In times of economic prosperity, many patients with significant dental caries are able to afford extensive dental restorations that are long-lasting and beautiful. Metal-containing and all-ceramic indirect restorations provide predictable strength and esthetics, but they are expensive, even for affluent patients. Often, because of the high cost of these restorations, people with moderate or low incomes cannot afford to have all of the restorations they need placed at one time. During times of economic distress, the high cost of such restorations becomes even more prohibitive.
Individual patient financial woes related to global financial crises require the dentist to assume a conservative orientation toward restorative oral health care. Can patients with significant dental caries be treated using minimally invasive procedures that allow retention of affected teeth for a reasonable service period of several years until they can afford more long-lasting restorative services? The answer to the question is yes, and that is the essence of this column’s topic.
In my opinion, we dentists have drifted too far toward the belief that crowns and other extensive and expensive restorations are the norm, not the exception, for oral care. The current global economic challenges may awaken us to the realization that some of the more conservative restorations serve predictably well for a time—and that such restorations also can be economically acceptable to the practitioner if he or she accomplishes several during each appointment.
In this column, using the typical patient with high caries rates and low economic resources as an example, I will suggest a treatment sequence and discuss the various affordable alternative restorative materials from which dentists may choose.
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TREATING A TYPICAL PATIENT WITH A HIGH CARIES RATE AND MINIMAL FINANCIAL RESOURCES
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The following sequence of examination, caries assessment, treatment planning and subsequent treatment represents a typical patient who has multiple carious lesions and minimal financial resources.
The dentist examines the patient and finds that many teeth need to be restored or extracted; in addition, the patient has some other oral care needs. At this point, numerous public health and academic dentists—as well as practitioners interested in analyzing the potential for continuing or increased caries involvement—suggest that the patient undergo a caries assessment test. Caries assessment testing will continue to be used as its value is recognized further. The test usually involves many factors: lactic acid, Streptococcus mutans counts, past caries experience, salivary buffer capacity, tooth anatomy (the presence of deep grooves), use of fluoridated toothpaste, consumption of sugar, snacking characteristics and others. The exact protocol for such tests varies, and dentists must make their own decisions about which of the described tests to use.1–7
This typical patient has no dental benefit program, or one that offers only minimal financial assistance. Furthermore, the patient has minimal personal financial resources. The dentist and the patient discuss and confirm a payment plan for intermediate-longevity restorative services, as well as for other immediately needed nonrestorative oral procedures. This plan may range from addressing emergency needs first (including restoring the deepest and most acute caries lesions, followed by restoring the less affected teeth as funds are available), to the more desirable, but still conservative, plan described below.
In one long appointment, the dentist extracts the unsalvageable teeth, treats other emergency needs and excavates the carious lesions before placing fast-setting, high-strength glass ionomer cement (GIC). The long appointment should provide enough time to restore most or all of the lesions at one sitting, thus making the treatment economically more acceptable to both the dentist and the patient. Restoring many teeth in one appointment involves less office overhead and is more efficient than restoring a few teeth in each of many separate appointments.
The dentist advises the patient of the intermediate longevity expectation for the GIC restorations and of the eventual need to restore the teeth with conventional materials. He or she prescribes 5,000 parts per million fluoride that the patient either is to apply to the teeth in trays once or twice per day in five-minute applications or is to brush on.
As the patient’s financial situation becomes more stable, the dentist can treat the provisionally restored teeth with restorations that have a greater potential for long-term service. If the patient still lacks sufficient funds, the dentist may accomplish the rehabilitation of the provisionally restored teeth in a segmented manner across months, or even years, as the patient is able to pay for the restorations.
I have treated many patients in the manner I have described, and most of them have changed through the years from being in a state of oral neglect to being oral health–conscious, loyal, grateful patients.
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MATERIALS FOR INTERMEDIATE RESTORATION OF CARIOUS LESIONS
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I recognize that controversy still exists regarding whether fluoride release from restorative materials has a clinically significant positive effect,8,9 and I know that some readers will object to the following part of this column. Most of the information in the literature regarding caries inhibition effected by fluoride-containing material is positive.10–19 I will include my positive clinical observations of such fluoride-containing restorations across many years. I have seen high resistance to subsequent caries when high fluoride–content restorative materials or cements rather than resin-based composite or amalgam have been used. The remainder of this article contains the research conclusions and observations of other researchers and clinicians regarding the fluoride-releasing restorative materials.
There are only a few materials that have been shown to release potentially therapeutic levels of fluoride:
- – compomer (such as Dyract eXtra, Dentsply Caulk, Milford, Del., and F2000, 3M ESPE Dental Products, St. Paul, Minn.);
- – resin-modified glass ionomer restorative materials (such as Fuji Filling LC, GC America, Alsip, Ill., and Ketac Nano, 3M ESPE Dental Products);
- – conventional GIC modified to have high strength and a fast setting time (such as Fuji IX GP Extra, GC America, Alsip, Ill., and Ketac Molar, 3M ESPE Dental Products).
Because the preponderance of positive research and clinical use has been related to the conventional glass ionomers, I will emphasize this concept for our example patient. However, I also provide a brief discussion of the several fluoride-releasing restorative materials.
Compomer
These materials have been used for various clinical situations, including restorations for pediatric teeth, liners and bases, and for some restorative uses in permanent teeth.12,20–27 Their fluoride release is minimal. Because they are easy to use, I use compomers for filling "potholes" and undercuts in crown preparations from which pieces of amalgam or resin-based composite have been removed. Compomers are bonded to dentin easily with most brands of bonding agents, they are light-cured and they can be placed quickly. They are not my choice for our example patient because these materials have been reported to have a fluoride release rate lower than that of GICs.12,20–27
Resin-modified glass ionomer restorative material
This material is one of my choices for repair of leaking crowns that are defective on gingival margins or for other restorations in areas that do not require great attention to esthetics but that require cariostatic activity. There has been significant research regarding resin-modified glass ionomer restorative materials.28–32 Their resin component makes them relatively easy to finish after placing and curing, and their esthetic characteristics are good, but not as good as those of resin-based composite.
Except in areas of both esthetic and cariostatic need, resin-modified glass ionomers are not my choice for our example patient. However, in my opinion, these relatively esthetically acceptable cariostatic materials are nearly ideal for patients such as seniors who have high caries activity in Class V areas.
Modified GICs
The use of high-strength, fast-setting GICs has been researched widely in developing countries. In particular, the atraumatic restorative treatment (ART) technique, which involves the use of GIC, has been the subject of significant observation and research. In the ART concept, the dentist excavates caries in an atraumatic, relatively painless manner without the use of rotary instruments, then places GIC. Research results regarding the use of GIC as a material, and specifically regarding the ART technique, are positive for intermediate term clinical success.22,33–52
Because of the positive research regarding GIC’s use in the ART technique, my own positive clinical experience with the materials and the many positive observations of my colleagues worldwide, these products are my choice for our example patient. Unfortunately, it is my experience from my activity on the global continuing education circuit that these materials (such as Fuji IX GP Extra and Ketac Molar) are underused in North America. I suggest that readers become familiar with these materials and incorporate their use into their practices. The situation of the example patient in this article represents an ideal indication for use of the GIC restorative materials, although other cariostatic materials previously described could be used as well. The GIC materials serve well for numerous years, are moderately acceptable esthetically and—although the concept is somewhat controversial—have a cariostatic, remineralizing effect.
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SUMMARY
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Every practice has at least some patients who cannot afford to have definitive oral restorative care but who have high dental caries activity and usually some teeth that need to be extracted. I have suggested a sequence for examination, treatment planning and subsequent treatment for such patients, with a proposal that the interim restorative treatment involve the use of high-strength, fast-setting modified GICs. An impressive amount of research and positive clinical observation substantiate the use of these materials. This type of treatment is well-documented as saving the teeth, at least until the patient can afford other more conventional restorative therapies.
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TREATING A TYPICAL PATIENT...
MATERIALS FOR INTERMEDIATE...
