Dental caries in children: clinical guidelines

List of Abbreviations

ICD-10 – International Classification of Diseases 10th Revision

OHI – oral hygiene index

DP – dental plaque

DD – dental deposits

DMF – decayed, missing, filled

df – decayed, filled

pH – acid-base balance

EPT – electric pulp testing

DEJ – dentinoenamel junction

Terms and Definitions

Enamel demineralization is the process of dissolution of dental enamel hydroxyapatite crystals.

Dental plaque (dental biofilm) is a colorless formation located on the dental pellicle, representing an accumulation of bacteria in the form of a biofilm.

Caries intensity is the sum of carious, missing, and filled teeth in an examined individual.

Caries prevalence is the number of individuals with dental caries relative to the number of examined individuals, multiplied by 100.

Caries resistance is the resistance of the organism and hard dental tissues to the action of cariogenic factors.

Caries is a nonspecific infectious disease of the teeth arising from a disruption of homeostasis in the oral cavity favoring bacterial acid production processes and manifesting as foci of enamel demineralization or dental cavities.

Enamel caries is a pathological process occurring after tooth eruption and characterized by demineralization and softening of the enamel.

Dentin caries is a pathological process in which caries affects not only the dental enamel, but also the underlying dentin.

Preparation (from preparation) is the intervention on dental tissues aimed at removing pathologically altered tissues and creating a cavity shape that ensures reliable retention of the filling.

Arrested dental caries is a stabilized carious process manifested by a dense pigmented spot.

Caries prevention is a set of measures aimed at preventing the onset of caries and eliminating risk factors.

Remineralization is the process of restoring enamel hydroxyapatite crystals by saturating hard dental tissues with mineral components.

Fluoridation is the procedure of treating teeth with high-fluoride preparations.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Dental caries is a nonspecific infectious disease of the teeth arising from a disruption of homeostasis in the oral cavity favoring bacterial acid production processes and manifesting as foci of enamel demineralization or cavities on the teeth.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The main cause of dental caries in children is considered to be the infectious factor – microorganisms of the dental biofilm (dental plaque). The most cariogenic microorganism is Streptococcus mutans (Str. mutans), which has a high degree of adhesion to the tooth surface, is capable of producing acids and extracellular saccharides from simple sugars, and multiplies well in an acidic environment. Acids cause enamel demineralization, while extracellular polysaccharides form the dental biofilm matrix and a gel-like medium that restricts saliva penetration and the neutralization of acids. Some other acidogenic streptococcal strains (Str. sobrinus, sanguis, salivarius), lactobacilli (Lactobacillus), and actinomycetes (Actinomyces viscosus) also play a significant role in the development of caries [1].

The development of caries in children is also promoted by other factors, referred to as cariogenic. Of greatest importance in childhood is improper nutrition, mainly the consumption of large amounts of sugar-containing (sucrose, glucose, fructose, etc.) foods and beverages [2].

Oral microorganisms, the nature and regimen of nutrition, enamel resistance, the quantity and quality of mixed saliva, the general condition of the organism, exogenous impacts on the organism, the fluoride content in drinking water, and the level of oral hygiene influence the occurrence of the focus of enamel demineralization in primary and permanent teeth, the course of the carious process, and the possibility of its stabilization in older children.

In children, the carious process proceeds more aggressively, which is associated with incomplete mineralization processes of hard dental tissues for several years after their eruption.

Permanent teeth erupt with incomplete mineralization processes, which is associated with a high susceptibility to caries in the fissures and blind pits of the first permanent molars. During the mineralization period of hard dental tissues of permanent teeth, the highest susceptibility of teeth to caries is noted, which is accompanied by the lowest acid resistance of enamel.

Initial stages of carious lesions form against the background of inadequate oral hygiene care and irrational consumption of carbohydrate food. At the same time, dental plaque containing cariogenic microorganisms forms on the tooth enamel surface. As a result of the enzymatic activity of dental plaque bacteria, organic acids are produced, local pH shifts toward the acidic side, focal enamel demineralization develops, and microdefects of subsurface enamel layers appear. At this stage, the process is reversible. Subsequently, microscopic connections are disrupted, the organic matrix of enamel is destroyed, and gaps appear along the enamel prisms, followed by cavity formation and involvement of underlying layers and dental tissues [1].

Stabilization of this process is possible in school-age children, while clinically it may be marked by the formation of a pigmented spot in the enamel area persisting for years.

1.3 Epidemiology of the Disease or Condition

Currently, dental caries is the most common disease of the dentition and maxillofacial system in children. Already at the age of 1–1.5 years, children exhibit tooth decay. The prevalence of this disease at age 3 reaches 57%. According to all-Russian national epidemiological surveys, the prevalence of caries in children aged 6–7 years increases to 84%, while 13% of children have caries of permanent teeth, primarily fissure caries. Subsequently, as the child's age increases, the prevalence and intensity of caries rise. In the 12-year-old age group, carious lesions are registered in 71% of cases, and among 15-year-old children, dental caries reaches 82% [1, 3].

More than 50% of all visits by the pediatric population for outpatient care are related to dental diseases and mainly dental caries and its complications across all age groups. The need for oral sanitation in 12–15-year-old children in some regions of Russia reaches 100%.

Researchers note a wide variation in the prevalence rates of primary tooth caries in different parts of our country among 3-year-old children – ranging from 28% to 85.9%, with caries intensity according to the "df" index ranging from 1.2 to 3.9 [4, 5, 6, 7]. At 6 years of age, this indicator increases – from 65.3% to 96%, and the "df" index ranges from 2.54 to 5.4. In the structure of "df", "d" predominates, which indicates an insufficient level of dental care provided to children [4, 5, 6, 7, 8].

1.4 Features of Coding the Disease or Condition

Dental caries (K02):

K02.0 – Enamel caries. "White (chalky) spot" stage [initial caries]

K02.1 – Dentin caries

K02.3 – Arrested dental caries

1.5 Classification of the disease or condition

1.5.1 Topographic classification of caries

Caries in the spot stage (macula cariosa)

Superficial caries (caries superficialis)

Moderate caries (caries media)

Deep caries (caries profunda)

1.5.2 Modified classification of carious lesions by localization (Black's classification)

Class I – Cavities located in the pits and fissures of incisors, canines, molars, and premolars.

Class II – Cavities located on the proximal surfaces of molars and premolars.

Class III – Cavities located on the proximal surfaces of incisors and canines without involving the incisal edge.

Class IV – Cavities located on the proximal surfaces of incisors and canines with involvement of the crown angle and incisal edge.

Class V – Cavities located in the cervical area of all tooth groups.

Class VI – Cavities located on the cusps of molars and premolars and the incisal edges of incisors and canines [1, 9].

1.6 Clinical presentation of the disease or condition

The spot stage corresponds to the ICD-DA code K02.0 – "Enamel caries. "White chalky spot" stage [initial caries]". Caries in the spot stage is characterized by color changes (matte surface) and subsequently texture changes (roughness) of the enamel resulting from demineralization, with no cavitated lesion present, or with small enamel defects not extending beyond the amelodentinal junction (superficial caries).

The dentin caries stage (moderate and deep caries) corresponds to the ICD-DA code K02.1 and is characterized by destructive changes in the enamel and dentin extending beyond the amelodentinal junction, while the pulp is covered by a thicker or thinner layer of preserved dentin without signs of hyperemia.

The cementum caries stage corresponds to the ICD-DA code K02.2 and is characterized by lesions on the exposed root surface in the cervical area. This form of caries does not occur in childhood.

The arrested caries stage corresponds to the ICD-DA code K02.3 and is characterized by the presence of a dark pigmented spot within the enamel (focal enamel demineralization).

The clinical presentation and course of the carious process in children depend on age, the type of erupted teeth (primary or permanent), and the degree of tooth tissue maturity [1].

1. Clinical manifestations of caries in early childhood (6 months – 3 years).

The carious process in young children can appear immediately after tooth eruption. Cavities are located on the smooth surfaces of the maxillary incisors. The appearance of white chalky spots on the vestibular surfaces of the upper incisors is characteristic. The process progresses rapidly: carious cavities appear in the areas of the spots, tending not to be self-limiting, and spread to the proximal and palatal surfaces of the incisors (circular, flat caries); partial or complete fracture of the tooth crowns is possible. The pulp and periodontium are involved early in the process, developing pulpitis and periodontitis. Later, canines and molars become involved.

2. Clinical manifestations of caries in children with established primary dentition (4–6 years).

The rate of spread of the carious process remains high, primarily due to the low degree of mineralization of the hard tissues of primary teeth. Complications can develop within a few months after the initial signs of the disease are detected. Multiple carious cavities or a single lesion involving two to three surfaces or the entire tooth crown can be found in each tooth. Secondary lesions frequently develop after treatment.

Caries in primary teeth develops sequentially: lower molars first, then upper molars, and finally upper anterior teeth. A characteristic feature is an asymptomatic (painless) course of the process. Second primary molars are affected by caries more often than first ones. As a rule, proximal caries develops only after the formation of the tooth contact areas is complete. The wide proximal contact between primary molars complicates early diagnosis of caries. Acute forms of caries develop more frequently in primary teeth.

3. Clinical manifestations of caries in children in mixed dentition (7–12 years).

In 7-year-old children with carious cavities in primary molars, a pronounced predisposition to caries of the first permanent molars is observed. In enamel caries (initial caries), dull chalky spots are found on the enamel surface. The surface of the spots is smooth in the initial stage. When the carious process stabilizes, demineralization stops and the spot becomes pigmented. If the process progresses, an enamel defect or a carious spot may form, which feels rough upon probing. In incompletely formed permanent teeth, fissure caries typically develops. Dentin caries (moderate caries) is characterized by the formation of a carious cavity extending deeper than the dentino-enamel junction into the mantle dentin. With a small entry opening in the enamel, the cavity in the dentin can be quite large.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The examination aims to establish a diagnosis corresponding to the patient model, rule out complications, and determine the feasibility of initiating treatment without additional diagnostic and therapeutic-prophylactic measures.

The main objective in diagnosis is to identify clinical and radiological signs of dental caries, determine the clinical form and course of the pathological process, assess severity, and select an appropriate treatment method. Diagnosis is performed for each tooth individually.

Criteria for establishing a diagnosis of dental caries:

Nosological form: Enamel caries

Phase: any

Complication: uncomplicated

ICD-10 code: K02.0

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Focal enamel demineralization (white spot on tooth enamel), carious defect within the tooth enamel

• Absence of pathological changes in periodontal tissues in the area of the carious tooth

• Absence of pathological changes in the root area and periodontal tissues according to X-ray examination data

Nosological form: Dentin caries

Phase: any

Complication: uncomplicated

ICD-10 code: K02.1

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Carious defect of the tooth crown within the enamel and dentin, not communicating with the dental pulp cavity

• Absence of pathological changes in periodontal tissues in the area of the carious tooth

• Absence of pathological changes in the root area and periodontal tissues according to X-ray examination data

Nosological form: Arrested dental caries

Phase: any

Complication: uncomplicated

ICD-10 code: K02.3

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Presence of a dark pigmented spot within the tooth enamel

• Absence of pathological changes in periodontal tissues in the area of the carious tooth

• Absence of pathological changes in the root area and periodontal tissues according to X-ray examination data

2.1 Complaints and Anamnesis

• All pediatric patients with dental caries are recommended to undergo history taking, oral and dental examination, and other necessary examinations to establish a diagnosis and prescribe appropriate treatment, with the results recorded in the dental patient's medical record (Table 1) [1, 10].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments. Rational therapy depends on a correct diagnosis, which can be made using various patient examination methods.

Diagnosis of dental caries includes history taking, clinical examination, and supplementary diagnostic methods.

The specific features of diagnostic procedures in children should be considered:

- varying levels of objectivity of information obtained from the child and third parties (parents interpret symptoms and history differently);

- subjectivity of the child's sensations during diagnostic tests;

- varying levels of interaction between the doctor, patient, and parents;

- inability to perform complex diagnostic procedures due to the child's age and psycho-emotional characteristics;

- limitations in performing certain examinations ( pulp vitality testing [EPT] of primary and incompletely formed permanent teeth, and X-ray diagnostics are difficult in young children).

Table 1 Requirements for the diagnosis of dental caries in outpatient and polyclinic settings

• When taking a medical history in pediatric patients with dental caries for the purpose of diagnosing the disease and drawing up a treatment plan, it is recommended to ascertain and record in the medical history:

  - taking into account the patient's complaints or clarifying them with their legal representatives (complaints of pain and discomfort in the area of a specific tooth, food impaction in the tooth/between teeth, change in the appearance of the tooth);

  - duration and circumstances of the onset of the disease [1].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments. The nature of complaints depends on the depth of the carious lesion.

Complaints in various forms of caries:

• Enamel caries (macule/spot stage): no complaints / complaints of a spot on the tooth / complaints of pain from sweet and sour stimuli. The pain disappears when stimuli are removed.

• Enamel caries (superficial caries): presence of a cavity in the tooth / complaints of pain from sweet and sour stimuli. The pain disappears when stimuli are removed.

• Dentin caries (moderate caries) – complaints of a cavity in the tooth / pain when consuming sour, sweet, cold, or hot food. The pain disappears when stimuli are removed.

Anamnestic data:

- features of the course of pregnancy, presence of pathology, timeliness of the mother's labor;

- region of the child's birth and residence (endemic areas of fluorosis).

- features of the first year of life, type of feeding in the first year of life;

- presence of somatic diseases and allergic reactions; a child health questionnaire must be completed;

- presence of intolerance to medications and materials used at this stage of treatment;

- timeliness of eruption of primary and permanent teeth;

- dietary features (dietary errors – abundance of carbohydrate foods and drinks, the child falling asleep with a bottle filled with drinks containing easily fermentable carbohydrates);

- presence and regularity of individual oral hygiene;

- previous visits to a pediatric dentist – how the child behaved, how and to what extent treatment was performed, whether local anesthesia and rubber dam isolation were previously used [1].

2.2 Physical Examination

1. External examination of the maxillofacial region (A01.07.005):

- in caries, facial configuration is not disturbed due to soft tissue edema of the face;

- upon palpation of lymph nodes, enlargement of regional lymph nodes associated with caries is not observed.

2. Examination of the oral cavity using auxiliary instruments (A02.07.001):

- assessment of oral hygiene status;

- examination of the oral mucosa;

- assessment of periodontal status;

- determination of bite (crowded teeth, mouth breathing can contribute to the development of caries);

- assessment of the condition of dental arches, paying attention to the intensity of caries (presence of fillings, degree of their marginal adaptation, presence of hard tissue defects in teeth, number of extracted teeth);

- assessment of the condition of each tooth (color, enamel relief, presence of plaque, presence of spots on visible surfaces of teeth and their condition after drying the tooth surface, presence of defects, area, shape of edges, surface texture, density, symmetry, and multiplicity of lesions).

During the physical examination, targeted identification is made of:

- inadequate psychoemotional state of the patient prior to treatment;

- acute lesions of the oral mucosa and red border of the lips;

- acute inflammatory diseases of oral organs and tissues;

- periodontal diseases in the acute stage;

- unsatisfactory oral hygiene;

- refusal of treatment [1].

Comments. Teeth examination is carried out in a specific order, starting with the teeth of the first quadrant and ending with the fourth. Drying the teeth helps to detect initial carious lesions. Chalky-white spots on the surface of tooth crowns indicate initial carious lesions. Hard tissue defects of the tooth with softening are diagnosed as caries. The symmetry and multiplicity of the lesions are assessed to determine the severity of changes and the rate of process progression, the dynamics of the disease, as well as for differential diagnosis with dental developmental defects [9, 10, 13].

2.3 Laboratory Diagnostics

Not performed for dental caries in children.

2.4 Instrumental Diagnostics

2.4.1. Examination of carious cavities using a dental probe (probing).

Comments. When probing the identified carious cavity, attention is paid to its shape, localization, size, depth, presence of softened dentin, change in its color, tenderness or, conversely, absence of pain sensitivity. Probing in caries is painful at the enamel-dentin junction when the process extends within the mantle dentin. It is recommended to determine the density of hard tissues, texture, and degree of surface homogeneity with a probe. Probing should be performed without excessive pressure. Whenever possible, painful manipulations should be avoided to prevent the development of odontophobia in the child.

Probing of the carious cavity does not always provide objective information, especially in young children.

2.4.2. Tooth percussion.

Comments.

Tooth percussion allows assessing tenderness associated with periodontal and periapical tissue involvement. In caries, percussion is painless [1].

2.4.3. Diagnostic imaging

Comments. X-ray examination in children with dental caries is performed to:

- detect hidden carious cavities on the proximal surfaces of the tooth, under a filling;

- determine the depth of the carious process and its proximity to the dental pulp;

- determine the correctness of preparation and filling of the carious cavity;

- perform differential diagnosis of caries with pulp and periodontal diseases;

- determine the physiological state of the tooth (degree of resorption or stage of root formation).

2.4.4. Electric pulp testing (EPT)

• In pediatric patients with dental caries, it is recommended to perform EDT (electric pulp testing) (A05.07.001) for lesions of permanent teeth within the dentin to clarify data on pulp vitality when performing differential diagnosis with pulpitis and periodontitis [1, 16].

Level of Certainty 5Level of Recommendation C (Level of Evidence – 5)

Comments. Electric pulp testing of a tooth is performed in dental caries to clarify data on pulp vitality and, accordingly, the diagnosis. The method is based on measuring the electrical excitability of the pulp. It is used in cases of asymptomatic caries, for differential diagnosis with pulp and periodontal diseases.

Normally, the pulp threshold excitation values are 2-6 µA. The threshold current values in caries do not exceed 12-15 µA. However, different device calibrations should be taken into account; during diagnosis, comparative measurements with neighboring or symmetrical intact teeth must be performed.

Electric pulp testing can be used in children of any age; however, since the method is based on subjective sensations, it is not always possible to obtain objective data on the state of the pulp of the examined tooth in younger children. The feasibility of this method in children is determined by the child's psycho-emotional state and the degree of cooperation with the physician. In children with primary teeth, this diagnostic method is most often not used due to the lack of an adequate reaction of the child to the examination [16, 17, 18].

To detect foci of hard tissue demineralization in initial caries, luminescent stomatoscopy (A03.07.001) may be performed in pediatric patients with dental caries [19, 20].

During luminescent diagnosis under the influence of ultraviolet rays, hard dental tissues acquire the ability to luminescence and normally emit a blue glow. In initial caries, in areas of enamel and dentin demineralization, the glow intensity increases, which serves as a decisive factor in diagnosis.

For the diagnosis of hard tissue demineralization foci in initial caries, transilluminating stomatoscopy (A03.07.002) can be performed in pediatric patients with dental caries [11, 21, 22, 23].

During transillumination, the luminescence of hard tissues occurs under the influence of green light. Demineralized hard tissues (enamel, dentin) appear brown under the green beam.

Laser fluorescence diagnostics can be used in children with dental caries to detect carious cavities on occlusal or smooth surfaces of teeth; for quantitative assessment of the degree of enamel demineralization [1, 24, 25, 26, 27].

After preliminary cleaning and drying of the tooth surfaces, a device for diagnosing carious tooth changes is used. The activating light is directed onto the tooth using an optical fiber and, gathering concentrically around it, helps to detect the carious lesion. A long-focus filter absorbs the reflected light wave and transmits the long-wave fluorescent glow. The digital display of the device shows the maximum fluorescence intensity (in units relative to the calibration standard) at the time of the study. Based on the digital data displayed on the device screen, the physician evaluates the degree of light beam penetration into the dental tissues. An indicator of less than 15 units characterizes the normal state of the enamel. Indicators of more than 15 units indicate the presence of a carious process in the enamel and dentin (the higher the indicator, the deeper the carious process has spread).

2.5 Other Procedures

2.5.1. Determination of oral hygiene indices

• In pediatric patients with dental caries, it is recommended to determine oral hygiene indices (Kuzmina E.M., Fedorov-Volodkina, Green-Vermillion, etc.) (A12.07.003) to assess the prevalence of dental plaque and calculus deposits [1, 28, 29].

Level of Certainty 4Level of Recommendation C (Level of Evidence – 4)

Comments: Local cariogenic factors have a damaging effect on hard dental tissues. Dental deposits (plaque and dental biofilm) contribute to the development of caries. Hygiene indices serve to determine the state of the oral cavity and to evaluate the results of the treatment.

E.M. Kuzmina's index is used to assess dental plaque in early childhood. Fedorov-Volodkina's hygiene index is used in children with primary dentition, and the Green-Vermillion simplified oral hygiene index OHI-S is used in mixed and permanent dentition.

Hygiene indices are determined before treatment and after oral hygiene instruction for monitoring purposes.

2.5.2. Vital staining of hard dental tissues.

Comments. A 2% methylene blue solution or an agent for detecting caries-affected dentin (caries indicator, caries marker) is used, which is applied to the studied tooth cleansed of plaque. Application time is 2-3 minutes. The tooth color changes in the presence of caries; the degree of demineralization is assessed on a 10-point scale. Enamel demineralized due to the carious process is easily stained, whereas dental developmental defects do not absorb the dye [19].

Vital staining of hard dental tissues can be used to determine the effectiveness of remineralizing therapy.

• Pediatric patients with dental caries are recommended to undergo determination of the number of Streptococcus mutans and lactobacilli in saliva to assess the probability of caries occurrence [30, 31].

Level of Certainty 4Level of Recommendation C (Level of Evidence – 4)

Comments. The probability of caries occurrence increases significantly in the case of:

- the result of the Streptococcus mutans test is more than 500,000 CFU/ml;

- a high count of lactobacilli (more than 500,000 CFU/ml) in saliva;

- a low salivary secretion rate (less than 0.7 ml/min);

- a salivary buffer capacity of less than 4.

2.5.5. Thermal testing of the tooth

• Pediatric patients with dental caries are recommended to undergo thermometry (dental thermodiagnosis) for permanent teeth lesions within the dentin (A02.07.005) to detect pain response and clarify the diagnosis in order to determine pulp vitality when performing differential diagnosis with pulpitis and periodontitis [1, 9, 16, 18].

LE 2Grade of recommendation B (Level of evidence – 2)

Comments. To perform the test, a directed stream of cold water or air is applied to the tooth under study for 10–15 seconds. Normally, temperature fluctuations within the range of 17–22 to 50–52 °C (indifferent zone) do not cause a dental pain response. When a pulp disease occurs, the boundaries of the indifferent zone narrow, and a pain response occurs to room temperature water (18–22 °C) or warm water (45–50 °C).

The feasibility of this method in children is determined by the child's psycho-emotional state and the degree of cooperation with the physician. In children with primary teeth, this diagnostic method is most often not used due to the lack of an adequate reaction of the child to the examination, as it is based on a pain reaction to a stimulus, which can cause a negative reaction in the child [9, 16, 18].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 «Conservative treatment»

General Principles

The principles of treatment for pediatric patients with caries of primary and permanent teeth provide for the simultaneous resolution of several tasks:

- elimination of factors causing the demineralization process;

- prevention of the further development of the pathological carious process;

- preservation of healthy hard dental tissues as much as possible, with excision of pathologically altered tissues followed by crown restoration if necessary;

- prevention of the development of pathological processes and complications of caries (pulpitis and periodontitis);

- improving the patients' quality of life [9, 32].

Treatment is carried out for each caries-affected tooth regardless of the degree of lesion and the treatment performed on other teeth. The treatment process is concluded with recommendations to the patient on the timing of re-examination and prevention.

Conservative treatment of caries in pediatric patients is aimed at:

- increasing enamel resistance to caries development;

- activating remineralization processes in the enamel;

- accelerating the maturation of dental enamel, including in the fissure area [1].

- restoring enamel structure in patients with "white spot" symptoms to prevent further caries development [9, 32].

3.1.1. Remineralizing therapy

• Remineralizing therapy (topical application of remineralizing drugs to the tooth area – A11.07.024) is recommended in the treatment of pediatric patients with enamel caries and arrested dental caries, as well as to accelerate the maturation processes of hard dental tissues in children with incomplete mineralization processes. This treatment method includes the use of drugs containing calcium and phosphates (gels, solutions, creams) [33, 34, 35, 36].

Level of Certainty 5Level of Recommendation C (Level of Evidence – 5)

Comments: Therapy with calcium and phosphate preparations in the presence of enamel caries symptoms and arrested caries is the most appropriate from the standpoint of the etiology and pathogenesis of caries.

A) Clinical procedure. Gel application is performed in the dental office. Procedure: cleaning teeth from plaque, isolation from saliva, drying, application of the preparation for 10–15 minutes. Recommendations: do not eat for 1 hour. Treatment course: 10–15 procedures. The timing and frequency of procedures are individual and regulated by the physician.

B) Application of remineralizing gel at home. Teeth cleaning, application of the gel in individually manufactured trays to the teeth for 10–15 minutes 2 times a day for 30 days.

Before starting treatment, in the presence of rough surfaces, grinding of hard dental tissues (A16.07.082) is performed until a smooth surface is achieved.

One month after the start of remineralizing therapy (topical application of remineralizing drugs to the tooth area – A11.07.024), a dental examination of the child must be performed to evaluate the achieved result [1].

3.1.2. Fluoridation of hard dental tissues

Comment. Fluoridation of hard dental tissues with fluoride-containing preparations (fluoride varnish) provides a prolonged effect of fluorides on tooth enamel. Fluoride varnishes, gels, and foams form a film adjacent to the enamel that remains on the teeth for several hours, and in fissures, grooves, and micro-spaces for several days and even weeks [45].

Application technique: cleaning teeth from plaque, isolation from saliva, drying of teeth, application of varnish, drying of varnish for 4–5 minutes. The fluoridation procedure is carried out with a frequency of one to eight times a year, depending on the activity level of dental caries and the risk of its development [1, 46, 47, 48].

3.1.4. Impregnation technique (silvering method).

• The impregnation technique of the lesion focus with preparations containing silver compounds (application of the tooth silvering method) (A11.07.023) is recommended in the treatment of initial forms of caries (enamel caries) of primary teeth in children. The purpose of enamel silvering: growth delay or death of cariogenic microorganisms. Reduced silver exerts not only a bactericidal effect but also obliterates enamel pores in demineralization foci, contributing to the stabilization of the carious process [49, 50, 51, Gao SS52].

LoE 2Grade of Recommendation B (Level of Evidence – 2)

Comments. The silvering method is the method of choice in the treatment of initial forms of caries of primary teeth in children. The silvering method is not recommended for use in the treatment of initial carious lesions in permanent teeth in children.

Methodology. The lesion focus cleaned of plaque is dabbed with a microbrush moistened with a preparation containing silver fluoride for 30–40 seconds. Preparations whose main active component is a complex salt – silveramine fluoride (Ag(NH3)2F) – are used. Course: 2–3 procedures after 7–10 days every 6 months. It is necessary to warn parents about the darkening of the treated carious foci before the procedure. Children with enamel caries of primary teeth who underwent the silvering method should visit a specialist once every three months for follow-up [1, 53, 54].

The resin infiltration method is the method of choice in the treatment of initial forms of caries in pediatric patients, used for minimally invasive treatment of white spot lesions on proximal and vestibular surfaces. The infiltration method is performed without tooth preparation using special preparations [55, 56, 57].

The infiltration method is used for the treatment of enamel caries in the white spot stage in children with primary and permanent teeth with completed mineralization (maturation) processes [58, 59].

The infiltration method is indicated in the treatment of caries without defect formation. This method involves filling the enamel pore system in demineralization foci with a polymer material after prior etching of the surface with 15% hydrochloric acid. It includes three stages: etching for 2–6 minutes, drying, and infiltration in two stages; the infiltrating component is applied to the prepared surface for 3 minutes and, after polymerization, re-applied for 1 minute.

When treating caries in primary teeth, all treatment stages are shortened in time. Etching is not performed as long as on permanent teeth – no more than 90 seconds, infiltration time – 1 minute [60, 61].

After applying the infiltration method, a course of remineralizing therapy (topical application of remineralizing drugs to the tooth area – A11.07.024) is recommended.

3.2 Invasive (surgical) treatment

Comments.

Algorithm for operative treatment of dental caries in children:

1. Anesthesia (as clinically indicated).

2. Cleaning the tooth from plaque

3. Carious cavity preparation:

   • Traditional preparation using rotary instruments (burs). Traditional carious cavity preparation using a dental drill and filling with various materials is possible for any localization of the carious lesion. Preparation is performed carefully, taking into account the tooth structure. Disadvantages of the method: formation of a smear layer on the dentin surface, vibration, formation of micro- and macro-cracks in the enamel.

   • ART technology (atraumatic restorative treatment) involves scraping out carious tissues with sharp hand instruments (excavator and enamel hatchet) and subsequent filling of the cavity with glass ionomer cement (GIC). Advantages: no loud, frightening sounds, no vibrational impact, possibility of use in children with high anxiety. Disadvantages of the method: longer duration of tooth tissue processing compared to traditional preparation; additional costs; more frequent caries relapses; the method is ineffective for enamel caries [65, 66].

   • The chemo-mechanical method of carious cavity treatment involves prior softening of carious tissues using a special gel (containing amino acids and sodium hypochlorite), followed by scraping with special hand instruments (excavator and enamel hatchet). Advantages: no loud, frightening sounds, no vibrational impact, no smear layer is formed on the dentin surface.

   • Kinetic preparation – treatment of the carious cavity with a stream of powder (aluminum oxide) and water supplied at high speed from a dental air-abrasive handpiece. Advantages: rapid removal of carious tissues, gentle opening of fissures, absence of a smear layer after treatment. Contraindications: preschool age of the child, chronic respiratory diseases.

   • Laser preparation – involves using an erbium laser to remove hard dental tissues. Due to laser hydrokinetics, ablation (evaporation) of hard tooth tissues occurs. Advantages: absence of a smear layer, formation of a sterile cavity, absence of overheating of tooth tissues, selective effect on carious dentin, preventive effect of enamel photomodification.

4. Medication treatment of the carious cavity: irrigation with antiseptic solutions (chlorhexidine** 0.05% solution – ATC code: D08AC02),

5. Placement of a calcium hydroxide lining paste as a therapeutic base (as clinically indicated).

6. Placement of a base/lining (as clinically indicated).

7. Cavity filling. Restoration of the anatomical shape of the tooth crown after preparation in children can be carried out by filling or using a standard protective crown).

8. Finishing and polishing of the filling.

9. Coating the tooth with dental fluoridating varnish or fluoride gel.

Currently, the following materials are used for permanent tooth fillings:

1) Dental cements (silicate, silico-phosphate, and glass ionomer) are used for permanent filling of carious cavities.

Used for filling carious cavities without occlusal load. They do not have high strength and dissolve in oral fluid.

Glass ionomer cements bond chemically to the tooth, preventing microleakage. They are biocompatible, do not require linings, release fluoride ions for a long time, and thereby exhibit preventive properties. Dental plaque does not form on the surface of a glass ionomer cement filling. These materials are radiopaque and are the preferred material for treating caries in primary and permanent teeth with incomplete mineralization processes [1, 67, 68, 69].

2) Composite filling materials (chemically cured composite filling materials, light-cured dental filling materials)

Chemical composites have high strength, low shrinkage, limited working time, and are used with a base lining.

Light-cured composites have high strength, color stability, and aesthetics.

Light-cured composites are recommended as first-choice filling materials as the most effective for filling all groups of teeth in children without age restrictions. In children with teeth undergoing incomplete mineralization, it is recommended to use composite materials in combination with a light-cured self-etching enamel and dentin adhesive (dental self-etching adhesive materials) or with a selective etching technique, followed by an adhesive protocol involving the use of a light-cured self-etching enamel and dentin adhesive (dental self-etching adhesive materials) [1, 70, 71, 72].

3) Compomer filling materials. The physical and mechanical properties of compomers are close to those of microfilled composite materials. This group of materials exhibits preventive properties due to fluoride release. They can be used with traditional dental adhesive systems (especially for large cavities and loads) or with a light-cured self-etching enamel and dentin adhesive (dental self-etching adhesive materials).

Positive properties include: long-term fluoride release, high adhesion to tooth tissues, biocompatibility with tooth tissues, strength, and aesthetics. Compomer materials are inferior to GIC in fluoride release, are characterized by lower wear resistance compared to composites, and the filling color changes as a result of water sorption. Compomer materials are used for filling all classes of cavities in primary teeth [69, 73, 74].

Standard temporary dental crowns are available in stainless steel and zirconia. Factory-made standard crowns of various sizes are advisable to use for the permanent restoration of primary molars and temporary restoration of permanent molars in case of damage to more than three surfaces of tooth crowns. The use of standard crowns does not require the inclusion of a laboratory stage in their application algorithm. When used correctly, the shape of the tooth is restored and the development of complications is prevented. They are cemented onto teeth with intact pulp, and a minimal amount of tissue is removed [75, 76, 77, 78, 79].

Ceramic inlays have good aesthetic properties. The ceramic mass and glass-ceramic used are more compatible with tooth enamel in terms of hardness, modulus of elasticity, and coefficient of thermal expansion than composite materials. Due to their physical properties, ceramic inlays can be used for occlusally load-bearing surfaces. Used for the restoration of permanent teeth in children [80, 81, 82].

The delayed method of caries treatment is indicated in infants and toddlers, children with a high caries activity index, and deep caries cases where complete removal of softened dentin from the floor of the carious cavity is impossible due to the risk of pulp exposure or because the child is uncooperative. The goal of the method is to increase the mineralization of dentin at the bottom and walls of the carious cavity.

During the first visit, affected enamel and carious dentin are removed from the walls of the carious cavity. Softened dentin in the area of the bottom of the carious cavity is not removed during the first visit. A therapeutic dressing (zinc oxide-eugenol paste, calcium hydroxide-based lining paste) is applied to the bottom of the carious cavity for a bactericidal effect and to stimulate the production of replacement dentin in the area of the tooth pulp chamber bottom (odontotropic effect), and the tooth is filled with a dental cement (or GIC). After 6-8 weeks, the temporary filling is removed, the bottom of the carious cavity is prepared to remove infected dentin, a therapeutic lining material is applied to the closest pulp horn, followed by placing an insulating base and filling the carious cavity. The use of this method reduces the risk of pulp chamber exposure during the preparation of the bottom of the carious cavity, stimulates the formation of replacement dentin in this area, thereby preventing the subsequent development of pulpitis [1, 83, 84, 85, 86, 87].

3.3 Other Treatment

3.3.1. Fissure sealing.

Comments. This method consists in the obturation of fissures and other anatomical depressions of healthy teeth with adhesive materials in order to create a barrier against external cariogenic factors (microorganisms and carbohydrates); along with this, the overall risk of dental caries is reduced, and enamel mineralization in the fissure area is accelerated when using glass ionomer cements and light-cured tooth fissure sealants. Sealing of tooth fissures is recommended for primary and permanent molars in children at risk of caries development, with a low initial level of fissure mineralization, and in teeth with deep fissures [88, 91, 92, 93, 94].

Two types of sealing are used. Non-invasive (simple sealing) is the isolation of fissures with sealants in order to limit actual risk zones from the action of cariogenic factors of the oral cavity. Invasive sealing is sealing with preliminary widening of the deepest fissures, as well as fissures with initial carious enamel lesions [1].

For non-invasive fissure sealing, glass ionomer sealants (glass ionomer cements) and light-cured tooth fissure sealants are used.

When performing invasive sealing, light-cured composite tooth fissure sealants are more frequently used. After cleaning the tooth, the entrance to the fissure is widened using dental diamond needle-shaped pointed (spear-shaped, lancet-shaped) burs by removing hard tissues in the area of the fissure walls. After grinding, the bottom and walls of the fissure must be accessible for inspection, and the hard tissues must be dense upon probing [1, 94].

In pediatric patients with caries localized in the area of tooth fissures, the method of preventive filling can be used. Preventive filling involves the preparation of a small carious cavity (up to 2 mm in diameter) on the chewing surface of molars and premolars, its direct filling using various filling materials, and the subsequent application of a sealant to the surface of the filling and adjacent healthy pits and fissures [95, 96, 97].

The indication for the preventive filling method is a carious lesion of a molar fissure, provided that the remaining fissures of the same tooth remain intact. Preventive coating provides additional micromechanical retention of the filling mass on the chewing surface of the tooth, significantly reduces the risk of secondary caries, and protects healthy pits and fissures from caries [1].

3.3.2. Professional oral hygiene

• Professional oral hygiene (A16.07.051) is recommended for pediatric patients with dental caries, regardless of the level of dental morbidity and the condition of the oral cavity organs.

  Removal of dental plaque containing pathogenic microflora, as the main etiological factor in the development of dental caries, helps prevent the development of caries and stabilize the process [1, 98].

LRP 5Level of Convincingness C (Level of Evidence – 5)

Comments. Professional hygiene is not the method of choice for treating caries, but it is etiotropic prevention of caries development. In addition, professional hygiene is one of the stages of complex treatment of pediatric patients with dental caries and a prerequisite for a good long-term treatment outcome.

All pediatric patients with dental caries should be instructed in oral hygiene for more effective home hygienic care and to reduce the risk of further caries development.

3.3.3. Use of probiotic preparations.

• Pediatric patients with dental caries are recommended to be prescribed dietary supplements containing probiotic complexes for the prevention and complex treatment of dental caries (A25.07.001) [99, 100, 101, 102].

LoE 2Grade of Recommendation B (Level of Evidence – 2)

Comments.

Dietary supplements containing probiotic complexes are available in the form of lozenges, mouthwashes, etc.

Probiotic microorganisms Lactobacillus spp. and Bifidobacterium spp. that are part of dietary supplements containing probiotic complexes are part of the normal oral microflora, are saccharolytic, and ferment carbohydrates, but are not cariogenic. These preparations are usually available in liquid form; their mechanism of action consists in the release of acidic products and bacteriocins during their vital activity, and an increase in secretory IgA.

The probiotic strain Streptococcus salivarius M18, which is part of dietary supplements containing a probiotic complex, produces salivaricins, which are local antibacterial substances capable of inhibiting the growth of oral infection pathogens, namely Streptococcus spp., Porphyromonas spp., Actinomyces spp., Aggregatibacter spp. The probiotic strain Streptococcus salivarius M18 produces the enzymes dextranase and urease, which reduce the accumulation of dental plaque and neutralize oral acidity. This probiotic strain is the basis of dietary supplements containing a probiotic complex for caries prevention in the form of lozenges starting from 3 years of age. The efficacy of this probiotic complex has been proven in studies in preschool children and leads to an improvement in the hygiene index, a pronounced reduction in caries, stabilization of its initial forms, and a decrease in the prevalence of gingivitis [100, 102].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Dental caries is a chronic disease; therefore, pediatric patients with dental caries require dynamic follow-up by a physician.

• The frequency of follow-up examinations for children with dental caries is recommended to be planned depending on age and the intensity of the carious process [1, 103, 104].

Level of Certainty 5Level of Recommendation C (Level of Evidence – 5)

Comments.

During each visit, the following measures are recommended:

• monitoring of the hygienic condition of the teeth;

• elimination of risk factors for caries and dentofacial anomalies;

• sanation of the oral cavity;

• professional oral hygiene;

• deep fluoridation of tooth enamel;

• sealing of the tooth fissure with a sealant (primary and permanent molars).

5. Prevention and Dispensary Observation

• As preventive measures for pediatric patients with dental caries, it is recommended to reduce the consumption of easily fermentable sugars, optimize oral hygiene, conduct oral hygiene education (A13.30.007), local application of remineralizing agents in the tooth area (A11.07.024), deep fluoridation of tooth enamel (A11.07.012), sealing of tooth fissures with sealants (A16.07.057), professional oral and dental hygiene (A16.07.051), and the use of probiotic preparations (A25.07.001) [1, 2, 38, 48, 88, 99, 101, 104].

Level of Certainty 5Level of Recommendation C (Level of Evidence – 5)

Comments.

Preventive measures in children with dental caries should be comprehensive, individually tailored depending on the risk of caries development and the child's age. Caries prevention measures should be aimed at eliminating the microbial factor and carbohydrate factor, increasing the resistance of hard tooth tissues, and enhancing the buffer and remineralizing functions of saliva.

6. Organization of Medical Care

Type of medical care: primary health care.

Conditions for providing medical care: outpatient.

7. Additional Information

7.1 Inadequate nutrition and drinking water

Dietary disorders and low fluoride content in water can lead to the occurrence of diseases, including dental caries.

The most probable cariogenic effect is noted with an excess of easily digestible carbohydrates (sugars, glucose) in the diet, a deficiency of minerals, trace elements, and vitamins, and a predominance of soft-textured foods in the diet. In addition, epidemiological studies have revealed a high prevalence of caries in children who consume water with an insufficient fluoride concentration (less than 0.6 mg/L).

These factors create a favorable background upon which the action of various pathogenic factors is easily combined and caries develops [1].

7.2 Past and comorbid conditions

Most somatic diseases can be accompanied by a significant prevalence and intensity of caries.

General diseases affect the hard dental tissues indirectly by altering saliva composition, salivary volume and flow rate, and reducing the level of caries resistance.

The most adverse effect of general diseases on teeth is observed during the period of their development, mineralization, and maturation.

Thus, these diseases create a background upon which unfavorable local cariogenic factors are easily realized [1].

7.3. Developmental defects of hard dental tissues.

Hereditary and acquired developmental defects of hard dental tissues in children are accompanied by impaired enamel and dentin structure, primarily impaired enamel mineralization. In children with hard dental tissue developmental defects against the background of low enamel mineralization, the carious process occurs more frequently and caries intensity is higher than in children with normal enamel structure.

Children with systemic enamel hypoplasia and amelogenesis imperfecta should be regarded as patients at high risk for caries. These children require follow-up care by a pediatric dentist and the provision of therapeutic and preventive care [1, 105].

Criteria for Evaluating the Quality of Medical Care

Group of diseases or conditions: Dental caries

ICD-10 code(s): K02.0, K02.1, K02.3

Nosological forms: Enamel caries, dentin caries, arrested dental caries

Type of medical care: Primary health care

Conditions for providing medical care: Outpatient

References

Appendix A1. Working Group Composition

1. Larisa P. Kiselnikova, MD, PhD, Professor, Head of the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

2. Tatyana E. Zueva, PhD, Associate Professor at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

3. Nataliya Yu. Vasilyeva, PhD, Associate Professor at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

4. Irina I. Malanchuk, PhD, Associate Professor at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

5. Elena E. Maslak, MD, PhD, Professor, Professor at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

6. Natalya V. Ozhgikhina, PhD, Associate Professor at the Department of Paediatric Dentistry and Orthodontics, Ural State Medical University of the Russian Ministry of Health.

7. Lyudmila I. Vorozhtsova, Chief Physician, Branch No. 4 of the Association "Stomatology" of the City of Yekaterinburg (Yekaterinburg).

8. Maksim A. Shevchenko PhD, Assistant at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

9. Anna D. Dakhnova, Senior Laboratory Assistant at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Paediatric dentists

2. Dentists

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing the levels of concordance of recommendations (LCR) for prevention, treatment and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Procedure for updating clinical guidelines – the mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health of the Russian Federation No. 620 dated December 30, 2003, "On the approval of protocols for 'The management of children suffering from dental diseases'."

2. Order of the Ministry of Health of the Russian Federation No. 910n dated November 13, 2012, "On the approval of the Procedure for providing medical care to children with dental diseases."

Appendix A3.1. List of medical services for the diagnosis and treatment of dental caries

(from the Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On the approval of the nomenclature of medical services")

Table 1. Collection of complaints, anamnesis, physical examination

Table 2. Instrumental diagnostics

Table 3. Other diagnostics

Table 4. Conservative treatment

Table 5. Surgical treatment

Table 6. Other treatment

Appendix B. Physician Action Algorithms

1. Enamel caries

Nosological form: enamel caries

Stage: "white ( chalky) spot" stage (initial caries)

ICD-10 code: K02.0

1.1. Diagnostic procedures:

1.1.1. Collection of complaints and anamnesis

1.1.2. External examination of the maxillofacial region

1.1.3. Dental examination using instruments

1.1.4. Tooth percussion

1.1.5. Determination of occlusion

1.1.6. Vital staining of hard dental tissues

1.1.7. Transillumination stomatoscopy

1.1.8. Luminescent stomatoscopy

1.2. Treatment.

1.2.1. Oral hygiene instruction

1.2.2. Supervised tooth brushing

1.2.3. Professional oral and dental hygiene

1.2.4. Local application of remineralizing agents to the tooth

1.2.5. Fluoridation of hard dental tissues

1.2.6. Application of tooth silvering method

1.2.7. Sealing of tooth fissures using light-cured fissure sealant or glass ionomer cement (if necessary)

1.2.8. Prescription of dietary therapy for oral and dental diseases

1.3. Recommendations.

1.3.1. Patients with enamel caries in the spot stage should visit a specialist semi-annually for monitoring, preventive examinations, and hygiene procedures.

1.3.2. Requirements for dietary therapy and restrictions on cariogenic foods. After each treatment procedure, it is recommended not to eat or rinse the mouth for 2 hours. Restriction of food and beverage intake with low pH values (juices, tonic drinks, yogurts) and thorough mouth rinsing after consumption. Restriction of carbohydrate retention in the oral cavity (hard candies, chewing gums). Thorough oral hygiene after breakfast and before bedtime. Additional information for the patient and their family members (See Appendix 4).

2. Dentin caries.

Nosological form: dentin caries

Stage: any

ICD-10 code: K02.1

2.1. Diagnostic procedures:

2.1.1. Collection of complaints and anamnesis.

2.1.2. External examination of the maxillofacial region

2.1.3. Dental examination using additional instruments

2.1.4. Examination of carious cavities using a dental probe

2.1.4. Dental thermal testing

2.1.5. Dental percussion

2.1.6. Electric pulp testing

2.1.7. Bite determination

2.1.8. Comprehensive diagnostic examination of the dentition using radiation imaging methods and tools.

2.2. Treatment.

2.2.1. Oral hygiene instruction

2.2.2. Supervised tooth brushing

2.2.3. Professional oral and dental hygiene

2.2.4. Preparation of the carious cavity.

2.2.5. Medicated treatment of the carious cavity

2.2.6. Filling of the carious cavity.

2.2.7. Polishing and finishing of the filling

2.2.8. Tooth restoration with a standard protective crown (if indicated).

2.2.9. Prescription of dietary therapy for oral and dental diseases

2.3. Recommendations.

2.3.1. Patients with dentin caries should visit a specialist every six months for monitoring, preventive check-ups, and hygiene procedures.

2.3.2. It is recommended to refrain from eating for 2 hours after treatment.

2.3.3. Requirements for dietary therapy and restrictions on the intake of cariogenic foods. Restriction of food and beverage intake with low pH values (juices, tonic drinks, yogurts) and thorough rinsing of the mouth after consumption. Limitation of carbohydrate retention in the mouth (hard candies, chewing gum). Thorough oral hygiene after breakfast and before bedtime. Additional information for the patient and their family members (See Appendix 4).

Appendix C. Patient Information

1. Tehes must be brushed with a toothbrush and toothpaste twice a day. After eating, the mouth should be rinsed to remove food debris.

2. Dental floss can be used to clean interdental spaces after receiving instruction on its use and upon the recommendation of a dentist.

3. If bleeding occurs while brushing teeth, hygiene procedures must not be discontinued. If bleeding does not stop within 3–4 days, a doctor must be consulted.

4. If, after filling and the wearing off of anesthesia, the filling interferes with dental occlusion, you should consult your attending physician in the near future.

5. If fillings are made of composite materials, foods containing natural and artificial colorants (e.g., blueberries, tea, coffee, etc.) should be avoided during the first 24 hours after tooth filling.

6. Temporary pain (hypersensitivity) may occur in the filled tooth during eating and chewing. If these symptoms persist for 1–2 weeks, a pediatric dentist must be consulted.

7. If sharp pain occurs in the tooth, you should consult your attending pediatric dentist as soon as possible.

8. To prevent chipping of the filling and the hard tooth tissues adjacent to the filling, it is not recommended to eat or chew very hard foods (e.g., nuts, rusks) or bite off large pieces (e.g., from a whole apple).

9. A pediatric dentist should be visited every six months for preventive check-ups.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.