Dental caries: clinical guidelines

List of Abbreviations

OH – oral hygiene

DP – dental plaque

IOSD – index of occlusal surface destruction

DC – dental caries

CBCT – cone-beam computed tomography

The DMFT(t) index is the sum of decayed, missing, and filled teeth in an individual

ICD-10 – International Classification of Diseases, 10th Revision

OPG – orthopantomography

OC – oral cavity

THT – hard tooth tissues

EPT – electric pulp testing

DAS – Dental Anxiety Scale

ICDAS – International Caries Detection and Assessment System

OHIP – Oral Health Impact Profile

Terms and Definitions

Dental caries is an infectious pathological process occurring after tooth eruption, characterized by demineralization and softening of hard tooth tissues (HTT) followed by the formation of a cavity defect [1,2,3,8,10].

Taking into account the etiopathogenetic characteristics of dental caries as a disease classified in ICD-10, dental caries (DC) is defined as a multifactorial disease of predominantly microbial origin, occurring after tooth eruption, in which, in the absence of adequate therapeutic and preventive measures, the demineralization of inorganic structures, destruction of the organic enamel matrix, and destruction of HTT (enamel, dentin, cementum) occur sequentially, leading to defect formation and a risk of inflammatory complications from the pulp and periodontium [1,2,3,8,10].

Enamel caries is the initial stage of caries, characterized by demineralization of inorganic enamel structures and destruction of its organic matrix, clinically manifested by the formation of a white spot on the tooth surface or a defect (cavity) within the enamel.

Dentin caries is an advanced stage of dental caries, characterized by progressive destruction of enamel and dentin with the formation of a defect (cavity) within the dentin.

Cementum caries is a carious lesion of the tooth root cementum, characterized by the formation of a spot or defect (cavity), occurring upon root exposure and gingival recession.

Arrested caries is a carious process in the stabilization stage, manifested by the formation of a hard pigmented spot on the enamel surface or pigmentation and hardening of the dentin.

Concept of "secondary caries" – a carious lesion developing after treatment, predominantly at the "restoration (filling, inlay) – tooth" interface [1,3].

Concept of "recurrent caries" – a pathological process developing in dentin at various intervals after operative-restorative treatment for DC, predominantly beneath a filling [1,3].

Other dental caries – carious lesions in HTT that developed after endodontic treatment of complicated forms of caries, such as pulpitis and periodontitis.

Caries with pulp exposure is a lesion of HTT manifested by the presence of a carious cavity within circumpulpal dentin while maintaining pulp vitality, creating a high risk of exposing the pulp cavity (accidental pulp exposure).

Dental caries, unspecified is a pathological process of carious origin developing in HTT, requiring additional diagnostic methods to establish a definitive diagnosis.

Enamel demineralization is the loss of the mineral component of tooth enamel.

Remineralization is the process of saturating HTT with mineral components.

Dental plaque (microbial biofilm) – an accumulation of microorganisms on the surface of teeth (fillings, dentures, etc.) formed as a specific ecosystem, the homeostasis disruption of which leads to the development of DC and increases the risk of periodontal and oral mucosa diseases.

Caries prevention is a set of measures to eliminate local, systemic, and other risk factors for caries, aimed at preventing the occurrence of DC.

Risk factor – an environmental, behavioral, or biological factor identified through long-term studies, the presence of which increases the probability of disease occurrence, while its absence or elimination reduces this probability. Risk factors are part of the causal chain leading to disease.

Caries risk assessment – the use of knowledge about factors related to caries development to identify patients with cariogenic risk factors, categorize them into high-, medium-, or low-risk groups, and select optimal therapeutic and preventive measures under existing circumstances.

Caries resistance – the resistance of HTT to the action of major cariogenic risk factors, developed in healthy individuals without systemic pathology who follow a balanced anti-caries diet.

Dental patient compliance – an individual characteristic of the patient reflecting their level of readiness to maintain dental health (oral hygiene) and the results of provided dental treatment.

Preparation of a carious cavity is a set of measures to remove affected (demineralized, necrotic, softened) HTT and shape the cavity (if necessary) for subsequent restoration of the tooth with a filling or prosthetic structures. Cavity preparation depends on the localization, extent of the lesion, and tooth group. HTT preparation can be performed either traditionally (using a turbine handpiece / micromotor and burs) or by alternative methods: using an air-abrasive mixture, ultrasonic scaler, laser, etc.

Restoration of HTT lost due to carious lesions is a set of measures to restore the anatomical shape, functional, and aesthetic properties of a tooth using various dental materials and technologies.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Dental caries is a multifactorial disease of predominantly microbial origin, occurring after tooth eruption, in which, in the absence of adequate therapeutic and preventive measures, the demineralization of inorganic structures, destruction of the organic enamel matrix, and destruction of HTT (enamel, dentin, cementum) occur sequentially, leading to defect formation and a risk of inflammatory complications from the pulp and periodontium [1,2,3,6,7].

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

The direct cause of enamel demineralization and HTT destruction with the formation of a carious defect (cavity) is organic acids (mainly lactic acid) produced by dental plaque (DP) microorganisms, primarily Str. mutans, Str. sanguis, Str. mitis, Lactobacillus acidophilus, during carbohydrate fermentation [1,2,3,6,7,26,27,28,29]. In cementum caries, in addition to cariogenic flora, the following pathogenic flora is also detected: Prevotella intermedia, Prevotella melaninogenica, Fusobacterium nucleatum, Campylobacter rectus, Capnocytophaga spp., Actinomyces viscosus, Actinomyces naeslundi, Candida spp. [1,2,3,6,7,26,27,28,29].

Qualitative and quantitative characteristics of dental plaque, diet and eating habits, level of enamel resistance, quantitative and qualitative composition of oral fluid, general systemic health status, exogenous effects on the body, fluoride concentration in drinking water, and patient compliance with oral hygiene (OH) maintenance are the main cariogenic factors influencing the onset of focal enamel demineralization (FED), the further progression of the process, and the impossibility of its stabilization [1,2,3,6,7].

The following main pathogenetic factors and stages of the onset and development of dental caries (DC) are distinguished. First – irregular dietary habits with frequent unstructured consumption of easily digestible carbohydrate foods as an "ideal" substrate for acid production by dental plaque microorganisms. Second – unsatisfactory oral hygiene practices, creating conditions for the formation of abundant dental plaque on the tooth surface containing acid-producing microorganisms, the activity of which leads to a local drop in pH to a critical level. Third – an "intermittent", and subsequently continuous process of tooth enamel demineralization with the gradual formation of a subsurface enamel lesion (white or chalky spot stage). If the acid production process continues, and enamel demineralization predominates over remineralization processes, a defect forms in the enamel that is visually determined (enamel caries). Fourth – invasion of microorganisms into the dentin with the dissolution of its mineral (sclerotic) part by acid-producing bacteria and subsequent disintegration of its organic components. Fifth – spread of infection into the dental pulp and periodontium. Sixth – tooth loss due to untimely or inadequate treatment of DC without eliminating cariogenic risk factors [1,2,3,6,7].

1.3 Epidemiology of the Disease or Condition

According to WHO data, dental caries is the most common disease of the maxillofacial system among the population of most countries worldwide; the population of more than 180 countries belongs to risk groups for DC development [9]. Dental caries can occur in early childhood, its prevalence increases with age, and in the adult population in the age group (35-44 years) reaches 98-99% [1,2,3,6,7,9].

The prevalence of DC in the population of the Russian Federation (RF), according to a national epidemiological dental survey in the key group of 12-year-old children, was 72% with an intensity of 2.51 teeth, and in the adult group aged 35-44 years it increased to 99% with an intensity of 14.35 teeth. The prevalence and intensity of DC in the population living in different climatic and geographical zones varies and depends largely on the fluoride content in drinking water [9].

Untimely or irrational treatment of dental caries can cause the development of inflammatory diseases of the pulp and periodontium, tooth loss, the development of purulent-inflammatory processes in the maxillofacial region, the formation of foci of odontogenic chronosepsis with subsequent sensitization of the body and the development of focally-induced systemic diseases [1,2,3,6,7].

Untimely treatment of DC, as well as tooth extraction due to complicated caries and its other complications, in turn, can lead to the development of secondary dental arch deformations and the occurrence of temporomandibular joint pathology.

Dental caries directly affects the quality of life of the dental patient, causing impairment of the chewing process up to the complete loss of chewing function with the subsequent development of digestive system diseases, forming serious restrictions on habitual dietary patterns, manifesting in some cases by a pronounced pain symptom requiring drug management, as well as noticeable aesthetic impairments in the smile zone [1,2,3,6,10].

WHO defines DC as a socially significant disease that has a high prevalence among the population of various countries, can manifest in different age groups, and negatively affects both dental and systemic health, as well as a person's quality of life [1,2,3,6,10].

1.4 Features of Coding the Disease or Condition

Dental caries (K02):

K02.0 – Enamel caries;

K02.1 – Dentin caries;

K02.2 – Cementum caries;

K02.3 – Arrested dental caries;

K02.4 – Odontoclasia;

K02.5 – Caries with pulp exposure;

K02.8 – Other dental caries;

K02.9 – Dental caries, unspecified [11,12].

1.5 Classification of the disease or condition

Classification by localization:

1) Fissure caries;

2) Contact (approximal) caries;

3) Cervical caries;

4) Ring (circular) caries.

Classification by clinical course:

1) Acute caries;

2) Chronic caries;

3) Acute fulminant caries;

4) Rampant caries;

5) Recurrent (secondary) caries.

Classification by lesion intensity:

1) Single lesions;

2) Multiple lesions.

Topographical classification of caries:

Caries in the spot stage (macula cariosa);

Superficial caries (caries superficialis);

Moderate caries (caries media);

Deep caries (caries profunda).

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

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

Class II – cavities located on the contact surfaces of molars and premolars.

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

Class IV – cavities located on the contact surfaces of incisors and canines involving the angle of the tooth crown and its incisal edge.

Class V – cavities located in the cervical region of all tooth groups.

Class VI – cavities located on the cusps of molars and premolars and the incisal edges of incisors and canines.

International Caries Detection and Assessment System (ICDAS II) [13-20]:

Code 0 – sound tooth enamel (transparent light enamel);

Code 1 – first visual changes in enamel surface visible only after drying and staining, not extending beyond fissures and pit sites;

Code 2 – distinctly visible changes in enamel surface identified without prior drying (white or pigmented), extending beyond the fissure/pit;

Code 3 – localized enamel breakdown without visible signs of dentin involvement or with mild shadowing, heterogeneous enamel surface, widening of fissures;

Code 4 – underlying dark shadow from dentin, with or without localized enamel breakdown;

Code 5 – distinct cavitation with visible softened dentin, involving less than 50% of the tooth surface;

Code 6 – extensive distinct cavitation with visible softened dentin, potentially involving the pulp and more than 50% of the dental crown surface.

1.6 Clinical presentation of the disease or condition

Enamel caries ("white spot" stage, initial caries) (K02.0)

Focal enamel demineralization (FED) (initial caries) manifests as the formation of white matte spot lesions on the tooth surface; it proceeds without cavity formation. Upon probing, the surface of the lesion may be smooth or rough, with no enamel defect detected. The spots are usually solitary and may be symmetrical. FED most commonly occurs in individuals with low/unsatisfactory oral hygiene practices. Predilection sites for FED: fissures and other natural pits, approximal surfaces, and the cervical region of the tooth crown [1,2,3,6,7].

Enamel caries (initial caries) – presence of enamel defects not extending beyond the amelodentinal junction.

Dentin caries (K02.1)

Dentin caries manifests as the formation of an enamel and dentin defect in the form of a cavity with a varying layer of preserved dentin without signs of hyperemia.

Patients may complain of sharp, localized pain from thermal, chemical, and mechanical stimuli, which subsides after their removal. Probing reveals a carious cavity within the dentin, filled with firm or softened demineralized dentin. Probing the carious cavity may cause brief pain in the area of the amelodentinal junction and/or the cavity floor. Dentin caries most commonly occurs against the background of low/satisfactory oral hygiene practices. Predilection sites: fissures, contact surfaces, and the cervical region of the tooth crown [1,2,3,6,7].

Cementum caries (K02.2)

Cementum caries manifests as the formation of a lesion (a spot or, more frequently, a cavity) on the surface of the exposed tooth root, most often in patients with gingival recession, inflammatory and dystrophic changes in periodontal tissues, predominantly in elderly and senile individuals. Patients may complain of sharp, localized pain from thermal, chemical, and mechanical stimuli, which subsides after their removal; a mild or asymptomatic course is not uncommon. Probing the floor and walls of the carious cavity reveals brief pain. Cementum caries most commonly occurs against the background of low/satisfactory oral hygiene practices [1,2,3,6,7,21]. In most cases, it has a progressive course. It occurs more frequently in elderly individuals, especially against the background of hyposalivation/xerostomia.

Arrested dental caries (K02.3)

Arrested caries is manifested by the formation of pigmented spots of various sizes and color intensities on the tooth surface. The spots are usually solitary and may be symmetrical. This form of dental caries is most often asymptomatic, with possible complaints of aesthetic defects and increased tooth sensitivity to chemical stimuli. The patient's general condition is not impaired; concurrent systemic pathology (endocrine/digestive system disorders) and poor oral hygiene are frequently identified. Upon probing, the spot surface is smooth, without disruption of the enamel-dentin junction integrity, and painless. Preferred localization: fissures and other natural pits, proximal surfaces, and the cervical region of the tooth crown [1,2,3,6,7,21].

Caries with pulp exposure (K02.5)

Caries with dental pulp exposure manifests as the formation of a deep carious cavity within the circumpulpal dentin layer. Complaints may be absent or (more frequently) manifested by sharp pain from thermal or mechanical stimuli that resolves after their removal; spontaneous pain is absent. From the anamnesis, the tooth may have been previously treated / untreated for dental caries. Probing is painful along the bottom of the carious cavity, and localized tenderness may be determined. The radiograph may show direct or indirect accidental pulp exposure during preparation, visualized due to the low radiopacity of demineralized dentin [1,2,3,6,7].

Other dental caries (K02.8)

- carious lesions in hard dental tissues developing after endodontic treatment of complicated forms of caries, such as pulpitis and periodontitis.

The clinical presentation of this form of dental caries depends on the size and topography of the carious cavity. Examination of the causal tooth may reveal the presence of a filling, a change in color and/or defects of hard dental tissues within the boundaries of the filling, as well as isolated crown defects, food impaction between teeth, sharp tooth edges traumatizing the buccal/lingual mucosa, and aesthetic defects [1,2,3,6,7].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of dental caries is established based on the analysis of interview results, clinical examination, and additional diagnostic methods. Dental caries diagnostics aim to determine the stage of the disease, the localization of the carious process, the degree of destruction of tooth structures, as well as the state of the pulp, periodontium, and periodontal tissues to select the optimal treatment method [1,2,3,6,7,21].

During the examination, the patient's factors that impede the immediate initiation of treatment or completely preclude its possibility are identified:

- intolerance to medicinal products and materials planned for use in dental caries treatment;

- presence of an acute periodontal disease in the patient at the time of examination;

- presence of acute inflammatory diseases of the oral mucosa and the red border of the lips in the patient at the time of examination;

- unsatisfactory/poor oral hygiene status;

- inadequate psychoemotional state caused by various factors;

- high level of patient anxiety related to upcoming dental treatment — conditions requiring appropriate medical or psychological correction;

- presence of a systemic disease or several systemic diseases (of moderate severity, medically controlled) in the patient that do not impair their ability to work, do not create risks for dental treatment, and do not limit its possibilities, but require consultation with relevant specialists to prepare for dental treatment;

- history of a severe systemic condition in the patient less than 6 months prior to visiting the dentist (acute myocardial infarction, acute cerebrovascular accident, etc.) that limits activity, threatens life, and creates a high risk for dental treatment;

- patient's refusal of treatment or of a specific treatment method offered.

Diagnosis and subsequent treatment of dental caries are carried out according to the plan below.

2.1 Complaints and Anamnesis

- complaints of pain (discomfort) in the area of a specific tooth causally related to thermal/chemical/mechanical stimuli, with clarification of the duration, nature, and possible causes of their occurrence;

- complaints of an aesthetic defect in the area of a specific tooth / patient satisfaction with their appearance;

- complaints of food impaction between teeth;

- timing of the onset of complaints;

- occupational hazards;

- dietary features;

- the patient's personal attitude toward oral hygiene, the state of their hygiene skills, and the methods and means of individual oral hygiene they use [1,3,10];

- the patient's region of birth and residence (endemic fluorosis areas);

- presence of periodontal diseases and oral cavity organ diseases [1,3,5];

- intolerance to medicinal products and dental materials proposed/planned for dental caries treatment [1,3,5,6,7,10];

- concomitant systemic diseases aggravating or precluding dental treatment [1,3,5,6,7,10];

- history of refusal of dental caries treatment;

- nature of and satisfaction with previous dental caries treatment, if any was performed.

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

Comments: complaints in dental caries are diverse and depend on the depth, topography, multiplicity of lesions, and other factors.

In enamel caries [initial caries], complaints may be absent; less frequently, a short-term reaction to chemical stimuli (sour, sweet, salty) or an aesthetic defect may be noted.

In dentin caries / caries with pulp exposure, complaints include the presence of a cavity in the tooth, food impaction between teeth or in the carious cavity, and short-term pain in response to thermal, mechanical, and chemical stimuli that resolves after their removal; complaints may be absent.

In cementum caries, complaints include a root defect of the tooth, predominantly in elderly individuals against the background of gingival recession, short-term pain in response to thermal, mechanical, and chemical stimuli that resolves after their removal, pain upon food impaction, discomfort and gingival bleeding during tooth brushing and eating.

Arrested caries presents with complaints of a dark pigmented spot on the tooth surface.

During history taking, the following are purposefully identified:

- inadequate psychoemotional state of the patient prior to treatment;

- refusal of treatment.

2.2 Physical Examination

Medical services for physical examination in accordance with the nomenclature of medical services are presented in Appendix A3.

During the physical examination, the localization of caries and the degree of destruction of the coronal part of the tooth are established. Tooth examination is performed in a specific order.

During the examination, the following are determined and evaluated:

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

- the state of each tooth (color, enamel relief, presence of plaque, presence of spots and their state after drying the tooth surface, defects);

- the presence of white chalky spots on visible tooth surfaces, area, edge shape, surface texture, density, symmetry, and multiplicity of lesions to establish the severity of changes and the rate of process development, disease dynamics, and differential diagnosis with non-carious lesions.

• All patients during diagnosis are recommended to undergo an assessment of the maxillofacial region and the oral cavity itself in accordance with WHO recommendations for the examination of dental patients: collection of history and complaints for oral cavity pathology, external examination of the maxillofacial region, examination of the temporomandibular joint (TMJ), visual examination for oral cavity pathology with evaluation of the mucosa, the state of hard dental tissues, dental arches, periodontal tissues, and existing dentures in the mouth [1,2,3,4,5,7,9].

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

2.3 Laboratory Diagnostics

Comments: a saliva viscosity value exceeding 1.45 indicates an unfavorable prognosis for dental caries development.

Comments: normally, the pH of stimulated saliva is 7.0 and higher; a pH of 6.5–6.9 indicates a moderate risk of dental caries; 6.0–6.5 indicates a high risk of dental caries; and a pH < 6.0 indicates a very high risk of dental caries.

2.4 Instrumental Diagnostics

Comments: the method is based on changes in the diffusion properties of enamel, recorded using liquid nuclear stains such as 1% methylene blue, basic fuchsin solution, etc. Areas of demineralized enamel readily absorb the dye and stain easily, whereas in non-carious diseases the enamel does not absorb the dye (except for hard tissue necrosis of the tooth) and remains unstained.

Comments: dental thermal testing is performed to establish a preliminary diagnosis of dental caries. Normally, temperature fluctuations within the range of 17-22 to 50-52°C (indifferent zone) do not cause a dental pain response. When the dental pulp is involved in the pathological process, the boundaries of the indifferent zone narrow, and the tooth responds to cold stimuli with pain, reacting to room temperature water (18-22°C) or warm water (45-50°C).

Comments: the EPT method is widely used in the diagnosis of dental caries because the current intensity and duration are easily dosed, and repeated EPT testing has no damaging effect on the tissues of the oral cavity and the body as a whole. EPT provides more accurate diagnostics than other instrumental examination methods. Normally, in enamel caries and dentin caries, the pulp excitation threshold values are 2-6 µA, in deep caries – 10-12 µA (rarely – up to 20 µA). EPT values exceeding 20 µA indicate the development of pulpitis and the need for endodontic treatment.

Comments: radiological examination is advisable to assess the size of the pulp cavity, the relationship between the carious cavity and the pulp chamber, the presence of communication with the pulp chamber, the evaluation of root formation, and the condition of periapical and periodontal tissues. The use of radiography in pregnant women is performed strictly according to indications and in minimal volume.

Comments: transillumination is harmless to the body and is in demand for assessing the condition of fissures and early preclinical diagnosis of occlusal caries.

The method is based on the difference in light absorption between healthy and caries-affected hard dental tissues (enamel and dentin) when examined under a cold light beam. When light passes through hard dental tissues, the enamel lesion appears as a dark spot clearly demarcated from the healthy perifocal enamel. The intensity of the dark color increases as the depth of the carious cavity increases; in deep caries-affected fissures with low optical density, a tissue glow extinction effect is observed as a dark zone. The diagnostic capabilities of the method also allow for the detection of denticles in the pulp chamber and subgingival calculus deposits.

2.5 Other Procedures

Comments: the IDOST index is used to select the method for restoring the anatomical shape of the coronal part of the tooth (with a filling, veneer, inlay, half-crown, crown, or post-and-core structures).

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

General approaches to the treatment of dental caries

Treatment of dental caries is carried out by a general dentist, and indicated cases involve an orthopedic dentist within the scope of core professional competencies, predominantly performed in outpatient clinic settings, and based on the principles of a comprehensive personalized approach.

Main directions and principles of treatment:

- elimination of major cariogenic risk factors; prevention of further development/progression of the pathological carious process; prevention of complications;

- evidence-based selection and individualized choice of dental materials for conservative and surgical-restorative treatment of dental caries;

- pain management at all stages of treatment;

- priority use of maximally atraumatic, minimally invasive treatment methods/techniques;

- preservation/restoration of the anatomical shape of the caries-affected tooth;

- preservation of the aesthetic parameters of the tooth / achievement of an aesthetic treatment effect;

- improvement of the dental patient's quality of life;

- fostering a sufficiently high level of patient compliance towards maintaining the level of dental health and oral hygiene achieved after dental caries treatment;

- provision of follow-up care by a general dentist for specific groups of patients with dental caries.

The choice of treatment method, scope of therapeutic, preventive, and rehabilitation measures are determined by the stage of the disease, intensity of the carious lesion, its localization and activity of progression, as well as the level of the patient's aesthetic requirements.

Only dental materials and medications authorized for use in the Russian Federation in the established manner are used in the treatment of dental caries, and their selection is coordinated with the patient.

Conservative (non-surgical) and surgical (invasive, restorative) methods are used in the treatment of dental caries. Various non-pharmacological approaches may also be used in the treatment regimen.

Conservative treatment of dental caries

Conservative treatment is indicated for patients with enamel caries (K02.0), arrested dental caries (K02.3) in the form of a spot, and is carried out using non-invasive / micro-invasive treatment methods (remineralization therapy, resin infiltration, deep fluoridation, microabrasion, etc.), which are characterized by high efficacy, biological feasibility, and atraumatic nature due to maximum preservation of hard dental tissue integrity and the use of biomimetic dental materials [1,2,35,36,38,41,44,45,46,47,48,64].

Treatment of patients with enamel caries (K02.0)

Comments:

The caries infiltration algorithm includes: application of a liquid or latex rubber dam to dry the tooth surface and protect soft tissues; etching the enamel with phosphoric acid for 2 minutes to open the porous system of the subsurface enamel layer; rinsing the acid off with water for 30 seconds and air-drying; 2-step enamel infiltration with a flowable composite (infiltrant) by applying the first portion for 3 minutes followed by light-curing (40 seconds) and the second portion followed by light-curing (40–60 seconds); polishing the surface of the infiltrated enamel with polishing cups. Treatment of proximal dental caries is performed after prior tooth separation to ensure better access to the lesion.

Considering that the infiltrated enamel surface retains increased roughness that promotes dental plaque accumulation, the patient is advised to pay special attention to the need for thorough regular POH and adherence to a "colorless" diet.

The infiltration treatment method provides high (82%) short-term (up to 6–12 months) aesthetic and functional results, however, 18–20% of patients develop long-term complications such as recurrent / secondary caries, staining of the infiltrated enamel, hyperesthesia, etc. Therefore, to ensure high and stable results and prevent complications of infiltration treatment, various options of combining it with methods of local application of remineralizing agents in the tooth area are recommended [1,2,3,4,7,8,9,16,35,36,41,43,45,47,71].

Comments: the treatment algorithm for enamel caries by microabrasion includes sequential rubber dam isolation of the operating field, grinding the affected enamel with a diamond finisher, polishing the ground enamel with a microabrasive paste, rinsing the oral cavity, and a final course of remineralizing therapy to strengthen the enamel structure. The procedure is performed 2 weeks after professional POH.

Treatment of patients with arrested dental caries (K02.3)

The choice of treatment method for arrested dental caries (K02.3) and cementum caries (K02.2) is determined by the localization of pigmented dental tissues (occlusal / proximal / vestibular tooth surfaces; location of pigmented spots in aesthetically significant / insignificant zones of the oral cavity), as well as patient preferences; in certain clinically non-manifest situations, treatment of arrested dental caries is not required – the dentist monitors the dynamics of the carious lesion (once a year) [1,2,3,7,9].

Operative-restorative (invasive, surgical) treatment of dental caries

Operative-restorative (invasive, surgical) treatment is indicated for patients with dentin caries (K02.1), cementum caries (K02.2), caries with pulp exposure (K02.8), and less commonly with enamel caries (K02.0) or arrested dental caries (K02.3).

Goals of operative-restorative treatment of dental caries:

- cessation of further progression of the carious process;

- creation of conditions for reliable fixation of fillings, inlays, veneers, half-crowns, and crowns;

- preservation / restoration of the anatomical shape of the caries-affected tooth;

- preservation / restoration of the functional capacity of the dentition as a whole;

- preservation / restoration of the aesthetics of the patient's dentition and face as a whole;

- prevention of local (pulp and periodontal) and/or systemic complications;

- improvement of the quality of life of the dental patient.

Operative-restorative treatment of patients with dentin and cementum caries

Methods of carious cavity preparation: conditions, selection features

Comments:

Features of Class I cavity preparation: to maximize the preservation of cusps on the occlusal surface prior to preparation, it is recommended to identify areas of enamel bearing the main occlusal load using articulating paper. Cusps are removed partially or completely if the cusp slope is damaged by 1/2 of its length. Preparation is carried out, where possible, within the contours of natural fissures.

Features of Class II cavity preparation: creation of access from the occlusal surface to ensure better visibility and instrumentation of the carious cavity. A correctly formed contact surface of the tooth should have a shape close to spherical. The contact zone between teeth should be located in the region of the equator and slightly above it – just like in intact teeth. For small cavities located at or below the equator on the proximal surfaces of teeth, it is recommended to create tunnel access (tunnel preparation) while preserving the marginal ridge. Cavity opening is performed from the masticatory surface, creating an occluso-proximal tunnel with small-sized burs.

Features of class III cavity preparation: creation of direct access if the adjacent tooth is missing or if there is a prepared cavity on the adjacent proximal surface of the neighboring tooth.

Features of class IV cavity preparation: creation of a wide bevel, in some cases an additional box on the lingual or palatal surface, creation of a retention form, since the adhesion of composite materials may be insufficient.

Features of class V cavity preparation: preparation of a rounded carious cavity with or without retention zones if the cavity is very small; use of retraction cords for gingival margin retraction; if necessary, correction (excisions) of the gingival margin mucosa to expose the operating field and removal of the hypertrophied gingival area (performed in two visits – at the 1st visit after surgical intervention, the cavity is sealed with a temporary filling of oil dentin until the gingival margin heals, at the 2nd visit – filling).

Features of class VI cavity preparation: conservative removal of affected tissues with possible preservation of enamel devoid of underlying dentin, which is possible due to the sufficient thickness of the enamel layer in the molar cusp region.

Comments:

Features of class II cavity filling: it is recommended to use matrix systems and interdental wedges for optimal adaptation of the restoration material to the gingival wall and to prevent excessive extrusion of material into the gingival wall area of the cavity (creation of an "overhanging margin"). Formation of the proximal slope of the marginal ridge should be performed using abrasive strips (finishing strips) or discs to prevent material chipping and food impaction.

Features of filling Class IV cavities: it is recommended to use matrix systems and matrices, the silicone key technique for restoring the oral wall and incisal edge of the tooth crown (mock-up and wax-up techniques).

Features of class V cavity filling (cement caries): it is recommended for filling defects on the vestibular surface of anterior teeth to choose a material with high aesthetic characteristics; use glass-ionomer (polyalkenoate) cements in patients with poor oral hygiene, which ensures long-term fluorination of hard dental tissues after filling and guarantees acceptable aesthetic results; use amalgam or glass-ionomer cements in elderly and geriatric patients, especially in cases of xerostomia. It is also possible to use compomer composite materials combining the advantages of glass-ionomer cements with high esthetics.

Features of filling in root caries: When preparing root caries / cementum caries, as a rule, there is no stage of opening the carious cavity; classical cavity formation is not necessary, since glass-ionomer cements and compomer composite materials recommended for use in root caries have chemical adhesion to hard dental tissues; for a greater aesthetic effect, pink shade compomers can be used to "camouflage" gingival recession.

Currently, the following materials for permanent tooth fillings are registered in the territory of the Russian Federation:

1) Dental cements (mineral, polymeric) are used for permanent filling of carious cavities. Mineral two-component cements are sparingly soluble in water and oral fluid. They are used for filling carious cavities without occlusal load. Polymeric cements chemically bond to the tooth, preventing microleakage. They are biocompatible, require no liners, and release fluoride ions for a long time.

2) Composites (chemical-cure, light-cure). Chemical composites have high strength, low shrinkage, poor color stability, and limited working time. Light-cure composites have high strength, and packable composites mimic the density of amalgam and constitute a viable alternative to amalgam. High color stability and esthetics, "command" polymerization and ease of use, cost-effectiveness. Light-cure composites can be used as filling materials for aesthetic restoration in the restoration of all tooth groups.

Treatment of patients diagnosed with "Caries with pulp exposure (K02.5)"

Surgical restorative treatment of "caries with pulp exposure" with complete or partial preservation of vital pulp is possible in the presence of the following indications:

- absence of spontaneous pain sensations;

- objective data on tooth preservation / vitality obtained during the examination;

- absence of general and local contraindications.

Surgical-restorative treatment of "caries with pulp exposure" with complete or partial preservation of vital pulp is not indicated in individuals who have:

- age over 30 years;

- severe systemic pathology;

- high caries intensity (DMFT > 7);

- class V carious cavities;

- poor oral hygiene status;

- pulp electroodontometry value decreased to 40 µA or more;

- changes in the periodontium and / or periapical tissues.

Comments: the frequency of adverse outcomes is 0.05 / 100 (95% CI: 0.001–0.30) and 2.38 / 100 (95% CI: 0.29–8.34), respectively, in teeth with a small (<5 mm²) and large (>5 mm²) communication between the pulp chamber and carious cavity [1,2,3]. The method of partial pulp preservation is vital pulp amputation – pulpotomy (only for multi-rooted teeth) [1,2,3,5,7].

Comments: non-selective (complete) removal of carious dentin is not considered the method of choice in the treatment of caries with pulp exposure. The success rate of caries treatment using the two-step selective removal of affected dentin after 5 years is 60%, whereas with non-selective removal of affected dentin it decreases to 46%.

Comments: the efficacy of MTA use 2 years after treatment is significantly higher than that of calcium hydroxide lining pastes. Calcium hydroxide-based preparations are indicated for use with the two-step technique and a base lining.

Other treatment

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Specific rehabilitation measures for patients with "Dental caries" have not been developed.

5. Prevention and Dispensary Observation

The following preventive measures exist for dental caries: community-based and individual. Community-based methods are implemented at the state level and include partial or total fluoridation of water, salt, and milk.

- pregnant women;

- children with incomplete mineralization of tooth fissures;

- patients with chronic gastrointestinal pathology;

- patients with low oral fluid pH values and low remineralizing capacity of oral fluid;

- patients with poor oral hygiene;

- patients with periodontal diseases;

- patients with DMFT index values > 9;

- patients with 3 or more carious cavities at the time of examination.

• Dynamic monitoring is recommended for individuals with low caries resistance (caries-susceptible patients) with check-ups every six months [1,2,3,7,8,9]. These recommendations are relevant for both primary and secondary caries prevention.

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

6. Organization of Medical Care

Treatment and preventive measures for dental caries are carried out in outpatient settings after diagnosis confirmation by dentists and general dentists, involving orthopedic dentists, oral surgeons, orthodontists, and dental hygienists when necessary.

7. Additional Information

Nutritional disorders and changes in the fluoride level in water can lead to the occurrence of diseases, including dental caries [1,2,3,5,6,7,10,111].

The most probable cariogenic effect is noted with an excess of easily digestible carbohydrates (sugars, glucose) in food, 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 dental caries in people who consume water with an insufficient fluoride concentration (less than 0.8 mg/L).

These factors create a favorable background against which the action of various pathogenic factors is easily combined and dental caries develops.

Most systemic diseases can be accompanied by a significant prevalence and intensity of caries [1,2,3,7,8,9,78].

Changes in the body arising from systemic diseases have an indirect effect on hard dental tissues by altering the composition and properties of mixed saliva, the rhythm of salivation, the functional activity of the dental pulp, the composition and properties of microflora, and the hygienic state of the oral cavity. The most adverse effect of general diseases on teeth manifests during their development, mineralization, and maturation. Thus, systemic diseases can create a favorable background for the easy realization of adverse local cariogenic factors.

A low level of knowledge and skills in maintaining oral hygiene and low compliance with dental health maintenance affect the occurrence and course of dental caries. For each patient with dental caries, it is recommended to select optimal individual strategies for maintaining dental health based on ethno-cultural, personal, age characteristics, and financial resources.

Toothbrushing instruction for adults.

The patient is advised to mentally divide each jaw into 5 segments:

- 2 groups of posterior teeth (left and right);

- 2 groups of premolars (left and right);

- the group of anterior teeth.

Toothbrushing should always be performed in a specific sequence, for example: lower right molars → lower right premolars → lower incisors and canines → lower left premolars → lower left molars → upper left molars → upper left premolars → upper incisors and canines → upper right premolars → upper right molars.

The cleaning scheme for each of the specified mental segments.

The toothbrush with applied paste should be placed at an angle to the gingival margin, and the outer (vestibular) and then inner (oral) surfaces should be cleaned with vertical sweeping movements directed away from the gingiva. The masticatory surfaces should be cleaned using reciprocating brush movements (back and forth) with a small amplitude and vibration so that the bristles can reach the grooves and fissures. Finally, the jaws should be clenched, and the cleaning completed with circular massaging movements on the outer surface of the teeth, extending over the gingival area toward the incisal edge or masticatory surface.

The patient must be taught to perform brush movements in a specific sequence while counting them. To completely remove plaque from each tooth surface, at least 10 toothbrush movements must be performed. When executed correctly, this method of toothbrushing takes approximately 3 minutes.

Bass toothbrushing method

This method was developed to remove dental plaque and food debris from the gingival sulcus through the combined use of a soft toothbrush and unwaxed dental floss.

Method features: use of vibrating toothbrush movements.

The working end is positioned at a 45° angle to the long axis of the tooth, applying slight pressure with the ends of the bristles against the enamel and gingival papillae. Then, with gentle pressure on the bristles, an attempt is made to insert them into the gingival sulcus. In this position, vibrating movements of the brush are performed with a small amplitude, thereby promoting high-quality plaque removal. It is recommended to perform 10 movements for each area.

Toothbrushing with an electric toothbrush.

The working part of the electric toothbrush with a rotating head is placed on the vestibular surface of the tooth and held for 1–2 seconds, during which it performs pulsing, oscillating, and reciprocatory-rotational movements that remove plaque. Then it is moved to the adjacent tooth, and in this manner, all teeth and surfaces are sequentially cleaned. The toothpaste foam generated during electric toothbrushing acts as a surfactant, increasing cleaning efficiency. Some models of electric toothbrushes feature a timer that emits a short signal every 30 seconds (the time sufficient to clean one jaw quadrant) and a longer signal after 2 minutes (the minimum toothbrushing time). When using this type of toothbrush, cleaning movements are performed in the direction from the gingiva to the incisal edge or masticatory surface of the tooth, but with a minimal amplitude of 2–3 mm. Since toothbrushes of this type exert the gentlest effect on hard dental tissues and periodontal tissues, they are recommended for patients with non-carious lesions, tooth hypersensitivity, periodontal diseases, orthodontic appliances, implants, or inadequate toothbrushing skills.

Contraindications to the use of an ultrasonic toothbrush: cardiac pacemaker, history of myocardial infarction (up to 6 months), oncological diseases, blood disorders, epilepsy, age under 9–10 years.

Supervised toothbrushing

This procedure implies toothbrushing performed independently by the patient in the presence of a specialist (dental hygienist or dentist).

Objectives of supervised toothbrushing:

- evaluation of plaque removal efficiency;

- correction of oral hygiene skills.

The procedure is performed in a dental office or oral hygiene room.

Procedure sequence:

- treatment of the patient's teeth with a disclosing agent, determination of the hygiene index, demonstration to the patient using a mirror of the areas with the highest plaque accumulation;

- toothbrushing by the patient in their usual manner; an hourglass can be used to monitor its duration;

- re-determination of the hygiene index, evaluation of plaque removal efficiency (comparison of hygiene index scores before and after toothbrushing), demonstration to the patient using a mirror of the stained areas where dental plaque was not removed during brushing;

- demonstration of the correct toothbrushing technique on models, recommendations to the patient on correcting deficiencies in oral hygiene care, instruction on the use of auxiliary hygiene aids.

During subsequent visits, the hygiene index is determined again, and if its value is unsatisfactory, the procedure is repeated.

Criteria for Evaluating the Quality of Medical Care

Group of diseases or conditions: Dental caries.

ICD-10 code(s): K02.

Nosological forms: Enamel caries, Dentin caries, Cementum caries, caries with pulp exposure, Arrested caries.

Type of medical care: primary health care.

Conditions for providing medical care: outpatient.

References

Appendix A1. Working Group Composition

1. Mitronin Alexander Valentinovich, Professor of Conservative Dentistry and Endodontics, Russian University of Medicine of the Russian Ministry of Health, Professor, Doctor of Medical Sciences.

   Conflict of interest: none.

2. Kuvaeva Marina Nikolaevna, Associate Professor at the Department of Conservative Dentistry and Endodontics, Russian University of Medicine of the Russian Ministry of Health, Candidate of Medical Sciences.

   Conflict of interest: none.

3. Ostanina Diana Albertovna, Associate Professor at the Department of Conservative Dentistry and Endodontics, Russian University of Medicine of the Russian Ministry of Health, Candidate of Medical Sciences.

   Conflict of interest: none.

4. Zablotskaya Natalya Vitalievna, Associate Professor at the Department of Conservative Dentistry and Endodontics, Russian University of Medicine of the Russian Ministry of Health, Candidate of Medical Sciences.

   Conflict of interest: none.

5. Belyaeva Tatyana Sergeevna, Assistant Professor at the Department of Conservative Dentistry and Endodontics, Russian University of Medicine of the Russian Ministry of Health, Candidate of Medical Sciences.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Dentists 31.05.03

1. Scale for evaluating levels of evidentiary validity (LEV) for diagnostic methods (diagnostic interventions)

2. Scale for assessing levels of evidence reliability (LER) for prevention, treatment, and medical rehabilitation methods, including those based on the use of natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

3. Scale for assessing levels of recommendation persuasiveness (LRP) for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Procedure for updating clinical guidelines.

The clinical practice guideline update mechanism provides for their systematic revision—at least once every three years or upon the appearance of new information regarding the management of patients with the given disease, but no more frequently than once every 6 months. The decision to update is made by the Russian Ministry of Health based on proposals submitted by medical non-profit professional organizations. The formulated proposals must take into account the results of comprehensive assessments of medicinal products and medical devices, as well as the results of clinical testing.

Appendix A3. Reference Materials

1. Order of the Russian Ministry of Health dated July 31, 2020, No. 786n "On Approval of the Procedure for Providing Medical Care to the Adult Population for Dental Diseases".

2. Order of the Russian Ministry of Health dated April 14, 2025, No. 203n "On approval of criteria for assessing the quality of medical care."

List of medical services for the diagnosis and treatment of dental caries

Table 1. Collection of complaints, anamnesis, physical examination

Table 2. Laboratory diagnostics

Table 3. Instrumental diagnostics

Table 4. Other diagnostics

Table 5. Conservative treatment

Table 6. Surgical treatment

Table 7. Other treatment

Appendix B. Physician Action Algorithms

Appendix B1. Caries treatment algorithm diagram

1. Enamel caries

Nosological form: enamel caries

Stage: any

ICD-10 code: K02.0

Nosological form: dentin caries, cementum caries

Stage: any

ICD-10 code: K02.1, K02.3

Nosological form: caries with pulp exposure

Stage: any

ICD-10 code: K02.5

Appendix B2. Selection of prosthetic designs

Restoration of the tooth crown using prosthetic (orthopedic) structures depends on the IROPZ index values.

Appendix C. Patient Information

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

Appendix G1. DMFT (t) index for assessing caries intensity

Russian title: DMFT index (teeth) for assessing caries intensity.

Source: Assessment of the prevalence and intensity of caries and non-carious lesions in the adult population of Barnaul / S.I. Tokmakova, O.V. Bondarenko, A.A. Shevtsova [et al.] // Modern Problems of Science and Education. – 2018. – No. 4. – P. 226. – EDN VKTEDC. [98].

In 1971, the DMFT index was recommended by the World Health Organization (WHO) as a universal criterion for determining the intensity of dental caries among all age groups of the population.

Type: index.

Purpose: The DMFT index reflects the level of susceptibility to caries or resistance to it in an individual; the dynamics of the DMFT index can characterize changes in the nature and volume of dental care provided to the population or in their motivation, as well as analyze the level of dental care delivery to the population.

Content:

The DMFT index is calculated based on three indicators

D — number of carious lesions

M — number of missing teeth

F — number of filled teeth

Calculation formula

DMFT = D + M + F, where:

D — number of carious (untreated) teeth;

M — number of missing teeth or tooth roots subject to extraction;

F — number of filled (treated) teeth.

Key (interpretation):

Explanations

DMFT index (t) - the sum of carious, filled, and missing teeth in one examined individual; 32 permanent teeth are taken into account, including wisdom teeth.

According to World Health Organization information, the average index for citizens aged 35–44 years is 6.3–12.7.

Appendix G2. Simplified Oral Hygiene Index (OHI-S)

Russian title: Simplified Oral Hygiene Index (OHI-S).

Source: Therapeutic Dentistry: National Guidelines / ed. by O.O. Yanushevich. - 3rd ed., rev. and supp. - Moscow : GEOTAR-Media, 2024 .-.988 p. [1].

Type: index.

Purpose: Determination of dental plaque and dental calculus.

Content: The dental plaque index is determined first, followed by the dental calculus index. The Simplified Oral Hygiene Index (OHI-S) is used to detect both dental plaque and dental calculus. The buccal surfaces of teeth 16, 21, and 24, and the lingual surfaces of teeth 36, 41, and 44 are stained. The numerical values of dental plaque are summed and divided by the number of teeth, i.e., by 6.

The following codes and criteria are used to assess dental plaque:

0 - no plaque;

1 - plaque covers not more than 1/3 of the tooth;

2 - plaque covers from 1/3 to 2/3 of the tooth surface;

3 - plaque covers more than 2/3 of the tooth surface.

The Plaque Index (PI) is calculated using the following formula: the sum of the codes is divided by the number of examined teeth (6).

The Calculus Index (CI) is determined in the same way as the dental plaque index, taking into account the following scores:

0 - no calculus;

1 - supragingival calculus covers less than 1/3 of the tooth surface;

2 - supragingival calculus covers 1/3-2/3 of the tooth surface, or separate particles of subgingival calculus are present;

3 - supragingival calculus covers more than 2/3 of the tooth surface, subgingival dental calculus is present.

The CI is calculated using the formula: the sum of the codes is divided by the number of examined teeth:

OHI-S = PI + CI. Normally, the CI should not exceed 1.

Key (interpretation):

Table 1. Oral hygiene evaluation criteria according to the Simplified Oral Hygiene Index

Notes: The index is used for an objective assessment of oral hygiene and risk factors for dental caries.

Appendix G3. Index of Occlusal Surface Destruction (IOSD)

Russian title: Index of destruction of the occlusal surface of teeth (IDOST).

Source: Firsova I.V., Makedonova Yu.A., Kamaletdinova R.S., Kobelev E.V. Modernization of the method for determining the tooth destruction index // International Journal of Applied and Fundamental Research. 2015. No. 3-4. P. 700-704 [33].

Type: index.

Purpose: Selection of the method for restoring destroyed tooth crowns. When choosing the method for restoring destroyed crowns of posterior teeth, it is advisable to be guided by the index of destruction of the occlusal surface of teeth (IDOST).

Content: The index is used to select the method for restoring the tooth crown.

It is calculated as the ratio of the cavity area to the area of the entire occlusal surface, taken as a unit.

Key (interpretation):

The IDOST value is always less than one:

with an IDOST up to 0.3, tooth filling is indicated;

with an IDOST within 0.3-0.6, inlay treatment is indicated;

with an IDOST within 0.6-0.8, crown treatment is indicated;

with an IDOST over 0.8, fabrication of post and core restorations is indicated.

Notes: Determining the degree of destruction of the occlusal surface of the tooth is a decisive factor in choosing the treatment method (filling, inlay, and artificial crown) in order to prevent further destruction of crowns and tooth extraction.