Dr. Philip Hudson should be commended for his excellent June JADA article, "Conservative Treatment of the Class I Lesion: A New Paradigm for Dentistry." As a member of the Cariology and Operative Dentistry Department at New York University College of Dentistry, I welcome and applaud any effort to bring the profession up to speed with what we are teaching our students.
One suggestion for a modification of the CDT-4 code would go a long way toward correcting many of the issues Dr. Hudson discusses. Code D2391 (one-surface posterior resin-based composite) explicitly states that it should be "used to restore a carious lesion into the dentin." The rationale for the requirement that the lesion extends into dentin can be questioned.
I suggest that if a bur was needed to remove the caries, then D2391 should be the proper code, regardless of the depth of the lesion. This would be consistent with what we are teaching our students, as it encourages them not to overprepare the teeth simply to get credit for doing a Class I restoration.
This also would be consistent with Roberson and colleagues,1 who state, "It is not necessary to extend the preparation in a pulpal direction if only a hard, dark line remains that cannot be penetrated by a sharp explorer, and the radiograph is negative for dentinal caries." This statement is made in the chapter on Class I cavity preparation, not in the sealant chapter. Lastly, and most importantly, this would be consistent with the best interests of our patients.
Another suggestion is to completely eliminate the term "preventive resin restoration," or PRR, from our vocabulary. If it is a preventive procedure, then it can’t be a restoration, which implies repair of tooth structure already lost. A better term might be "conservative resin restoration," or CRR, defined as a Class I restoration utilizing a minimally invasive preparation. The D2391 code would be appropriate for this restoration.
One other point mentioned by Dr. Hudson deserves comment. He wrote that "insurance companies resist the philosophy of early intervention" because they are not health care providers, and they have no interest in what is best for our patients unless it can be shown to be cost-effective. They will continue to cover only what they have always covered for as long as possible, unless we can show them a better way. Only pressure from the ADA, through the establishment of reasonable CDT codes, can foster a change in the reimbursement pattern of the carriers.
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