I decided to write this column in spite of knowing that I will receive criticism for taking a stand on a controversial topic—namely, the restoration of initial carious lesions. Nevertheless, I feel that I must express the following observations and opinions about this issue in view of the conflicting comments I constantly receive on it from practitioners and third-party payers.
 |
DENTAL RADIOGRAPHS AND CARIES
|
|---|
Several years ago, I1 reported on a research project that caused significant controversy. A colleague and I found that initial dental caries could be easily misdiagnosed from standard dental radiographic film. In our project, we used extracted teeth with visually observable dental caries, radiographs of those teeth and dissections of the teeth to show the actual depth of caries or demineralization. The project demonstrated that extremely small radiolucencies shown on typical dental films often were dental caries or demineralization deeper than the radiographs indicated—deeper by at least two times and in some cases by many times.
After publication of the article, many practitioners contacted me to verify these findings. However, I also was contacted by a few people who insisted that minor carious lesions should be remineralized. Many other practitioners described having made a common clinical finding: carious lesions that did not appear at all on typical well-exposed dental radiographs were clearly apparent as extending into dentin when crown preparations allowing visual access were made on adjacent teeth.
In 1999, Clinical Research Associates2 published a research article on digital radiographs, demonstrating that the available versions of digital radiographs did not show initial or even deep lesions any better than the most commonly used dental radiographs. (Author’s note: The actual digital images produced by several devices can be seen at "www.cranews.com" by clicking on "Additional Study Details" and then on the listing for "Digital Radiography.")
It is my strong clinical opinion that the current generation of dental radiographs provides only a slight indication of the presence of initial dental caries.
|
AIR ABRASION AND ITS CONTRIBUTION TO THE INITIAL CARIES DILEMMA
|
|---|
Thousands of dentists now use air abrasion techniques. Their observations to me about the ability of dental radiographs to demonstrate caries, or about dentists’ ability to determine the presence of caries clinically, support the contention that radiographs do not show dental caries adequately. Recently, a dental researcher who is especially knowledgeable in air abrasion remarked to me that "any stained groove has caries present unless the patient is a heavy coffee or tea drinker, or if the patient smokes" (Rella P. Christensen, Ph.D., oral communication, July 2000).
When cutting teeth with air abrasion instruments, clinicians commonly observe that teeth not showing any sign of caries either radiographically or clinically have deep carious lesions. Some of these lesions are deep enough that the dental pulp may be damaged.
Although the concept of "watching" radiographically observable dental caries for a period has been a standard practice for many dentists, continuation of the concept for all patients is questionable in light of the previous statements.
|
SUGGESTIONS FROM THIRD-PARTY PAYERS
|
|---|
On the basis of radiographs, some third-party payers have alleged that dental practitioners sometimes restore teeth that do not need to be restored. However, ethical practitioners who are restoring teeth on a routine basis know that the methods currently available to determine the presence of initial dental caries are not reliable or accurate.
In spite of the above statement, some third-party insurance companies are suggesting lengthening the time between recall appointments to intervals as great as 18 months. In my opinion, the decision about when to restore specific teeth cannot be made according to a hard-and-fast rule set by any company or organization. I believe that decisions about when to restore a tooth and how often to examine a patient must be made according to the professional judgment of the practitioner treating the patient. Only that person knows the level of caries actually present in the patient’s mouth.
|
NEED FOR DENTAL CARIES DETECTION DEVICES
|
|---|
The development of devices to detect initial caries is long overdue. At this time, only one device is popular on the market: the Diagnodent (Kavo America Corp.). The manufacturer states that this device is able to detect dental caries by laser transmission. From reports I receive while on the dental lecture circuit, practitioners’ views of the Diagnodent are mixed but optimistic, ranging from cautious optimism to enthusiastic use. Further study of the device is required. Other caries detection devices have been on the market over the years, but none has stood the test of time. Several new caries detection concepts are under evaluation at this time. The need for such devices is immediate.
I believe that decisions about when to restore a tooth and how often to examine a patient must be made according to the professional judgment of the practitioner treating the patient.
|
WHEN SHOULD CARIOUS LESIONS BE RESTORED?
|
|---|
The issue of when carious lesions should be restored is extremely controversial. The following suggestions are opinions of practitioners throughout the world, as reported to me during speaking and teaching engagements. I have blended these suggestions with my views, and readers must judge them according to their own experience and clinical observations. I will discuss the subject as it relates to patients in different stages of life.
In childhood.
It is easy to determine if a child has a high level of caries activity. The carious lesions are soft and tooth-colored, and they progress rapidly. In such a child, any slight radiolucency visible on a dental radiograph should be restored. This includes slight radiolucencies that do not penetrate the dentinoenamel junction on proximal surfaces. Slowly progressing caries that are pigmented, hard in texture or both do not need to be restored as aggressively in children. Lesions shown radiographically to penetrate the dentin should be restored.
In adolescence.
Most people in this age group do not have an adequate diet. Usually, they consume soft drinks, candy and other sugar-containing soft foods at high rates. The practitioner must analyze any adolescent patient’s diet and oral hygiene regimen to see if an aggressive or a conservative orientation to tooth restoration is necessary. In spite of dental personnel’s attempts to improve patients’ oral hygiene, major changes in behavior appear to be difficult to make, especially in this age group. In my opinion, the adolescent patient at high risk of developing caries should undergo restoration of teeth with lesions that are evident on radiographs, but that do not necessarily penetrate the dentinoenamel junction when viewed radiographically. If the patient’s caries activity is low, a more conservative approach may be adequate.
In adulthood.
The same restoration concepts apply to adults as to children and adolescents. People at high risk of developing caries need immediate restorations of lesions that by the standards of the past would have been merely watched. On the other hand, lesions that have been dormant for many years may be observed for additional years without any dental intervention.
I do not like to make any decision on the apparent caries activity of a patient until I have watched the patient for at least one six-month recall period. At that time, I reevaluate the progress of the lesions as judged by all available methods. If the lesions are progressing, then tooth restoration should be performed.
In older adulthood.
When treating an older adult patient, the clinician often finds it difficult to judge the need or lack of need for restoration of dental caries. If the patient is physically or psychologically debilitated, all suspicious tooth areas should be restored. If the patient is in good health and has good oral hygiene, the clinician should use the same judgment as suggested earlier for younger patients. The health of many mature people degenerates severely as they near the end of life. In older patients, difficult decisions must be made, on the basis of life expectancy, about whether it is necessary to restore lesions that earlier in life would have required restoration.
|
CONCLUSIONS
|
|---|
There are many different opinions about whether or not to restore initial carious lesions in teeth. The opinions range from a conservative preference for remineralizing initial lesions to a more aggressive preference for restoring all suspicious carious lesions. In this column, I have made several suggestions about restoring carious lesions; these are based on my own experience and research, and the opinions of practitioners as offered to me on many speaking assignments over the years. In the end, as with most clinical situations in dentistry, each practitioner must make his or her own decisions on the basis of experience and the patient’s needs and history.
TOP
DENTAL RADIOGRAPHS AND CARIES
AIR ABRASION AND ITS...
