Dental caries

Since the Soviet time, necessity and possibility to spare dental tissues has been undervalued. An early start of the restoration cycle and suboptimal quality of filling materials caused progressive enlargement of cavities: the restorations failed, the cavities were further enlarged. This led to fractures and extractions often at a young age. Initial and questionable carious lesions, found at preventive medical examinations (so-called dispensarizations) [1], were treated by dry cutting, sometimes with dull rotary instruments, which led to excessive removal of hard tissues. At schools, the dental dispensarizations were recommended to be performed twice yearly [2]. The consent for the treatment was often not asked especially from children and adolescents or their parents. The dental treatment was in fact compulsory: “The doctor identifies children who evade the treatment and takes measures jointly with the school administration” [3]. If an adolescent or even medical student asked “not to drill”, a trick sometimes followed: “I’ll just inspect”; a switched off handpiece introduced into the oral cavity, then followed cutting. Poor-quality filling materials did not hold long. Due to the early start and acceleration of the restoration cycle, the “tooth death spiral” [4] and extensive dental prosthetics at an age around 30 years have been not infrequent.

The checkups and treatments were performed under the time pressure. The explorer fixation in a pit or fissure (stickiness), enamel surface roughening and discoloration were regarded as diagnostic criteria of caries. Individual anatomic features of pits and fissures as a possible cause of the explorer stickiness were not discussed in handbooks and monographs. According to the international literature, the probing of suspected lesions is obsolete, since it achieves no gain of sensitivity and can cause damage. Apparently, the overdiagnosis of dental caries has been continued until today: “The prevalence of dental caries in 3-year-old children was 67%, in six-year olds 87% and in 12-year olds 92%” [5]. Caries was found in 92.9% of children 1.6-2.5 years old [6]. Conscripts (18-19 years old) reportedly had caries in 85%, requiring treatment 76% of the cases [7]. Kozlova et al. claimed the 100% prevalence of caries in adults [8]. Corresponding figures in the international literature are generally lower. Dental dispensarizations have been largely abandoned in the 1990s; but the large-scale privatization of dentistry created new problems (discussed below). Vladimir Putin, in his address to the Federal Assembly on 21 April 2021, instructed the Ministry of Health to expand the program of preventive medical examinations. It can be reasonably assumed that when dispensarizations are resumed en masse, some of the previous failings may come back.

Superficial caries has been defined as a lesion limited to the enamel without involvement of the enamel-dentin junction. Mechanical preparation and restoration has been recommended for superficial occlusal caries and superficial caries in general both in children and in adults [9-12]; this recommendation was sometimes stressed as obligatory [13]. According to a recent textbook, enamel caries in fissures, pits or approximal surfaces must be treated by cutting and filling [14]. In some manuals, mechanical preparation was recommended also for areas of enamel discoloration with an intact surface, without waiting for the cavity formation [13,14]. In a recent instruction, invasive treatment of pigmented flecks has been recommended as “more efficient” than remineralization [15]. Accordingly, many lesions treated by mechanical preparation were in fact anatomic variations of the grooving, fissures and pits, pigmented fissures, etc. As far as we know, dentists would not apply dry cutting to discolored pits and fissures or demineralized enamel surfaces in their children and relatives. This means that there has been deliberate infliction of harm in some circumstances [16].

In regard to the fissure sealing, Russian authors recommended mechanical preparation for the treatment of (supposed) superficial caries [17,18]. If caries is diagnosed, mechanical preparation is deemed indicated. Pigmentation of tissues in a fissure was designated as an important symptom of caries [19]. Preparation of fissures has been recommended even in the absence of caries symptoms; it was designated as a “gold standard” diagnostics of occlusal caries. Preparation of one fissure for diagnostic purpose has been suggested as an option in order to decide what to do with other fissures and pits [19]. According to the international literature, even medium occlusal caries in the permanent dentition may be treated by non-invasive fissure sealing. Remineralization of dentin within sealed caries lesions is possible in teeth having vital pulp. The pigmentation per se is clinically insignificant [20,21].

First restorations were usually placed in childhood. Exploration with a probe has often been performed with excessive force, which could be partly explained by the fact that “enamel softening” was presented by handbooks as a diagnostic criterion of early caries [10,12]. It is known that demineralized but non-cavitated enamel and dentin lesions can be remineralized [20-22]. Nonetheless, the exploration with the probe has been recommended also in a recent monograph [23]. As for the endodontic therapy, it can be seen on radiograms that the quality of root canal treatment was often inadequate; and sometimes only traces of fillings are visible in the roots. Procedural quality was additionally impaired by the limited availability of effective anesthesia. Pulpitis treatment and endodontic manipulations had usually been performed without local anesthesia, after arsenic trioxide devitalization of the pulp until the mid 1990s and in places also later. Dental anxiety prevented patients from asking professional help after restoration failures and tooth fractures so that some of them waited for pulpitis or periodontitis, which finally ended with extractions.

The traditional approach to caries (extension for prevention) has not been questioned by many leading experts. According to the National manual of therapeutic dentistry, “it is necessary to remove all damaged tissues” [24]. Analogous recommendations have been given in most recent textbooks and manuals both for adults and for children [12,14,25,26]. With this approach, a removal of hard dental tissues is inevitable. The recent Manual of pediatric dentistry recommends removing only demineralized tissues, mentioning the possibilities of de- and re-mineralization. On other pages of the same book, a “maximal removal of pathologically changed dental tissues” is suggested [27]. A complete removal of non-viable, carious and pigmented dentin has been usually recommended [15,18,23,28-31]. Insensitivity of dentin during diagnostic preparation (“drill test”) is considered as a sign of its non-viability, “which is important for determining the extent of preparation” [30]. In the international literature, a non-selective removal of dentin is generally not recommended. For deep lesions, complete caries excavation is considered to be overtreatment. Recent research supports less invasive strategies, highlighting that a complete removal of soft dentin may not be always necessary. Selective removal of soft dentin in deep lesions leaving it on the cavity surface adjacent to the pulp is often indicated [20,21,32-34].

The term MID appears increasingly often in Russian-language publications, although recommendations are sometimes vague. Some authors depict MID as a time-consuming individual approach practicable only at expensive private clinics [31]. Note that MID often implies avoidance of mechanical preparation, observation and/or topical treatment, which may be neither exceedingly expensive nor time-consuming. Some papers about MID have no references being in fact aimed at promotion of certain products or services [35,36]. Caries risk assessment aimed at the treatment individualization has been rarely discussed, while the proposed criteria - number of cavities, restorations, missing and devitalized teeth - are inadequate because the role of iatrogenic factors is not taken into account. Teeth after repeated restorations were described as having “carious process below the level of gingival margin” [37] if even the patient had not noticed any spontaneous tooth decay for decades, also after restoration failures or fractures. In other words, iatrogenic damage as a result of the accelerated restoration cycle, so-called tooth death spiral [4], has been ascribed to caries. Along with other criteria of the caries risk, individual histories should be taken into account. If a patient does not notice any tooth decay over years, despite restoration failures or tooth fractures, it can be considered as an argument in favor of less extensive preparation. Apparently, frequent gingival bleedings i.e. blood in the oral cavity tends to inhibit tooth decay due to bactericidal properties of blood, frequent mouth washings and more conscious diet. Patients should be involved in treatment decisions in a meaningful way, with due consideration given to their needs, desires and possibilities [38].

Thanks to the free Internet resources, some Russian-language literature has been partly adjusted to the international prototypes. Certain foreign books have been translated, while the quality of translation is uneven [39]. On the other hand, some Russian manuals are partly based on international handbooks [40,41]. Controversies of caries treatment in Russia give rise to questions that should be answered on the basis of scientific evidence: what kind of dental lesions, in children and in adults, must be treated by mechanic preparation and which ones can be left for observation or non-invasive therapy. The general deceleration of tooth decay because of the widespread use of fluorides, better oral hygiene and more conscious diets are arguments in favor of less extensive preparations.

Gingival Recession and Periodontal Conditions

Gingival recession (GR) is a displacement of the gingival margin apically from the cement-enamel junction. The prevalence of GR increases with age; it varies from 8% in children up to 100% after 50 years [42]. A patient may present with symptoms including sensitivity of exposed dentin, root caries and esthetic concerns. GR is distinguished from periodontal pocketing; both types of the gingival attachment loss can be found in the same patient [43]. Among predisposing factors are destructive periodontal disease, mechanical trauma including excessive brushing, root prominence and other anatomical factors, arsenic trioxide devitalization of the pulp, traumatic exodontia with excessive socket curettage (discussed below), other dental and periodontal treatments [26,44].

There have been a number of studies confirming an association between the dental plaque index and GR. There is an opinion, though, that the plaque and calculus itself has little or no impact on the gingival attachment [45]. It can be reasonably assumed that subgingival plaque and calculus are secondary to the attachment loss and not vice versa. No association between calculus and GR was found in adolescents [46]. An argument about plaque as a source of germs might be plausible in case of inflammation, although diverse microflora is a norm for the oral cavity. The relationship between plaque/calculus and GR differs among social classes. In people with insufficient oral hygiene and access to the dental care, subgingival calculus is more extensive and correlates with the periodontal attachment loss; while in those with adequate oral hygiene the relation of GR to periodontitis is less evident [42,45]. The concept of oral hygiene is sometimes not well defined as it is confounded with esthetics. There are statements in the Russian literature that are not supported by scientific evidence, for example: “Hard-bristled toothbrushes do not damage the gums and exert a therapeutic effect on periodontal tissues, reducing GR due to the effect of mechanical stimulation” [47]. This is generally at variance with the international literature. Along the same lines, recommendations of gum massage with fingers and laser therapy of GR appear doubtful. The damaging effect of such treatments may be masked by the placebo effect. Like other types of electromagnetic radiation, laser causes warming at lower doses and injury at higher absorbed energies. Although low-energy lasers are used for the periodontal treatment, several systematic reviews have found no proven clinical benefits, while some studies have shown controversial results and questioned effectiveness [48]. Theoretically, a non-thermal photochemical antimicrobial effect of laser is possible; but studies with temperature measurements are needed to prevent thermal damage of atrophic tissues. Anyway, antimicrobial mouth wash is technically easier. The supposed promotion of tissue repair by laser may be a part of an injury-and-repair sequence potentially damaging atrophic tissues. Other laser applications (photoablative, photodynamic therapy, removal of diseased pocket lining epithelium, etc.) are beyond the scope of this review.

Furthermore, the calculus removal (scaling and root planing) is often offered to patients, designated as a “crucial factor of periodontium preservation” [26], being “very important” [49]. The same experts noticed that tissue traumatizing is unavoidable at that. The scaling has been associated with damage to enamel and soft tissues, excessive tooth sensitivity and GR [50,51]. In particular, subgingival calculus may be locked into tooth irregularities, so that it may be difficult to avoid traumatization [41]. The scaling has sometimes been performed in conditions of suboptimal quality assurance [52]. In the author’s opinion, the mechanical calculus removal is not indicated at least for older patients with GR and modest esthetic demands. From the viewpoint of general pathology, being an atrophic condition, GR can advance due to repeated injury. Besides, it has been reported that excessive tooth brushing not only contributes to GR, but also can damage enamel. Among tooth brushing factors associated with cervical lesions (notched enamel and/or dentin) are frequency and manner of brushing as well as hardness of the bristles [53].

In earlier Russian-language literature GR was often discussed within the scope of periodontitis i.e. together with cases characterized by marked inflammation of gingival pockets. Accordingly, GR was sometimes regarded as an inflammatory condition of predominantly infectious etiology, which is not the case for GR without inflammation. The latter was also referred to as periodontal atrophy or involution [54]. As generally for age-related atrophy, the prevailing approach must be avoidance of traumatizing manipulations, minimization of soft-tissue damage, gentle handling of tissues in periodontal surgery. The treatment of GR should be seen within the framework of minimally invasive periodontal therapy and MID in general. The surgical treatment of GR is beyond the scope of this review.

Tooth Extraction

The above considerations pertain also to exodontia with curettage of tooth sockets. In the international literature a gentle curettage is generally recommended. In Russia the curettage of the socket bottom and walls has been often performed intensely, aiming at a complete removal of granulation tissue. The following was typically recommended: after a tooth extraction, granulation tissue and remaining granuloma are removed with a spoon-shaped curette [37,55,56]. “The manipulation should be performed especially carefully near anatomical structures (the mandibular canal, the maxillary sinus, the nasal cavity)” [37]. The presumed granulation tissue may be indistinguishable from normal gingiva, while indications to its complete removal are questionable as ripening granulation tissue becomes fibrotic. In this regard, histological examination of curettage materials could be a topic of research. Especially in conditions of gingival atrophy and retraction, excessive curettage of the socket may contribute to a root denudation of neighboring teeth, leading to enhanced sensitivity and pain sometimes intensive enough to entail a next extraction. In a previously reported case, a patient with GR underwent extraction of the tooth 16. Intensive socket curettage was performed in spite of the patient’s protests. After the extraction, marked GR remained in the area of neighboring teeth, with increasing root sensitivity [57]. Subsequently, an extraction of the tooth 17 became necessary. A complaint was written to the healthcare authority, which was replied with the argumentation that “the treatment was performed in accordance with the diagnosis and in required volume.” It should be stressed that a method, even if extensively used, is not necessarily in accordance with modern standards of care, and that practitioners should replace outdated methods with improved ones [58].

Privatization of Russian Dentistry

The large-scale privatization of dentistry in the 1990s created new problems. Some practitioners avoid conservative treatment of advanced lesions and manipulate patients towards extractions and prosthetics. Dentists often choose treatment plans based on commercial considerations rather than clinical indications [59], which is acknowledged in private conversations. Catch phrases are used: “Your tooth has a hairline fracture”; “the alveolar bone has been dissolved, you will lose your tooth soon”, or alike. In case of exodontia, some dentists at state polyclinics offer a choice: “Do you want a paid or free injection?” The payment is unofficial i.e. under-the-counter. Anesthesia after the free injection is incomplete. After a painful extraction, the patient would rather decide in favor of paid services, especially if multiple teeth have to be extracted. Pain should not be used for manipulation towards paid services. According to the WMA Resolution, the pain treatment is a human right. Formally, the obligatory insurance in Russia covers basic dental treatments; but some personnel at polyclinics accept under-the-counter payments. In conditions of lawfulness and high ethical standards, market relations give rise to a sound competition in the areas of healthcare quality and innovations. In contrast, where there is disrespect for laws, regulations and ethics, the competition turns towards discrediting free healthcare, manipulation of patients towards paid services, harassing of non-paying patients, etc. In dentistry, this included examinations with a probe applying excessive force, hints about poor quality of filling materials, inadequate anesthesia etc. Unfriendly attitude towards non-paying patients in medical institutions has been noticed since the economic reforms of the 1990s. Especially some aged people perceive such attitude as insulting and don’t seek medical help even if they have symptoms or a chronic disease. Apparently, this is one of the reasons of the relatively short life expectancy in Russia. War veterans enjoy advantages in the healthcare and everyday life; however, there are misgivings that the veteran status has been awarded gratuitously to some individuals from the privileged milieu. Those participating in the Ukraine war, factually or on paper, will obtain the veteran status hence acquiring privileges over fellow-citizens. Some of them will fill high positions without proper selection and training. More details and references are in the book [16].

Entering the tooth restorative cycle should be avoided as long as reasonably possible. An economical re-routing of dental practices is needed, so that they could survive using preventive and minimally invasive methods more extensively. Dental treatments at the polyclinics, providing free care to patients with obligatory medical insurance, must be performed on the state-of-the-art level. Improvements in educational and ethical standards of healthcare providers at all levels are needed. The principle of informed consent must be rigorously observed. For this scenario to be realized, the first step that needs to be taken includes the exchange of experience through the implementation of temporary programs for Russian dentists to go abroad and authorized foreign advisers to come to Russia. The warmongering should be discontinued to facilitate international cooperation; otherwise the backlog in the healthcare in some parts of the world will deepen.

Declaration

No conflict of interest.

1. Jargin SV. Potential issues associated with dispensarisations in Russia. Public Health. 2021; 198: 29-30.
2. Taicher SM, Trofimova LG. Experience in the dispensarization of school-age children. Vopr Okhr Materin Det. 1970; 15: 93.
3. Betelman AI. Instructions for sanitation of the oral cavity of schoolchildren. Moscow: NKO SSSR. 1936.
4. Mokeem LS, Garcia IM, Melo MA. Degradation and failure phenomena at the dentin bonding interface. Biomedicines. 2023; 11: 1256.
5. Suntsov VG, Voloshina IM. The role of clinical examination in the children dental health consolidation. Stomatologia detskogo vozrasta i profilaktika - Paediatric Dentistry and Dental Profilaxis. 2011; 10: 12-14.
6. Kamchybekova ASh, Cholokova GS, Abykeeva RS. Prevalence and inensity of tooth decay for the children of early age. Vestnik KSMA n.a. I.K. Akhunbaev. 2022; 2: 143-6.
7. Iordanishvili AK, Soldatkina AS, Serikov AA. Dental diseases in people of recruit age. Bulletin of the Russian Military Medical Academy. 2015; 4: 106-8.
8. Kozlova NV, Sklyar HA, Karpunina SA. Karies zubov, prichiny vozniknoveniia i metody lecheniia (Dental caries, causes and treatment methods). Bulletin of Scientific Conferences. 2018; 4: 35-37.
9. Borovsky EE, Kopeikin VN, Kolesov AA, Shargorodsky AG. Stomatology. Handbook for practical training. Moscow: Meditsina. 1987.
10. Iakovleva VI, Tro?mova EK, Davidovich TP, Prosveriak GP. Diagnostic, treatment and prevention of stomatological diseases. Minsk: Vysheishaya shkola. 1992.
11. Kolesov AA. Stomatology of childhood. Moscow: Meditsina. 1991.
12. Zelensky VA. Pediatric Dentistry Textbook. Moscow: SIMK. 2023.
13. Lukinykh LM. Lechenie i profilaktika kariesa zubov (Treatment and prevention of dental caries). Nizhny Novgorod Medical Academy. 1998.
14. Orekhova LYu, Ulitovsky SB, Yaremenko AI. Stomatologia profilakticheskaia (Preventive dentistry) Textbook. St. Petersburg: Chelovek. 2023.
15. Anurova AE, Kosyreva TF, Safroshkina VV, Davidyan OM. Karies zubov v detskom vozraste. Sovremennye metody diagnostiki i lecheniia (Dental caries in childhood. Modern methods of diagnosis and treatment). Moscow: RUDN. 2017.
16. Jargin SV. Selected Aspects of Healthcare in Russia. Cambridge Scholars Publishing. 2024.
17. Avraamova OG, Muravyova S. Fissurnyi karies: problemy i puti ih resheniia (Fissure caries: problems and solutions). Stomatology for All. International Dental Review. 2006; 1: 10-14.
18. Prityko AG, Voronin PA, Voronin VA. Karies zubov (Dental caries). Moscow: N.I. Pirogov Medical University. 2024.
19. Terekhova TN, Popruzhenko TV, Klenovskaya MI. Profilaktika kariesa v iamkah i fissurah zubov (Prevention of caries in pits and fissures of teeth). Moscow: MEDpress-inform. 2010.
20. Carvalho JC, Dige I, Machiulskiene V. Occlusal caries: Biological approach for its diagnosis and management. Caries Res. 2016; 50: 527-42.
21. Kidd EAM. Essentials of dental caries, 3rd ed. Russian edition. Moscow: Geotar-media. 2009.
22. Desai H, Stewart CA, Finer Y. Minimally invasive therapies for the management of dental caries - a literature review. Dent J (Basel). 2021; 9: 147.
23. Chigarina SE. Karioznye porazhenia zubov (Carious lesions of the teeth). Samara: Slovo. 2020.
24. Dmitrieva LA, Maksimovsky YuM. Terapevticheskaia stomatologia (Therapeutic dentistry) National manual. Moscow: Geotar-media. 2021.
25. Durnovo EA. Stomatologia (Dentistry) Textbook. Moscow: Geotar-media. 2025.
26. Trunin DA., Postnik MA. Therapeutic Dentistry: Textbook. Moscow: Geotar-media. 2024.
27. Leontiev VK, Kiselnikova LP. Detskaia terapevticheskaia stomatologia: nacionalnoe rukovodstvo (Paediatric therapeutic dentistry: national manual). Moscow: Geotar-media. 2021.
28. Britova AA. Kariesologia i zabolevania tverdyh tkanei zubov (Cariesology and diseases of hard tissues of teeth). Moscow: Yurayt. 2019.
29. Daurova FYu, Kogevnikova LA, Khabadze ZS, Makeeva MK. Cariology and non-caries lesions. Moscow: RUDN. 2017.
30. Kunin AA, Sushchenko AV, Belenova IA. Karies zubov (Dental caries). Voronezh: Nauchnaia kniga. 2018.
31. Silin AV, Abramova NE, Kibrotsashvili IA. Karies zubov (Dental caries). St. Petersburg North-Western Medical University. 2016.
32. Bjørndal L, Simon S, Tomson PL, Duncan HF. Management of deep caries and the exposed pulp. Int Endod J. 2019; 52: 949-73.
33. Field J. Pre-clinical dental skills at a glance. Wiley-Blackwell. 2021.
34. Innes NPT, Frencken JE, Bjorndal L, Maltz M, Manton DJ, Ricketts D. Managing carious lesions: consensus recommendations on terminology. Adv Dent Res. 2016; 28: 49-57.
35. Lomiashvili LM, Pogadaev DV, Elendo MB, Mihailovskij SG. Minimally-invasive methods of dental caries treatment. Klinicheskaya stomatologiia. 2010; 1: 30-37.
36. Rzhanov EA. Minimally-invasive treatment of dental caries. Klinicheskaya stomatologiia. 2005; 1: 24-27.
37. Tarasenko SV. Hirurgicheskaia stomatologia (Oral surgery). Moscow: Geotar-media. 2023.
38. Krebs KA. Response from the AAP. J Am Dent Assoc. 2005; 136: 1563-1565.
39. Wolf HF, Hassell TM. Priodontology. Russian edition. Moscow: MEDpress-inform. 2014.
40. Dmitrieva LA. Parodontologia (Periodontology). National manual. Moscow: Geotar-media. 2014.
41. Newman MG, Takei HH, Carranza FA, editors. Carranza’s Clinical periodontology. 9th ed. Philadelphia: Saunders. 2002.
42. Corranza FA, Rapley JW. Clinical feature of gingivitis. In: Newman MG, Takei HH, Carranza FA, editors. Carranza’s Clinical periodontology. 9th ed. Philadelphia: Saunders. 2002; 269-278.
43. Tanner AC, Kent R Jr, Van Dyke T, Sonis ST, Murray LA. Clinical and other risk indicators for early periodontitis in adults. J Periodontol. 2005; 76: 573-81.
44. Sculean A. Periodontal regeneration therapy. Russian edition. Moscow: Azbuka stomatologa. 2012.
45. White DJ. Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits. Eur J Oral Sci. 1997; 105: 508-22.
46. Stoner JE, Mazdyasna S. Gingival recession in the lower incisor region of 15-year-old subjects. J Periodontol. 1980; 51: 74-76.
47. Perova MD, Fomicheva EA, Fomicheva AV. Recession of periodontal tissues. The current state of knowledge. Novoe v stomatologii. 2005; 5: 38-45.
48. Theodoro LH, Marcantonio RAC, Wainwright M, Garcia VG. Laser in periodontal treatment: is it an effective treatment or science fiction? Braz Oral Res. 2021; 35: 99.
49. Grudyanov AI. Bolezni paradonta (Periodontal diseases). Moscow: MIA. 2022.
50. Bastendorf KD, Strafela-Bastendorf N, Lussi A. Mechanical removal of the biofilm: is the curette still the gold standard? Monogr Oral Sci. 2021; 29: 105-18.
51. Worthington HV, Clarkson JE, Bryan G, Beirne PV. Routine scale and polish for periodontal health in adults. Cochrane Database Syst Rev. 2013; 12.
52. Goryachev DN, Sagdiev RI. Medicinskaia etika i deontologia v stomatologicheskoi praktike (Medical ethics and deontology in dental practice). Kazan: Medicine. 2015.
53. Heasman PA, Holliday R, Bryant A, Preshaw PM. Evidence for the occurrence of gingival recession and non-carious cervical lesions as a consequence of traumatic toothbrushing. J Clin Periodontol. 2015; 16: 237-55.
54. Zuhrt R, Kleber M. Periodontologie. Leipzig: Johann Ambrosius Barth. 1988.
55. Afanasyev VV, Abdusalamov MR, Belolapotkova AV. Hirurgicheskaia stomatologia (Surgical dentistry). Moscow: Geotar-Media. 2021.
56. Robustova TG, Biberman YaM. Tooth extraction. In: Hirurgicheskaja stomatologia (Surgical dentistry). Moscow: Medicine. 1996; 100-146.
57. Jargin SV. On the minimally invasive approach to the gingival recession. J Indian Soc Periodontol. 2013; 17: 394-6.
58. Zinman EJ. Medico-legal issues. In: Rose LF, Genco RJ, Cohen DW, Mealey BL, editors. Periodontal Medicine. Hamilton, Ontario: Decker. 2000; 273-288.
59. Maksimovskaya LN. Antologia konflikta v stomatologicheskoi praktike (An anthology of conflict in dental practice). Moscow: Geotar-Media. 2020.