saline solution for removing of the food and mucilage rests. 2. Clean the surface of lesion by wet steriled cotton tampon, removing necrotic film or debris. 3. Prepare slide. 4. Put on lesion or examed area sterile rubber marker. 5. Transfer imprint on slide. 6. Repeat collection of material but more deep layers. 7. Dry microscopic slide and fix it by methanol. 8. Carry out coloration of slide. 5.13. Vital coloration by hematoxylin according Derazhne. Goal: to detect atypical epithelium of OMM. Equipment: 1% solution of hematoxylin, cotton ball, pincer. Methodology of conducting: 1. Apply solution of hematoxylin on OMM. 2. Conduct evaluation after 2 – 3 min. 3. Atypical epithelium become dark-violet color, in norm – pale-violet. 5.14. Nikolsky’s symptom. Goal: for verification of acantholytic Pemphigus. Equipment: dental mirror, pincer, cotton balls.

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Methodology of conducting: І variant : 1. Pull aside soft tissues by dental mirror. 2. Catch a margine of bulla operculum by pincer and pull it up. 3. It is observe detachment of visually healthy mucosa in a case of “positive” symptom. ІІ variant : 1. Pull aside soft tissues by dental mirror. 2. Take a cotton ball by pincer and rub area of tissue between two lesions. 3. It is observe detachment of visually healthy mucosa on a place of rub in a case of “positive” symptom. ІІІ variant : 1. Take a cotton ball by pincer and rub distant from lesions area of tissue. 2. It is observe detachment of visually healthy mucosa or derma on a place of rub in a case of “positive” symptom. 5.15. Morphological examination of OMM. Goal: to conduct sampling out of lesion center for morphological examination. Equipment: local anesthetic solution, syring, needle, gauze napkins, scissors or scalpel, solution for fixation, needleholder, atraumatic needle with suture material. Methodology of conducting: 1. Rinse an oral cavity by normal saline solution for removing of the food and mucilage rests. 2. Carry out a block anesthesia. 3. Conduct a sampling by scalpel or scissors on a border between healthy and pathologically changed tissue. Size of the sample 3 – 5 mm. 4. Conduct suturing. 5. Send a sample to pathomorphological lab; mark a short anamnesis, figures of objective examination and preliminary diagnosis. 5.16. Pulp testing (EOD). Goal: to master a skill of pulp testing carry out. Equipment: device for pulp testing, kit of instruments for examination, wet gauze napkins, plastic spatula, gloves, cotton rolls, gauze.

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Methodology of conducting: 1. Put on gloves and use plastic spatula instead of dental mirror. 2. Apply passive electrode on patient right arm over wet napkin and fix it by gauze. 3. Make an isolation of tooth and dry it. 4. The tip of active electrode wind by cotton turund and aplly to: a) middle of cutting edge in incisors and canines; b) apex of buccal cusp in premolars; c) apex of mesial-buccal cusp in molars; d) bottom of carious cavity, if it present; and turn the tumbler of current on device till sensation of slight tingling. 5. Discomfort sensations appear at current strength 2 – 6 mkA in norm. 6. Repeat examination to improve figures. 5.17. Benzidine [Adler’s] test. Goal: to master the skill of purulent exudates in periodontal pockets detection using benzidine test. Equipment: solution of benzidine, polyethylene glycol, acetic acid, H2O2, microscopic glass, pincer, cotton turunds. Methodology of conducting: 1. Make an isolation of the gum by cotton rolls, and dry the cervical part of teeth by air jet. 2. Apply on the microscopic glass one drop of solution which consists of: 0,5 g of benzidine, 10,0 g of polyethylene glycol, 15 ml of acetic acid in dilution 1:1000 and mix with a drop of H2O2 3% solution. 3. This mixture installed in to periodontal pockets using turunds. In order to exudates character, the changing of it color takes a part from blue till green. 5.18. Test of Rotter in modification of N. M. Yakovetz. Goal: to master the skill of vitamin C saturation testing in tissues. Equipment: syringe, needle, dye of Tilmans, cotton rolls. Methodology of conducting: 1. Dry a dorsum of the tongue by cotton roll. 2. Apply on the linea mediana of the tongue 1 drop of 0,06% solution of Tilmans dye using needle with diameter 0,2 mm.

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The time of macula decolouration, which is more than 16 – 20 sec., testify to the effect that insufficiency of vitamin C in tissues (it needs 16 – 20 sec., for macula decolouration in norm). 5.19. Cytological examination of periodontal pockets contents. Goal: for verification of the periodontal tissues disease. Equipment: sterile rubber markers, slides, reagents for fixation and coloration, normal saline solution. Methodology of conducting: 1. Sampling of swabs 3 – 4 hours after teeth brushing. 2. Rinse an oral cavity by normal saline solution for removing of the food and mucilage rests. 3. Prepare slide. 4. Insert sterile rubber marker (size of the working part not bigger than 1 mm) into periodontal pocket next way: squeeze closely by internal surface to the tooth on the level of dento-gingival junction, and external - to symmetric surface of gum. 5. Transfer swab on to slide. 6. Carry out coloration of sample. 5.20. Cytological examination of periodontal pockets contents. Goal: detection of periodontal pockets microbial contents for subsequent diagnostics and medicamentous treatment chois. Equipment: root needle, cotton turund, slides, normal saline solution, reagents for fixation and coloration. Methodology of conducting: 1. Carry out examination on an empty stomach or 3 – 4 hours after meal; do not brush the. 2. Rinse an oral cavity by normal saline solution for removing of the food and mucilage rests. 3. Prepare slide. 4. Conduct an isolation of exame area by cotton rolls. 5. Dry the exame area with slight jet of air. 6. Insert root needle with sterile cotton turund in to the periodontal pocket till 2 mm in depth. 7. Transfer the sample on slide. 8. Conduct coloration of slide.

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6. The techniques of periodontal tissues and oral mucosa membrane diseases treatment 6.1. Rinse Goal: to estimate the rightness of oral cavity rinsing by a patient. Equipment: glasses, solution for rinse (the natrium tetraborate or hydrocarbonate). Methodology of conducting: If patient feel good, he or she rinses oral cavity by himself. For this purpose collects 10-15 mls of antiseptic solution in to a mouth and conducts 10 energetic motions by mimic muscles and spit out. It is so repeated a few times on a draught 4-5 minutes. 6.2. Oral bath Goal: to estimate the rightness of oral bath conducting by a patient. Equipment: 1. Infusions of herbares (sage (Salvia), tutsan (Hypericum), chamomile (Matricaria), nettle (Urtica)). Methodology of conducting: A patient collects in a mouth 5-10 mls of solution and retains him in an oral cavity 2-3 minutes. Oral bath must be repeated in 2-3 hours. 6.3. Oral irrigation: 6.3.1. Irrigation with a help of irrigator: Goal: to lay hands on methodology of OMM irrigation. Equipment: irrigator, solutions for irrigation (slight solution of potassium permanganate1:5000, solution of furacillin - 0,02%, ryvanol 1:1000, solution of citral - 10-15 drops on 100-150 mls, aetacridinum lactate - 1:5000, herbal medicines: celandine (Chelidonium), marigold (Calendula), tutsan (Hypericum), succus kalanchoe). Methodology of conducting: 1. Warm up solution for irrigation to 22-36 0C. 2. Collect warmed-up solution in irrigator. 3. Enter a tip of irrigator in to the patient’s mouth, press starting of irrigator, conduct an irrigation. 6.3.2. Irrigation with a help of syringe: Goal: to lay hands on methodology of OMM irrigation with a help of syringe. Equipment: syringe with safety canule, solutions for irrigation

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(slight solution of potassium permanganate1:5000, solution of furacillin 0,02%, ryvanol - 1:1000, solution of citral - 10-15 drops on 100-150 mls, aetacridinum lactate - 1:5000, herbal medicines: celandine (Chelidonium), marigold (Calendula), tutsan (Hypericum), succus kalanchoe). Methodology of conducting: 1. Put warmed-up to 22 0C solution in to a syringe. 2. Enter the needle of syringe in to oral cavity, not touching teeth and oral mucous membrane. 3. Press out solution in to the oral cavity. 4. Especially carefully wash interdental spaces and affected area. 6.4. Gingival application of solutions Goal: to master technique of gingival application in a case of periodontal diseases. Equipment: syrynge (volume 10 ml) and needle with safety tip, stomatological pincer, cotton rolls, gauze tampons, solutions of antiseptics (infusion of sage, solution of chlorhexidini (0,05%)), distilled water. Methodology of conducting: 1. Rinse oral cavity by antiseptic solution using syringe (infusion of sage), after that patient has to spit out. 2. Conduct isolation of gingiva by cotton rolls. 3. Saturate gauze turunda by chlorhexidine solution. 4. Apply wet gauze turunda on the gingival surface. 5. Put over turunda with antiseptic dry cotton rolls. 6. Patient should close a mouth. 7. Exposition – 15 – 20 minutes, after that cotton rolls and gauze turundas remove by pincer. 8. Rinse an oral cavity by distilled water. 6.5. Gingival application of ointments Goal: gingival applications of ointments are used for local treatment of periodontal tissues diseases. Equipment: syrynge (volume 10 ml) and needle with safety tip, stomatological pincer, spatula, cotton rolls, gauze turundas, solution of chlorhexidini (0,05%), methyluracill ointment (5%), distilled water. Methodology of conducting: 1. Rinse oral cavity by chlorhexidine solution using syringe, after that patient has to spit out.

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2. Conduct isolation of gingiva by cotton rolls. 3. Apply methyluracill ointment on gingival surface using spatula and cover by dry gauze turundas. 4. Request patient to close a mouth. 5. Exposition – 15 – 20 minutes, after that cotton rolls and gauze turundas remove by pincer. 6. Wash out a rest of ointment by jet of water. 6.6. Installation of the solutions Goal: installation in to the periodontal pockets of liquid forms of medications, that are used for conservative treatment of periodontal pockets in case of generalized periodontitis. Equipment: syringe with safety needle (volume 10 ml), stomatological pincer, cotton rolls, thin cotton turunda, solution of chlorhexidine (0,05%), distilled water. Methodology of conducting: 1. Irrigate an oral cavity by chlorhexidine solution using syringe, after that a patient spit out the solution. 2. Dry and isolate gums with cotton rolls. 3. Installed a thin cotton turunda with chlorhexidine solution in to periodontal pocket. 4. Apply dry cotton rolls on gingiva. 5. Ask patient to close a mouth. 6. Duration of manipulation – 15 min., after that remove cotton rolls and cotton turunda out of periodontal pocket. 7. Irrigate an oral cavity with distilled water using syringe. 6.7. Installation of the ointments Goal: : installation in to the periodontal pockets of ointments, that are used for conservative treatment of periodontal pockets in case of generalized periodontitis. Equipment: syringe with safety needle (volume 10 ml), stomatological pincer, thin separate spatula, cotton rolls, cotton balls, solution of chlorhexidine (0,05%), ointment of Methyluracilum (5%), distilled water. Methodology of conducting: 1. Irrigate an oral cavity by chlorhexidine solution using syringe, after that a patient spit out the solution.

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2. Dry and isolate gums with cotton rolls. 3. Insert the ointment into periodontal pocket by the thin separate spatula. 4. Apply dry cotton rolls on gingiva. 5. Ask patient to close a mouth. 6. Duration of manipulation – 20 min., after that remove cotton rolls using pincer. 7. Remove a rest of ointment by cotton balls. Irrigate an periodontal pocket with distilled water using syringe. 6.8. Application of therapeutic periodontal dressing Goal: therapeutic periodontal dressing applied on the gum for a long period of time ( 2-3 hours) for prolongation of medicines activity, and used for local treatment of periodontal tissues diseases. Equipment: syringe with safety canule (volume 10 mls), stomatological pincer, spatula, separate spatula, cotton tampons, cotton rolls, powder of zinc oxyde, powder of artificial dentine, solution of chlorhexidine (0,05%), methyluracil ointment (5%). Methodology of conducting: 1. Therapeutical dressing prepared ex tempore, by mixing on frosted surface of glass plate, in order to recipe: Rp: Zinci oxydi Dentini aa Ung. Methyluracili 5% q.s. ut f. past. 2. The oral cavity is irrigated by solution of chlorhexidine from a syringe, whereupon a patient spit out this solution. 3. Gums dry out and insulate from saliva by wadding rolls. 4. On the surface of gums first from oral, and then from a vestibular side by means of spatula apply a periodontal dressing so that she lay on cervical part of crowns of teeth, covering a gingival edge and closing orifice in a periodontal pockets. 5. A dressing is designed by means of separate spatula and cotton tampons. 6. It enters at interdental intervals, connecting vestibular and oral parts, covers gums on all draught, does not promote a bite and not included in a periodontal pocket, cutting edges and masticatory surfaces of teeth remain free. 7. Time of consolidation 8-10 minutes, whereupon insulating

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wadding rolls remove by means of pincers. 8. A patient is asked to close a mouth. Duration of procedure - 2-3 hours. 6.9. Application of isolating periodontal dressing Goal: isolating periodontal dressing applied on the gum for a long period of time with the aim of isolation after surgical operations or for prolongation of medicines activity which used for local treatment of periodontal tissues diseases. Equipment: syringe with safety canule (volume 10 mls), stomatological pincer, spatula, separate spatula, cotton tampons, cotton rolls, solution of chlorhexidine (0,05%), methyluracil ointment (5%), zinc-oxyde-eugenol impression material, stripes of latex. Methodology of conducting: 1. Isolating dressing prepared ex tempore, by mixing on frosted surface of glass plate, (basic and catalyst pastes of impression material take in even amounts, which are necessary for dressing). 2. The oral cavity is irrigated by solution of chlorhexidine from a syringe, whereupon a patient spit out this solution. 3. Gums dry out and insulate from saliva by wadding rolls. 4. Installed methyluracil ointment into periodontal pockets by using a thin separate spatula. 5. On the surface of gums first from oral, and then from a vestibular side by means of spatula apply a periodontal dressing so that she lay on cervical part of crowns of teeth, covering a gingival edge and closing orifice in a periodontal pockets. 6. A dressing is designed by means of separate spatula and cotton tampons. 7. It enters at interdental intervals, connecting vestibular and oral parts, covers gums on all draught, does not promote a bite and not included in a periodontal pocket, cutting edges and masticatory surfaces of teeth remain free. 8. The surface of bandage densely press by latex stripes. 9. Time of consolidation 2 - 3 minutes, whereupon insulating wadding rolls remove by means of pincers. 10. A patient is asked to close a mouth. Duration of procedure - 1-2 days.

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6.10. Coagulation of hyperthrophed interdental papillae. Goal: to master technique of hyperthrophed papillae coagulation. Equipment: diathermo-coagulator, active electrode of needeble shape (spear-shaped), curette, cotton rolls, chlorhexidine (0,05%). Methodology of conducting: 1. Conduct isolation of gingival papilla by cotton rolls. 2. Insert active electrode till a base of papilla and switch-on of device. 3. Cut the papilla out of vestibular and oral surfaces. 4. Duration of coagulation when current strength tills 15 mA, 2 – 4 seconds. 5. Necrotized tissues removed by curette or excavator. 6. Rinse oral cavity with 0,05% solution of chlorhexidine. 6.11. Curettage of periodontal pockets. Goal: Curettage of periodontal pockets is conducted for removing of subgingival dental tartar, microbal plaque, granulations, bands of vegetans epithelium, removal of periodontal pockets in depth a 3-5 mm. Equipment: syringe with safety canule (volume 10 ml), disposable syringe with needle (5 ml), local anesthetic, stomatological pincer, spatula, excavator, currets, separate spatula, finirs, polirs, cotton rolls, gauze tampons, solution of chlorhexidine (0,05%), methyluracil ointment (5%), ZnO powder, artificial dentine. Methodology of conducting: 1. Irrigate an oral cavity by chlorhexidine solution using syringe, after that a patient spit out the solution. 2. Make a block or infiltration anesthesia. 3. Make a therapeutical dressing ex tempore, by mixing components on rough surface of glass plate according prescription: Rp: Zinci oxydi Dentini aa Ung. Methyluracili 5% q.s. ut f. past. 4. Dry a gingiva and make isolation by sterile gauze tampons. 5. Remove subgingival dental tartar and pathologically changed cementum of the root by sharp zone-specific curette. Start your movements from tooth cervix and gradually deepening towards the apex of root. 6. Make polishing of the root surface by finirs and polirs. 7. Rinse the periodontal pocket by a warm solution of chlohexidine о (36 ) under the pressure using syringe.

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8. Remove granulative tissue from a bottom of periodontal pocket using sharp curette. 9. Insert a curette till the bottom of pocket, press gingival margin to the tooth surface using first finger, cut a granulations and bands of epithelium by vertical movements in direction to a tooth’ crown. 10. Control the movements of instrument by a finger to prevent perforation of gingival wall. 11. The sequence of movements: vestibular part of pocket – lateral surfaces of pocket – oral part of pocket. 12. Conduct a manipulation in the area of 3 – 4 incisors or 2 – 3 molars simultaneously. 13. Irrigate an operative field by solution of chlorhexidine; after that press the gums to teeth surface by gauze tampons and apply periodontal dressing. 6.12. Splintage of teeth by GlasSpan system. Goal: to remove mobility of teeth using of adhesive splintage constructions. Equipment: «GlasSpan» starter kit, floweble light-curing composite filling material, micro-hybride light-curing composite filling material, stripes of different grain, diamond burs of different shapes, polishing discs, wooden wedges, polishing paste. Methodology of conducting: 1. Make cleaning and brushing of teeth which should be splint. 2. Make isolation of operating field using cofferdam. 3. Process an enamel by the diamond cone-shaped burs in the ultrafast mode for the desurfacing of fluorine layer. 4. Measure off the segment of “GlasSpan” fibre of necessary length, apply adhesive on it ends, make polymerization and cut using scissors. 5. Etch of enamel; wash-out the etching gel by the jet of water and air, dry, apply adhesive and make polymerization. 6. Accommodate wooden wedges in interdental spaces. 7. Apply the portion of floveble composite evenly, along the working field, not to polymerize. 8. Apply adhesive on prepared glass-fiber stripe; accommodate stripe along the working field; make an even condensation of stripe to the first portion of material; make polymerization. 9. Apply the layer of mycrohybride composite over glass-fiber stripe; make modeling and polymerized.

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10. Make final treatment of construction surface, using polishing discs. 11. Make final treatment of interdental spaces using abrasive stripes. 12. Make bite checking using articulation paper, without excessive loading on stabilized teeth. 6. 13. Applications on OMM. Goal: to master technique of applications on OMM. Equipment: 1. Cotton tampons, rolls, balls; gauze napkins; 2. Bowls; 3. Pincer; 4. Fluid medicines (solutions, tinctures, liniments, emulsions) Methodology of conducting: 1. Fill a bowl with solution for application. 2. Conduct an isolation of salivary glands ducts with cotton rolls. 3. Dry affected area by cotton tampons. 4. Saturate sterile gauze napkin by medicinal solution, squeeze by pincer, to prevent drain of it. 5. Apply napkin on the affected area. 6. Exposition 15 – 20 minutes, change the napkin three times, each 5 minutes. 6.14. Lubrication an OMM: Goal: to master technique of OMM lubrication. Equipment: 1. Cotton balls, brush, spatula; 2. Different ointments. Methodology of conducting: 1. Conduct an isolation of salivary glands ducts with cotton rolls. 2. Lubricate an OMM by cotton ball, brush or spatula carefully, thin layer. 3. Carry out lubrication 1 – 2 times daily, 5 – 6 days. 6.15. Aerosol therapy: Goal: to master technique of aerosol therapy on OMM. Equipment: 1. Medicines in aerosol package (trimecaine, lidocaine, and inhalipt). Methodology of conducting:

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1. Warn the patient to stop breathing in a moment of aerosol applying for 2 – 3 seconds. 2. Apply an aerosol. 6.16. Medicamentouse and surgical treatment of erosions, aphthes, ulcers, fissures. Goal: to master technique of medicamentouse and surgical treatment of OMM erosions, aphthes, ulcers, fissures. Equipment: 1. Syringe, irrigator, chip-blower, glass, bowls, spatula, excavator, scalers, scalpel, pincer; 2. Cotton rolls, balls, tampons, gauze napkins; 3. Solutions, tinctures, ointments, liniments, crems, emulsions, pastes, powders. The sequence of medicamentouse and surgical treatment of OMM erosions, aphthes, ulcers and fissures: І. Phase of hydratation: 1. Anaesthesia of operation field. 2. Treatment of oral cavity and lesions by antiseptic solutions. 3. Treatment of lesions by necrolytic remedy. 4. Surgical treatment of operation field (removing of necrotizing tissues by excavator or pincer with permanent irrigation by antiseptics). 5. Removing of local irritative factors except extraction of teeth’ roots. 6. Treatment of lesions by antibacterial, anti-inflammatory, enzymes inhibitor and osmotic remedy. ІІ. Phase of dehydratation: 1. Antisaptic treatment of lesions. 2. Treatment of lesions by stimulators of reparative processes and keratoplastics. Methodology of conducting: 1. Conduct topical anaesthesia of operating field. Apply anaesthetic jel or solution in aerosol package on mucosal membrane with cotton ball for 3 – 5 min. 2. Carry out antiseptic rinsing of oral cavity and lesion by warm solutions (potassium permanganate, furacillin, rivanol 1:1000, citral 10 – 15 drops on 100 – 150 ml of water). Conduct irrigation by syringe under the pressure. 3. Remove necrotizing films carefully by cotton balls saturated in

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antiseptics and provide permanent irrigation of oral cavity. Do not remove firm crusts and films. 4. After such preparation apply cotton or gauze tampons with enzyme on already dried surface. Exposition 15 – 20 minutes, change the tampon three times, each 5 minutes. After that almost necrotizing films removed by cotton ball; if not – repeat application of enzymes for 10 minutes. 5. Lubricate erosive surfaces by keratoplastic remedies after removing of necrotizing debris. 6. Do not carry out of proteolytic treatment if ulcers, aphthas, erosions or fissures are not cover with fibrinous debris. 6.17. Medicamentouse treatment of hyperkeratosis area. Goal: to master technique of hyperkeratosis area medicamentouse treatment. Equipment: 1.Syring, irrigator, chip-blower, glass, bowls, pincer; 2.Cotton rolls, balls, tampons and gauze napkins; 3.Oil solution of vit. А, infusion of lint. Methodology of conducting: 1. Conduct an isolation of salivary glands ducts with cotton rolls. 2. Dry affected area by cotton tampons. 3. Lubricate an affected area by oil solution of vit. A. 4. If it is observed ttrend to spreading of hyperkeratinization: a) conduct antiseptic treatment of affected area; b) dry affected area; c) apply gauze napkins saturated by lint’ infusion on affected area for 20 min. d) repeat application two times daily till clinical effect appear. 6.18. Removing of dental deposites by mechanical technique. Goal: removing of dental deposites is a very important stage of periodontal diseases treatment, because it extremely decreases quantitative and changes qualitative contants of microflora in periodontal pockets for a long time. Equipment: syringe (volume 10 ml) and needle with safety tip, 10% lidocaine in aerosole package, stomatological pincer, spatula, scalers, curettes, excavator, separate spatula, finirs, polirs, cotton rolls, gauze tampons, solution of chlorhexidine (0,05%), erythrosine, distill water.

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Methodology of conducting: 1. Irrigate an oral cavity by chlorhexidine solution using syringe, after that a patient spit out the solution. 2. Carry out topical anaesthesia by 10% lidocaine in aerosol package. 3. Dry gingiva and conduct isolation with gauze tampons. 4. Carry out a detection of dental deposites with erythrosine. 5. During removing dental deposites off maxilla, vestibular surface of frontal and all surfaces of premolars and molars on mandible it is most comfortable position of doctor in front of patient. When removing dental deposites off lingual surface of mandible frontal teeth it is most comfortable position of doctor – back of patient. 6. Using different scalers and most rare excavator remove supragingival deposites: start from cervical area, after that remove visible subgingival tartar, change instrument for curette and go in deep of periodontal pocket. Remove dental deposines out off all tooth surfaces, according some sequence till complete smoothing of tooth surface. 7. Carry out permanent antiseptic rinsing of interdental spaces and periodontal pockets by 0,05% solution of chlorhexidine during dental deposites removing. 8. Conduct finishing and polishing of all tooth surfaces after deposites removing.

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SECTION 2

PEDIATRIC DENTISTRY 1. Prevention of the main stomatological disorders 1.1. Determination of TER-test ( test of enamel resistance). 1.2. Clinical assessment of the enamel remineralization speed (CAERStest). 1.3. CRT test. 1.4. Non-invasive fissures sealing. 1.5. Invasive fissures sealing. 1.6. Fluoride varnishing of the teeth. 1.7. Application of fluoride-containing. 1.8. Elimination of mineralized dental deposits. 2. Treatment of complicated caries in immature primary and permanent teeth at different stages of roots development 2.1. Application of the de-vitalizing paste on dental pulp in a primary tooth 2.2. Pulp amputation in primary tooth at the stage of root stabilization 2.3. Vital pulp extirpation in permanent immature tooth at the stage of not completed roots (deep amputation) 2.4. Silver impregnation of the root canals in primary mature tooth at the stage of stabilization 2.5. Silver impregnation of the root canals in primary tooth at the stage of root resorption 2.6. Root canal impregnation with resorcinol-formalin liquid in a primary tooth 2.7. Root-canal onbturation in primary and permanent teeth with plastic hardening material based on resorcinol-formalin 2.8. Root-canal onbturation in primary and permanent teeth with plastic hardening material based on zinc-oxide eugenol 2.9. Root-canal obturation in primary and permanent teeth with plastic non-hardening material

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3. Preparation of carious cavities in primary and permanent teeth depending on the choice of dental materials. 3.1. Preparation of carious cavities for amalgam 3.2. Preparation of carious cavities for glass ionomer cement 3.3. Preparation of carious cavities for composite 3.4. Class I by Black cavities preparation in primary teeth. 3.5. Class II by Black cavities preparation in primary teeth 3.6. Class III by Black cavities preparation in primary teeth. 3.7. Class IV by Black cavities preparation in primary teeth. 3.8. Class V by Black cavities preparation in primary teeth. 4. Restoration and impregnation of carious cavities in children 4.1. Pulp capping 4.2. Silver impregnation of carious cavity in primary tooth 4.3. Class II restorations with glass ionomer cement 4. 4.Class V restoration with glass ionomer cement 4.5. Class ІІІ restoration with chemically-cured composite 4.6.Class IV restoration with light cure composite 5. Extraction of primary teeth in children. Local anesthesia in children 5.1. Extractions of primary teeth in children. Local anesthesia in children. 5.2. Extraction of primary Mandibulary incisors. 5.3. Extraction of primary Maxillary canines. 5.4. Extraction of primary Mandibulary canines. 5.5. Extraction of primary Maxillary molars. 5.6. Extraction of primary Mandibulary left molars. 5.7. Extraction of primary Mandibulary right molars. 5.8. Local topical anesthesia in children. 5.9. Regional maxillary block technique anesthesia in children. 5.10. Mandibular Tooth anesthesia in children. 5.11. Inferior alveolar and lingual nerve blocks. 5.12. Infraorbital nerve block anesthesia.

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1.1. Determination of TER-test ( test of enamel resistance) Algorithm of practical skill Theme: conduct TER-test ( test of enamel resistance). Objective: to assess the ability of dental enamel to withstand the harmful effect of organic acids as an indication of resistance to dental caries. Method of practical skill 1. The patient is seated in a position when the central upper incisors are positioned horizontally. They are isolated from the saliva by cotton rollers. 2. One drop of 1,0 normal solution of hydrochloric acid is applied on the cleaned by distilled water and dried vestibular surface of the upper central incisor . Diameter of the drop has to be 2 mm. 3. After 5 seconds the acid is washed away with distilled water and the tooth surface is dried. 4.The etched surface is disclosed with 1%solution of methylene blue for 5 seconds. 5. The colouring agent is removed afterwards from the tooth surface by a dry cotton pledget. 6. The etched area is shaded in blue. The intensity of the shading reflects the depth of the damage to enamel . 7. Evaluation is managed by the printing reference scale in blue color. The more intense is the color of etched area,the lower is enamel resistanse to the acids. This indicator is very important in the pre-nosological diagnosis of dental caries. Materials and equipment: 1. Instruments for examination (dental probe, mirror, tweezers). 2. 1N solution of hydrochloric acid. 3. Pipette. 4. Distilled water. 5. 1% water solution of methylene-blue. 6. Printing reference scale . 7. Cotton rolls. 8. Cotton pledget. 9. Models of the jaws. 10. Stopwatch.

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1.2. Clinical assessment of the speed of enamel remineralization (CAERS-test). Algorithm of practical skill Theme: assessment of CAERS-test ( clinical assessment of speed of enamel remineralization). Objective: to determine the enamel’s resistance to the acids and remineralisation qualities of saliva. Method of practical skill. 1. The patient is seated when the central upper incisors are positioned horizontally. They are isolated from the saliva by cotton rollers. 2. One drop of 1,0 normal solution of hydrochloric acid is applied for 60 seconds on the cleaned by distilled water and dried vestibular surface of the upper central incisor. Diameter of the drop has to be 2 mm. 3. After one minute the solution is dried with a cotton pledget. 4. Paint the etched surface with a drop of 2% methylene blue solution for 1 minute. 5. The colouring agents is removed from the tooth surface with a dry cotton pledget. 6. Etched area is shaded in blue, the intensity of shading reflects the depth of damage to the enamel . 7. On the next day the same surface is disclosed by a methylene blue solution until the lesion is able to absorb the agent. 8. Intensity of the shading and the duration of the etched enamel to maintain the ability to absorb coloring agent is the digital indicator of dental tissues to resist dental caries. Interpretation of the results: – Shading of the tooth up to 1-3 days indicates a good remineralization qualities of saliva and a high speed of enamel remineralization ; – Shading of the tooth up to 4 days indicates a moderate remineralization qualities of saliva and a slow speed of enamel remineralization. Materials and equipment: 1. Instrument for examination (dental probe, mirror, tweezers). 2. 1N solution of hydrochloric acid ( рh 0,3 - 0,6). 3. Pipette. 4. Distilled water. 5. 2% water solution of methylene-blue. 6. Printing reference scale (blue colour).

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7. Cotton rolls. 8. Cotton pledgets. 9. Models of jaws. 10. Stopwatch. 1.3. Clinical assessment of CRT (color reaction time) test Algorithm of practical skill Theme: assessment of CRT- test ( color reaction time). Objective: to determine the speed of enamel solubility in the acid Method of practical skill. 1. The patient is seated when the central upper incisors are positoned horizontally. They are isolated from the saliva by cotton rollers. 2. The filter paper disk (diameter 3 mm) that was prior saturated with the 0.02% water solution of crystal violet is applied on the cleand with distilled water and dryed vestibular surface of the upper central incisor. 3. This disc is coated with 1.5 ml of 1N solution of hydrochloric acid by a pipettes. 4. The time when the colour is changed from yellow to violet is measured in seconds. 5. It is mandatory to conduct local mineralization therapy after the conducting of CRT-test . 6. Interpretation of the results: CRT>60 second – low enamel solubility, high caries resistance; CRT