Organization of dental services and assistance to the population. Organization and structure of a dental clinic, therapeutic department, dental office. Sanitary and hygienic standards. Principles of organizing the work of a dental clinic.
Issues of organizing dental care have always been the focus of national healthcare.
The last decade has been characterized by technical progress, the introduction of modern equipment and new technologies into the practice of dentists.
The main structure, as before, remains state municipal medical institutions, which, despite the increasing outflow of specialists to the private dental sector, provide the largest volume of dental care.
In the system of state and municipal urban healthcare services, there are three levels of dental care.
First level. First-level institutions include: dental departments in multidisciplinary clinics, medical units, as part of the central district hospitals (central district hospitals) and other medical institutions, dental offices in enterprises, educational institutions, kindergartens, agricultural enterprises, antenatal clinics and other institutions . At the first level, the bulk of measures for individual prevention and treatment of the most common types of dental pathology are carried out, ending with sanitation of the oral cavity and, if necessary, simple dentures.
Second level is represented by state and municipal dental clinics in administrative districts of cities, where highly qualified specialized care is provided in the main profiles of the dental specialty: therapeutic dentistry with endodontics, surgical dentistry and dental prosthetics. As a rule, such dental clinics also perform the functions of unique methodological and practical centers for organizing dental care and implementing municipal dental programs in the service area.
On the third level highly qualified and specialized consultative, diagnostic and therapeutic assistance is provided in such narrow areas of dentistry as periodontics, endodontics, diseases of the oral mucosa, dental neurology, complex dental prosthetics, orthodontics, maxillofacial orthopedics, dental implantation, plastic surgery, oncostomatology, etc. d. Institutions at this level should primarily include dental clinics of the constituent entities of the Federation, scientific and educational medical institutes, and specialized centers. The main flow of patients at the third level should be formed as a result of referrals from specialists of the previous (first and second) levels. At this level, organizational and methodological management of the dental service of a constituent entity of the Federation is carried out.
DENTAL CLINIC
Dental clinics occupy a special place in the structure of the city dental service.
The regulations on the dental clinic were approved by order of the USSR Ministry of Health dated December 10, 1976? 1166.
Regulations on the dental clinic
1. Dental clinic is a medical and preventive institution whose activities are aimed at the prevention of dental diseases, timely identification and treatment of patients with diseases of the maxillofacial area.
2. A dental clinic is organized in the prescribed manner and operates among the population, at industrial enterprises, in higher and secondary educational institutions, construction and other organizations, including, in appropriate cases, in children's groups.
3. The boundaries of the area of operation of the clinic, the list of organizations that it serves, are established by the health authority according to the subordination of the clinic.
4. The main objectives of the clinic are:
a) carrying out measures to prevent diseases of the maxillofacial area among the population and in organized groups;
b) organization and implementation of activities aimed at early detection of patients with diseases of the maxillofacial area and their timely treatment;
c) provision of qualified outpatient dental care to the population.
5. To carry out the main tasks, the clinic organizes and conducts:
Complete sanitation of the oral cavity for all persons visiting the clinic for dental care;
Complete sanitation of the oral cavity in pre-conscription and conscription contingents;
Emergency medical care for patients with acute diseases and injuries of the maxillofacial area;
Dispensary observation of certain groups of dental patients;
Qualified outpatient dental care with timely hospitalization of persons in need of inpatient treatment;
Examination of temporary disability of patients, issuance of sick leave and recommendations for rational employment, referral to medical labor expert commissions of persons with signs of permanent disability;
The whole complex of rehabilitation treatment of pathologies of the maxillofacial area and, above all, dental prosthetics and orthodontic treatment;
Activities to improve the qualifications of doctors and nursing staff.
6. The dental clinic may include:
Departments of therapeutic and surgical dentistry (including, in appropriate cases, children’s);
Mobile dental units;
Dental prosthetics departments;
Organizational method room;
Auxiliary units (X-ray, physiotherapy rooms);
Registry;
Administrative and economic part;
Accounting.
The specific structure of the clinic is established by the health authority according to subordination.
7. The staff of the dental clinic is established according to the current staffing standards and standard staffing levels.
Traditionally established structure of the dental clinic includes the following divisions (see diagram below):
1) registry;
2) dental departments: therapeutic, surgical, orthopedic with a dental laboratory, pediatric dentistry;
3) primary examination room;
4) emergency dental care office;
5) physiotherapy room;
6) X-ray diagnostic room.
In addition, the clinic can organize departments and rooms to provide highly specialized dental care to patients. These include a periodontal office, an office for receiving patients with pathological changes in the oral mucosa, anesthesiology, orthodontics, prevention, acupuncture, hirudotherapy, and functional diagnostics rooms. Large dental clinics (regional, city) have departments (offices) of implantology, anesthesiology and resuscitation, restorative therapy, endodontics, clinical diagnostic laboratories, central sterilization rooms, pharmacies and others.
The structure of the dental clinic includes a general, children's, and orthopedic registry.
The tasks of the registry include: storing outpatient records, regulating the flow of patients, informing visitors, reference work, storing and processing sick leave certificates, recording doctors' house calls.
The dental profession belongs to a group of increased risk of infectious diseases. During dental surgery, infection can be transmitted from patient to patient, dentist and vice versa.
Asepsis is a system for preventing infection from entering a wound during operations and preventing the development of nosocomial infections. Asepsis includes a set of measures to ensure the sterilization of instruments and materials
SCHEME
and compliance with procedures during operations and invasive surgical procedures.
Medical and operating rooms, dressing rooms, treatment rooms must be subject to routine, constant and general cleaning using chemical disinfectants and physical factors: bactericidal, bacteriostatic and mechanical influences. Drills and other mechanical cutting instruments should be easy to process aseptically. After surgical interventions, separate collection of used materials in hard containers is provided: gauze napkins, balls and metal instruments - needles, blades, scalpels.
Doctors working in a surgical outpatient department and in a hospital should cut their nails short and ensure that there are no cracks or hangnails. Before the operation, the doctor, using a sterile brush and soap, washes the hands and forearms, rinses them and, after wiping them with a sterile napkin from the tips of the fingers to the elbows, treats them with a swab moistened with alcohol and an antiseptic solution. In recent years, hand treatment with a 20% chlorhexidine solution has become common, as well as accelerated methods of treatment with antibacterial drugs (Zerigel, 96% ethyl alcohol), ND-410 solution.
Before the operation, the patient’s face is treated with alcohol and the oral cavity with a 0.12% solution of chlorhexidine or its derivatives, and the surgical field is isolated with sterile sheets.
The listed measures create a barrier to exogenous infection, and in 90% of cases it comes from the external environment when sterility is violated during operations: from the air, impostatically, due to infection of suture material, instruments and devices.
Infection can occur endogenously - from the skin, from the oral cavity, and ENT organs. Factors of nonspecific protection of the patient and his immunity are of great importance in activating endogenous infection.
In both clinic and hospital settings, especially in inflammatory diseases, cross-hospital infection occurs, which often causes postoperative purulent complications.
Compliance with asepsis is of great importance for the protection of doctors and medical personnel, patients from infection with viral hepatitis
titans C and group B, syphilis, tuberculosis, tetanus, anthrax, HIV infection.
An important part of asepsis is the sterilization of instruments. It consists of pre-sterilization cleaning, packaging, sterilization, monitoring its effectiveness and delivery of instruments to the surgical site.
Mechanical cleaning of instruments, syringes or carpule holders, and device systems is carried out using brushes and sterile detergents and antiseptics. Burs, cutters, circular saws, sharp curettage spoons, rasps, and osteotomy instruments should be processed especially carefully. Mechanical and antiseptic cleaning of instruments is complemented by ultrasonic treatment. After purulent interventions, instruments are especially carefully mechanically cleaned and additionally soaked in antiseptic solutions.
Instruments are sterilized using physical factors or chemicals. Physical methods of sterilization include steam, hot air (dry air), filtration, infrared and radiation methods. Currently, the most common sterilization is in dry steam sterilizers with packaging of each instrument. For air sterilization, craft bags are used, for steam sterilization, vegetable multilayer parchment is used. Multilayer packaging is the most reliable.
Individual devices (endoscopes, units of devices for hemosorption, lymphosorption) are cleaned and sterilized in a gas sterilizer.
The tips of dental drills are sterilized by boiling in petroleum jelly followed by centrifugation.
Chemical sterilization is most appropriate in the form of low-temperature exposure using formaldehyde and ethylene oxide gases. This method is very convenient as it only takes 20 minutes.
Dressing material - napkins, tampons, balls, bandages are packed in a towel or sheet and placed in containers, sterilized at a pressure of 2 atm and a temperature of 132.9 ° C for 20 minutes. Robes and sheets are also sterilized. The suture material is first treated in a triple solution, washed with running water, dried and sterilized by boiling in distilled water.
water for 20 minutes. The use of packaged disposable needles with suture material is also effective.
Impressions, protective plates, mouthguards, dental splints after rinsing in running water for 1 minute are disinfected in 0.5% chlorhexidine solution, MD-520 (50% glutaraldehyde and 50% alkylbenzyldimethylammonium chloride), 0.1% desoxon, 6 % hydrogen peroxide solution, and plasma disinfection is also used. After treatment with disinfectant, orthopedic medical splints, mouthguards, etc. are washed. in running water.
To control sterilization, ampoules with benzoic acid, resorcinol, antipyrine, ascorbic or succinic acid powder, pilocarpine hydrochloride, thiourea are placed between the material and the packaging tool. These medicinal substances have a high melting point (110-200 ° C) and their melting indicates the optimal sterilization temperature.
The sterility of preoperative rooms, operating units, materials and instruments is checked by the bacteriological method - inoculation under aerobic and anaerobic conditions, as well as placing test tubes with a spore-bearing, non-pathogenic culture of microorganisms in containers. The absence of microorganism growth indicates the sterility of instruments and materials. Constant monitoring of the sterilization process can be carried out by placing biological indicators in the boxes. It should be borne in mind that the endospores of tetanus, anthrax, mycobacterium tuberculosis, viruses, including the AIDS virus, fungi, and Vibrio cholerae are poorly destroyed and high- and medium-level disinfectants are most effective in combating them.
In dental clinics, it is necessary to screen staff for dangerous and viral infections. Personnel must undergo an annual medical examination with blood testing for the presence of hepatitis A, B, C, D viruses, HIV infection, and be vaccinated against hepatitis B and diphtheria twice a year.
Considering the increase in the number of patients infected with HIV infection and AIDS patients, when operating on urgent patients, it is necessary to take increased precautions and work in double gloves and goggles, using only disposable instruments.
Infectious diseases transmitted during dental procedures
Basic requirements for operating a dental office
Before starting work and after the end of the work shift, the manipulation table, table for storing sterile instruments, dental chairs, sinks, sink taps are disinfected by wiping twice with a rag moistened with a 1% chloramine solution, after which the bactericidal lamp is turned on. The sterile table is set for 6 hours. Sterile instruments can also be stored in sterile packaging or in a bactericidal chamber such as “MicrocidMed” in order to prevent secondary contamination of dental instruments.
Pre-sterilization treatment of dental instruments
Conducted by a nurse. Stages:
1. Soaking (detachable products are placed disassembled) in a 3% solution of chloramine, or a 6% solution of hydrogen peroxide, or a 5 - 8% solution of alaminol for 60 minutes.
2. Rinse for 15 seconds with running water.
3. Soaking (full immersion) in a biolot solution heated to 40 °C for 15 minutes.
4. Rinse each instrument in the same solution with brushes or cotton-gauze swabs for 15 s.
5. Rinsing sequentially: with tap and distilled water (at the rate of 200 ml of tap water for each product) for 1 and 0.5 minutes, respectively.
6. Drying in the open air.
Points 2, 3, 4 are intended for using solutions of chloramine and hydrogen peroxide.
Soaking of spent burs and endodontic instruments is carried out for 30 minutes in disinfectant. solution (3% hydrogen peroxide, 10% ammonia and 70% alcohol mixed in equal quantities), then in a biolot solution (at a temperature of 40 ° C) for 15 minutes.
Soaking used cotton-gauze swabs, gloves, masks, etc. produced in a 3% solution of chloramine or 5 - 8% solution of alaminol for 120 minutes.
Quality control of pre-sterilization treatment assessed by using azopyram (azopyram, 3% hydrogen peroxide solution in a 1:1 ratio, applied with a pipette to the instrument or wiped with a swab) or amidopyrine (95 g alcohol + 5 g amidopyrine. 2 drops each: amidopyrine, 3% hydrogen peroxide, 30% acetic acid) samples. A blue-violet color indicates the presence of blood. 1% of simultaneously processed products of the same name (but not less than three products) are subject to control.
Disinfection of dental instruments
Before and after use, dental handpieces are wiped twice with 70% alcohol or 3% chloramine solution, then passed through a burner flame. Disinfection of tips can also be carried out in disinfection systems “Terminator”, “Assistina”, special “pockets”, etc.
Dental mirrors are immersed for 60 minutes in a closed container with a 3% chloramine solution or 6% hydrogen peroxide. Then they are rinsed with distilled water and wiped with a sterile cloth. Mirrors are stored in a sterile tray or in a closed sterile container.
Casts, attachments for guns for rinsing the tooth cavity, knives for cutting crowns, Kopa crown remover, etc. disinfected by wiping twice with a 1 - 3% chloramine solution (or special disinfection solutions) with an interval of 10 minutes.
During a therapeutic appointment, gloves are washed with running water and soap, wiped with alcohol or a special solution. During a surgical procedure, gloves should be disposable and sterile.
Sterilization
Sterilization is the complete destruction of microorganisms and their spores on (in) the sterilized object.
Requirements for sterilization
Sterilization must be carried out directly at the workplace, or the object to be sterilized must be placed in an impenetrable package (before or after sterilization).
After sterilization, the object must not contain living microorganisms. The object must not be modified during the sterilization process. After sterilization, the object must remain sterile for a long time.
Classification of sterilization methods
1. According to the obligate state of the sterilizing agent:
a) liquid methods;
b) using gaseous substances;
c) plasma sterilization;
d) using radiation.
2. According to the factor of influence on the object being sterilized:
a) penetrating or volumetric (destroy the protein of microorganisms);
b) having a superficial effect.
3. According to the method of influencing the sterilized object:
a) chemical;
b) physical;
c) combined.
Types of sterilization used in dentistry
Liquid
Chemical. This type of sterilization includes easy-to-use methods of soaking, treating instruments in solutions (for example, hydrogen peroxide 3%, 6%; hypochlorous acid salts; chloramine 1 - 3%, etc.). The solutions can also be used to process impressions during ultrasonic processing. The advantages of the method are the ability to process internal channels of small diameter and low processing temperature. The disadvantages of the method are: surface exposure, compliance with safety regulations, processing time (minimum 10 hours), mandatory several washes, harmful effects on personnel, waste disposal problems.
Thermal. Boiling. Sterilization of all-metal dental instruments (burs, needles, pluggers, hooks, reusable syringes, etc.), materials can be carried out by boiling in distilled water with the addition of 1 - 2% sodium bicarbonate solution for at least 30 minutes. The method is penetrating. Environmentally friendly. However, the duration of the procedure and the inability to boil sharp cutting instruments limit the use of this method.
Sterilization of dental handpieces can be carried out by boiling for 1 hour in petroleum jelly with the addition of a 2% solution of hydroxyquinol, followed by centrifugation. The method is reliable, penetrating, but time-consuming and requires special equipment.
Gas
Chemical. Gas sterilization with ethylene oxide. The object to be sterilized is kept in a gas environment for 1 hour, after which the room must be ventilated for 10 hours. The reliability of the method is very high (100% sterilization). The method is penetrating. It has high productivity, since it is carried out centrally, in large batches of the sterilized object. There are no restrictions on materials that can be subjected to this method. Sterilization can be carried out in packaging. All disposable instruments undergo this treatment. The disadvantages of the method are: the use of highly toxic gas, which can have a harmful effect on the environment, the possibility of current
significant precipitation on surfaces after treatment, duration of the procedure.
Ozone sterilization. The object is kept in an ozone atmosphere for 1.5 hours (for example, in an SS-5 apparatus). The method has no restrictions on the materials of the object being sterilized. However, large amounts of ozone are toxic, and the length of the process does not add to the advantages of this sterilization method.
Thermal. Dry heat method. It is the most common in dentistry because it is easy to use, environmentally friendly, and allows the processing of an object in packaging. However, not all instruments can be sterilized using this method. The object is kept at a temperature of 180 °C for 1 hour. The dry-heat oven cannot be filled (low reliability). High temperatures require compliance with safety precautions.
Steam (autoclaving) method. The sterilizing agent in this case is steam heated to 120 °C under a pressure of 1.1 atm. for 12 minutes, up to 134 °C - for 4 minutes. The method is penetrating, environmentally friendly, and the speed is high. However, high temperature and humidity limit its use for cutting tools and require compliance with safety precautions. Recently, the method has become widespread.
Glasperlene method. It is also penetrating, but is used only for sterilizing small instruments. The working part of the instruments is immersed in a medium heated to 240 - 270 °C for several seconds.
Plasma sterilization
Plasma is the fourth state of matter. For this type of sterilization, argon is used, passed through alternating current. The method is penetrating. The effect of ball lightning is used. Bombardment with atoms and molecules of the plasma substance of the sterilized object breaks the bond between the proteins of microorganisms, resulting in their death. Sterilization occurs at a temperature of 60 - 80 °C for 10 - 12 minutes. Device "Plasmodin-2".
Sterilization methods using radiation
Radiation sterilization. The use of penetrating ionizing radiation, the source of which is Co 60, is possible only in industrial conditions due to the risk of personnel exposure.
The method has the same positive characteristics as the gas (ethylene oxide) method.
UV sterilization. The use of ultraviolet radiation is only possible for open surfaces of the object being sterilized. The method is simple, but when the device operates for a long time, a large amount of ozone is released.
IR sterilization. Infrared radiation is also used to sterilize exposed surfaces (surface exposure) of the object being sterilized. But the method produces heating of surfaces.
Microwave sterilization. Ultra-high frequency currents (electromagnetic radiation) have a sterilizing effect. The method is ineffective and harmful to personnel, but the effect on the object being sterilized is short-lived.
Sterilization control
Sterilization control is carried out in one of the following ways:
Selective microbiological control (flush is sown on nutrient media);
The use of chemical indicators (indicator strips that change color at a certain temperature);
The use of biological indicators (strips with test microbial cultures, which after sterilization are placed in nutrient media; if there is growth, the entire batch is rejected).
Sterilization of instruments in case of threat of HIV infection
The virus dies at a temperature of 46 °C for 30 minutes.
Disinfectants (WHO, 1986): ethyl alcohol 70° - 10 min, 50° - 12 min; propyl alcohol 75° - 1 min, ethyl alcohol with acetone 1:1 - 10 min; chlorhexidine 4% - 5 min, 3% - 10 min; sodium hypochloride 0.5% - 1 min, 0.1% - 10 min; hydrogen peroxide 3% - 1 min, 0.3% - 10 min; formaldehyde 0.2% - 5 min, 2% - 1 min; phenol 5% - 1 min; Lysol 0.5% - 10 min; paraformaldehyde 0.6% - 25 min.; polyvinylpyralidone 10% - 1 min; chloramine 2%, formaldehyde 40% 1:1 - 10 hours for mirrors.
The main link in the system of providing dental care to the population in Russia is the dental clinic. The traditionally established structure of dental clinics includes departments of therapeutic dentistry, surgical dentistry, orthopedic dentistry with a dental laboratory, physiotherapy, and an x-ray room (usually for the production of dental x-rays). Currently, the structure of dental clinics includes departments (rooms) of anesthesiology, departments (rooms) for the treatment of periodontal diseases and oral mucosa, restorative therapy, implantology, rooms (rooms) of oral hygiene and preventive departments. In large dental clinics, functional diagnostic rooms, a clinical laboratory, a centralized sterilization room, and a pharmacy kiosk are deployed. Mobile dental care units are organized in republican, regional, and regional dental clinics, as well as in dental clinics at central district hospitals.
In the regulations on dental clinics (Appendices 4 and 5 to the order of the USSR Ministry of Health No. 1166 of December 10, 1976, paragraph 7) it is noted that “... the specific structure of the clinic is established by the health authority according to subordination.” We have presented an approximate structure of a regional dental clinic (diagram 2.1).
Regional dental clinics are located in regional centers (cities). On organizational and methodological issues, they are subordinate to the republican dental clinics. The main objectives of these clinics are organizational and methodological guidance and medical and advisory assistance in the work of dental institutions located in rural areas and cities of regional subordination.
Dental clinics in cities of regional subordination, which are part of the central district hospitals, provide organizational and methodological management of all dental institutions in the region, provide medical and advisory assistance in the work of dental institutions in the region.
City dental clinics located in cities of republican and regional subordination provide organizational and methodological management of interdistrict and district dental clinics of a given city and provide medical and advisory assistance in their work. In cities that do not have a district division, a city dental clinic is also created, performing the same functions in relation to other dental institutions.
In accordance with modern requirements, the structure of dental clinics provides for the creation examination rooms. The dentists working there provide justified (according to indications) referral of patients to clinic doctors who provide specialized dental care, and prescribe the necessary additional examinations, which also saves the working time of other clinic doctors. In addition, doctors in examination rooms should provide assistance to patients with acute dental pain if it is not possible to refer them to the appropriate department or office.
The dental clinic is designed to provide highly qualified dental care to the population. Its main tasks are determined “Regulations on the dental clinic”, approved Order of the USSR Ministry of Health of December 10, 1976 No. 1166 (Appendix 4).
1. Implementation of measures for the primary prevention of dental diseases among the population.
2. Providing a full range of highly qualified dental care to the population in all specialties.
3. Organization of statistical accounting and reporting.
4. Study and dissemination of best practices, introduction of new methods of prevention, diagnosis and treatment of dental diseases.
5. Advanced training of doctors and nursing staff.
6. Advisory work, accompanied by the issuance of a medical report to patients indicating the diagnosis, treatment and further recommendations.
Dental therapeutic department is part of the structure of a dental clinic, and can also be organized as part of a general medical institution (polyclinic, medical unit, central district hospital). Its staff depends on the size of the population served and the volume of work performed. The organizational structure of the dental therapeutic department can be presented as follows (Diagram 2.2).
In large dental clinics, with a large number of medical positions (more than 20), 2-3 departments can be organized. However, each of them specializes in the treatment of certain diseases of the oral cavity, for example, a department dealing with the treatment of diseases of the oral mucosa, periodontal disease, endodontic department or restorative therapy. In private dental institutions, as well as in small clinics or departments, rooms for highly specialized appointments may be allocated.
Scheme2.2. Structure of the dental therapeutic department
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Features of the organization of dental care for the children's population are determined, first of all, by the high level of dental morbidity in childhood and adolescence: more than 80% of children suffer from dental caries, 95% from periodontal diseases.
Outpatient dental care for children is provided by the following dental institutions:
. children's dental clinics;
. children's dental departments (offices) of general medical institutions;
. dental offices of educational institutions.
Children's dental clinics as independent health care facilities are organized in large cities with a child population of at least 60-70 thousand people. In cities with a child population of up to 20 thousand, dental care is provided in children's departments (offices) of dental clinics for adults.
The main tasks of the children's dental clinic include:
. ensuring high-quality treatment and diagnostic process based on the standards of medical care for children suffering from dental diseases;
. organizing and conducting routine preventive examinations and sanitation of the oral cavity of children in institutions of preschool, primary general, basic general, secondary (complete) general, special education, primary and secondary vocational education;
Providing emergency dental (surgical) care to sick children with acute diseases and injuries of the maxillofacial area;
. conducting dispensary observation of children with pathology of the dentoalveolar system with assessment of the level of dental health of children;
. referral of sick children for inpatient treatment to specialized dental departments in the prescribed manner;
Carrying out complex orthodontic treatment for children with dental and facial anomalies;
. analysis of dental morbidity in children and development of measures to reduce and eliminate the causes contributing to the occurrence of diseases and their complications;
. introduction of modern methods of prevention, diagnosis and treatment of dental diseases of the maxillofacial area in children;
Carrying out sanitary education work among the population, including with the involvement of nursing staff of medical institutions, teaching staff of schools and preschool institutions, parents, using all media (print, television, radio broadcasting, visual propaganda, etc. .);
Equipping the structural units of the clinic with medical equipment, instruments, as well as medicines and consumables in accordance with the list of equipment and instruments;
. maintaining records and compiling medical reports in the prescribed manner.
There are certain requirements for the structure of a children's dental clinic; the presence of at least 2-3 orthodontist offices, a psychologist’s office, and a games room. If dental care for children is provided in a department that is part of a dental clinic for adults, then mandatory conditions include the presence of a separate entrance for children and at least two rooms (surgical, therapeutic).
One of the features of organizing the work of children's dental clinics is the widespread use of the method of planned sanitation.
The main figure in the children's dental clinic is a pediatric dentist who has received a higher professional education in the specialty "dentistry" and has completed an internship in the specialty "general dentist" or a clinical residency in the specialty "pediatric dentistry."
Specialized care is provided by specialist dentists (therapist, surgeon, orthopedist, orthodontist) who have undergone professional retraining in pediatric dentistry in accordance with the requirements of the educational standard, standard program and curriculum, approved in the prescribed manner and received a specialist certificate in the relevant specialty. In addition, dentists can provide dental care to children.
The main task of a pediatric dentist is to carry out preventive, diagnostic, therapeutic and sanitary educational work aimed at the optimal development of the dental system of children. For this purpose, he carries out planned sanitation of the oral cavity of children, medical examination of those in need of constant dynamic observation.
If necessary, provides emergency dental care to children on an outpatient basis, in accordance with the established procedure, refers children with pathologies of the maxillofacial area for inpatient treatment in specialized dental departments, etc.
O.P. Shchepin, V.A. Medic
11.1 Organization of dental care for the urban population
Dental care for the urban population is provided in a variety of institutions or departments, from a dental office to an independent specialized dental clinic.
The beginning of this organizational hierarchy is the dental office - the most massive structural unit of the service. The pinnacle of organization and concentration of all its types is an independent specialized dental clinic with departments of therapeutic, surgical and orthopedic dentistry, a department or office of pediatric dentistry, orthodontic, physiotherapy, x-ray rooms and a laboratory.
Such a highly specialized institution with a sufficient number of highly qualified specialists makes it possible to comprehensively resolve issues of diagnosis and treatment of patients, make maximum use of property, equipment, instruments and have the opportunity to consult patients with various specialists in one institution.
The capacity of dental clinics varies and is determined by the number of full-time medical positions.
Table No. 3. Categories of independent dental clinics and staffing standards for medical personnel (approximate distribution by departments and offices)
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Name of departments and offices | |||||
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1. Chief physician | |||||
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2. Deputy Chief Physician | |||||
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3. Heads of departments | |||||
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4. Branches: | |||||
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Therapeutic | |||||
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Surgical | |||||
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Orthopedic | |||||
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5. Offices: | |||||
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Orthodontic | |||||
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Physiotherapeutic | |||||
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X-ray | |||||
The vast majority of patients is treated in the therapeutic department, so from 30 to 15% of the entire medical staff of the clinic are directly involved in the treatment of diseases of the oral cavity and teeth. The share of dental surgeons is 7-8%, and orthopedic dentists are 16-18%.
Urgentdental care During the opening hours of the clinic, he is the dentist on duty, and at night, he is the doctor at special emergency dental care points, organized in several clinics in the city.
In addition to the budgetary network of dental clinics, self-supporting clinics are opening in cities, which provide highly qualified dental care to all residents, regardless of age, place of work and residence.
Chief physician of the dental clinic carries out management of all treatment and preventive, organizational, methodological, economic and financial activities, controls the implementation of activities aimed at improving the quality and culture of medical care for the population, analyzes the performance indicators of the institution and individual specialists, appoints and dismisses medical and administrative personnel, imposes disciplinary sanctions on employees for violation of labor discipline.
As a loan manager, he controls the correct use of the budget, is responsible for sanitary conditions and the implementation of fire safety measures, etc.
Deputy for medical and preventive work bears responsibility for the quality of examination and treatment of patients, medical examination, rational use of medications, equipment, and advanced training of medical staff. He resolves issues of hospitalization of patients together with the organizational and methodological office, studies the experience of other dental clinics, and holds production meetings.
Each department is headed manager, which ensures the organization of correct and timely diagnosis, high-quality treatment and prevention of diseases, appropriate maintenance of medical records, advanced training of doctors and nursing staff, preservation and use of equipment, instruments and medicines.
Staffing standards for medical personnel in dental clinics are determined by Decree of the Ministry of Health of Ukraine No. 33 dated February 23, 2000. According to him, in urban dental clinics for adults located in cities with a population of more than 25 thousand people, they are as follows:
1-4 positions of dentists and dental surgeons in total per 10 thousand adult population of the city where the clinic is located;
2.5 positions in total per 10 thousand adult rural population;
2.7 positions in total per 10 thousand adult rural population;
2 positions of dentists and orthopedists, who are maintained on self-support or with special funds, are established on the basis of:
1 position per 10 thousand adult population of the city where the clinic is located;
0.7 positions per 10 thousand adult rural population;
0.8 positions per 10 thousand adult rural population.
The positions of heads of departments are established by:
dental department - 1 position for every 12 positions of dentists and dental surgeons, but no more than 3 positions per clinic;
Dental prosthetic department (maintained on self-support or at the expense of special funds) - 1 position per clinic, in which, according to current staffing standards, at least 4 positions of dentists and orthopedists are established.
The position of deputy chief physician for medical affairs is provided for in the staff of the clinic, where there are at least 40 medical positions, including the position of the chief physician.
The positions of dental surgeons in the departments of maxillofacial surgery are established at the rate of 1 per 25 beds. In accordance with the standards for providing the population with hospital beds for certain profiles, beds for dentistry are not provided. They are deployed in large cities in one of the city hospitals in agreement with local health authorities. The position of the head of the surgical dental department is established instead of 0.5 of the position of a doctor if there are less than 60 beds in the department.
To serve patients in hospitals of regional, central city, city hospitals, medical units organize dental offices at the rate of 1 position for 600 beds, in tuberculosis hospitals - 0.5 for every 250 beds, but not less than 0.5 positions in hospitals.
The positions of nurses in medical offices are established on the basis of one position per:
1 position of a dental surgeon;
2 positions of dentists and orthodontists;
3 positions of dentists and orthopedists.
In dental offices, where the staff provides for 1 position of a dentist, at least 1 position of a nurse is introduced.
In dental laboratories that are self-supporting, the number of dental technicians is set depending on the amount of work on prosthetics at the rate of 2-3 positions per orthopedic dentist. The position of a senior dental technician in a dental laboratory is provided for every 10 positions of dental technicians, but not less than 1 position for 3 dental technicians instead of one of them.
The positions of junior nurses are established at the rate of 1 position for 1 position of a dental surgeon, or for 3 positions of dentists of other specialties.
A mandatory structural department of any dental clinic is the registry (with a medical archive), which regulates the flow of patients and carries out accounting, statistical and reference information activities.
The reception desk works in two shifts. Its work should begin in 20-25 minutes. before admitting patients. Depending on the capacity of the clinic, several registrars may work at the reception desk in one shift. The registrar fills out the passport part of the dental patient’s medical record, issues a coupon for an appointment with a doctor, which indicates the date and time of the appointment, the doctor’s name, office number, and floor. Medical records are transferred to the offices. Registrars supervise the self-registration of patients for appointments and provide information about the work of other medical institutions in the city.
Calculations of registrar positions are made according to the principle of 1 registrar for every 5 positions of doctors who conduct receptions, but not less than 1 position per shift.
To save time, an examination room is organized in the clinic, the dentist of which ensures reasonable referral of patients to other rooms and, if necessary, provides emergency care.
The therapeutic department has rooms for the treatment of diseases of the teeth, periodontium and oral mucosa. Large clinics may have 2 therapeutic departments.
When one chair is installed in a therapeutic dentistry office, the room must have an area of at least 14 square meters. m. For each additional chair you need to allocate at least 7 square meters. m. Doctors of the department of therapeutic dentistry work in 2 shifts according to the schedule. The most effective was the provision of therapeutic dental care on a local-territorial basis.
In view of the patient’s right to choose a doctor, outpatient appointments are carried out on the principle of free appointment, and according to the local-territorial principle, only dispensary work is carried out.
The dentist is appointed as the chief physician of the clinic. In his daily work he reports to the manager. department, deputy chief physician for medical treatment and chief physician. Doctor's orders are mandatory for middle and junior staff of the department within the limits of their functional duties.
The dentist is obliged:
ensure effective and high-quality provision of dental care to patients;
provide emergency care in cases of anaphylactic shock, collapse, loss of consciousness and other emergency conditions;
take part in medical examinations of the population;
conduct an examination of temporary disability;
conduct dispensary observation of certain contingents;
systematically improve your professional level by applying modern methods of diagnosis, treatment and prevention of dental diseases;
constantly take care of improving the professional theoretical skills of middle and junior staff;
carry out sanitary education work among the population;
adhere to workplace safety rules.
The dentist is responsible for:
failure to fulfill the production plan and poor quality treatment of patients;
the occurrence of complications after treatment due to his fault;
poor quality and untimely maintenance of necessary medical documentation;
irrational use of available diagnostic and treatment equipment, instruments and other medical equipment.
The results of medical examinations and observation data of patients during outpatient visits allow us to select dispensary groups for further recording, observation and treatment.
D1– healthy and practically healthy individuals who do not have dental diseases, periodontal disease or malocclusions. This also includes patients who have a compensated form of caries, diseases of the mucous membrane associated with unhygienic maintenance of the oral cavity and patients after traumatic damage to the dental system. Their sanitation is carried out once a year.
D2– persons who have subcompensated numerous caries, dental fluorosis, increased fragility, gingivitis, periodontitis, leukoplakia, trigeminal neuralgia, after surgical interventions and dental injuries, those who have inflammatory processes (osteomyelitis, odontogenic lymphadenitis, etc.) , are undergoing orthodontic treatment, etc. They are inspected and sanitized at least 2 times a year.
D3– persons with sub- and decompensated forms of caries, generalized periodontal disease and periodontitis, diseases of the marginal periodontium caused by diseases of the internal organs (periodontal syndrome), as well as those who require complex dental treatment with a severe course of the disease, with chronic recurrent aphthous stomatitis, etc. d. This group is examined and sanitized 3 times a year or more.
Dental surgery department provided only in large dental clinics if the clinic has 6 or more dental surgeons on staff.
The structure of such a department includes: an operating room, a preoperative room, a sterilization room, and rooms for the temporary stay of patients after surgery. The area of the surgical department with one dental chair is 23 sq.m. for each subsequent chair - +7 sq.m.
In dental clinics of II-V categories there is only a surgical room.
In recent years, the structure of surgical departments of dental clinics has included restorative treatment and rehabilitation rooms. This makes it possible to ensure continuity in outpatient and inpatient treatment of patients, increase its efficiency and reduce the duration of temporary disability.
The main responsibilities of a dental surgeon at a polyclinic are:
reception of primary and secondary patients, diagnosis of diseases, provision of emergency and planned surgical care;
advisory assistance to patients;
referring patients for consultation to specialized institutions and for inpatient treatment;
conducting medical examinations in the oral cavity;
medical examination of patients according to profiles;
examination of temporary disability;
carrying out medical rehabilitation at the stage of after-treatment of patients with injuries, inflammatory processes of tissues of the maxillofacial area.
Dental orthopedic care is one of the foundations of tertiary prevention. Without orthopedic intervention, it is impossible to consider dental patients cured, because Almost all of them have damage to the dentofacial apparatus.
The relevance of orthopedic dental care for the child’s body is confirmed by scientific observations, which show that among preschool children, 20-25% have various disorders in the development of the jaw system, and 5-7% of them require emergency orthopedic care.
Orthopedic care is provided in departments or offices of dental clinics. Doctors of the orthopedic department provide medical care to adults and children in cases where there are no children's dental facilities.
For orthopedic treatment, patient populations are formed by independently seeking help, as well as by patients referred by dentists of other specialties.
The activities of the orthopedic department are supported by self-supporting or special funds. Free or preferential treatment is provided to participants in the liquidation of the Chernobyl accident, disabled people of war, labor and persons equivalent to them, pensioners, and children.
The orthopedic department includes patient reception rooms, a dental laboratory and a foundry.
The doctor on duty examines the patient and selects the design of the necessary prosthesis. If the patient needs sanitation of the oral cavity, he is referred to a therapist or surgeon who provides treatment and preparation for prosthetics.
After preparing teeth for dentures, the orthopedic doctor takes an impression and, through a nurse, passes it on to the production manager. The manager determines the deadline for the intermediate stage of prosthesis manufacturing and appoints the patient for the next visit. Depending on the organization of work of dental technicians, orthopedic care can be provided in three forms:
individual - when the dental technician completely makes the denture himself;
brigade – when there is a distribution according to the type of prosthesis;
step-by-step – when there is a distribution of operations on one prosthesis.
Every regional, city and district dental clinic (department) organizes an appointment with an orthodontist for the treatment and prevention of malocclusions and jaw deformities in children. The positions of orthodontists are distinguished from the positions of pediatric dentists. With a standard of 5.0 doctors per 10 thousand children, 0.5 positions are allocated to orthodontics.
The positions of dental technicians to service the work of orthodontists are established on a 1:1 basis.
Surgical dental inpatient departments are organized in regional and large city hospitals. The number of beds in them depends on the population that lives there and on the use of the hospital as a clinical base for universities.
An independent department is created if it has from 40 to 60 beds. For inpatient treatment of patients with pathology of the maxillofacial area in small settlements, specialized beds are deployed in one of the surgical departments of a city or district hospital with the consent of local health authorities. According to staffing standards, there are 25 beds per dental surgeon in the hospital.
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The most important tasks of dental organizations are a set of dispensary measures for prevention, early detection, treatment and rehabilitation of patients with oral diseases. salivary glands and jaws.
More than 90% of patients receive general and specialized dental care at ASTU, which include:
. state and municipal dental clinics for adults and children (republican, regional, district, regional, city, district);
. dental departments (as part of multidisciplinary hospitals, medical units, departmental institutions, etc.);
. dental offices (in dispensaries, antenatal clinics, general medical (family) practice centers, health centers of industrial enterprises, educational institutions, etc.):
. private dental organizations (clinics, offices, etc.).
Patients receive inpatient specialized dental care in the maxillofacial surgery departments of multidisciplinary hospitals.
The availability of dental care to the population depends on many factors: pricing policy, organizational forms of its provision, the provision of the population with dentists (dentists), etc. Currently, dental care is provided to the population in the following organizational forms: centralized, decentralized, mobile.
In the centralized form, the population is received directly at the dental clinic or in the dental department (office) as part of another medical institution.
A decentralized form of providing dental care to the population involves the creation of permanent dental offices at health centers of industrial enterprises and in educational institutions. This form is most suitable for organizing dental care for the working population and students. The advantage of this form is undeniable, but it is advisable to organize such offices in enterprises with 1,200 employees or more and educational institutions with 800 or more students.
The on-site form is most effective for providing dental care to rural residents, children in preschool institutions, the disabled, single and elderly citizens. It allows us to bring both general and specialized dental care to these categories of citizens as close as possible.
Persons suffering from acute dental pain, traumatic injuries to teeth, jaws and other acute dental pathologies should be provided with emergency dental care. Round-the-clock provision of emergency dental care to the population in large cities is carried out by emergency departments for adults and children (in the structure of dental clinics) and offices operating within the structure of emergency medical care stations (departments).
The main task of specialists working in dental organizations, regardless of the form of ownership and departmental affiliation, is the sanitation of the patients’ oral cavity.
Sanitation of the oral cavity (from the Latin sanus - healthy) is a comprehensive improvement of the organs and tissues of the oral cavity, which includes the treatment of caries, elimination of non-carious tooth tissue defects by filling, removal of tartar, treatment of periodontal diseases, removal of damaged teeth and roots, not subject to conservative treatment, orthodontic and orthopedic treatment, training in oral hygiene skills, etc.
There are two forms of oral sanitation: by referral and planned.
Sanitation of the oral cavity on request is carried out for patients who independently apply to a dental clinic (department, office) for medical help.
Planned sanitation of the oral cavity is carried out at the place of study, work in a dental office or in a clinic. First of all, the oral cavity is sanitized for persons working in hazardous industries or in enterprises with such working conditions that contribute to the intensive development of dental diseases: for example, dental caries in workers confectionery or flour mills, acid necrosis of enamel in persons in contact with acid vapors, gingivitis in greenhouse workers, etc.
Planned sanitation is also indicated for persons suffering from various chronic somatic diseases in order to avoid the formation of foci of odontogenic infection. Planned sanitation is carried out for children in kindergartens, schools, boarding schools, sanatoriums, health camps, and pediatric hospitals.
Depending on the population served, the prevalence of dental diseases and the availability of dental care in a particular area, planned sanitation of the oral cavity can be carried out using the following methods:
. centralized;
. decentralized;
. brigade;
. mixed.
Centralized method
Planned sanitation of the oral cavity is carried out directly in the dental clinic or dental department within the structure of a medical institution, which makes it possible to organize the reception of patients with the necessary laboratory and instrumental tests and consultations with specialists. However, in some cases it can be difficult to organize a visit to the clinic for persons subject to planned sanitation, especially children. In this case, a decentralized method of planned rehabilitation is used.Decentralized method
Sanitation of the oral cavity is carried out directly in preschool institutions, schools and enterprises through the organization of dental offices. If the number of students in schools is insufficient (less than 800 people), a dental office is opened in one of them, which serves children from 2-3 nearby attached schools.This ensures the necessary level of accessibility to dental care for children, maximum coverage of their sanitation and preventive measures. The weakness of the method is that dental offices are insufficiently equipped with special equipment, so children with complex diseases and, if necessary, additional diagnostic tests are sent to a dental clinic.
Brigade method
Planned sanitation of the oral cavity is carried out by a visiting team of dentists from a district or regional dental clinic. Teams, as a rule, consist of 3-5 doctors and one nurse; they go directly to schools, preschool institutions, and enterprises, where they carry out sanitation of the oral cavity of children and adults for the required period of time. For these purposes, specially equipped transport is used.Mixed method
Provides for a combination of certain methods of planned sanitation of the oral cavity based on the capabilities of the territorial health care system, the availability of dental institutions, their availability of qualified personnel, and the necessary diagnostic and therapeutic equipment.In children, the method of planned sanitation is usually implemented in two stages.
The first stage is to examine the child’s oral cavity and determine the types of dental care needed.
The second stage is the provision of dental care as soon as possible until complete rehabilitation.
In some cases, planned rehabilitation includes a third stage - subsequent active dynamic monitoring of sick children.
Planned sanitation of the oral cavity in children should be considered as the main means of preventing dental caries and timely correction of maxillofacial anomalies. Planned sanitation, regardless of the forms and methods used, provides for mandatory repeated (control) examinations of children every 6 months.
The success of planned rehabilitation of children in organized children's groups largely depends on the coordinated actions of the heads of children's dental clinics and preschool and school educational institutions. For this purpose, planned rehabilitation schedules are drawn up in advance, and organization and control of their implementation are ensured.
O.P. Shchepin, V.A. Medic
