Caries Management and Preventive Dentistry
Richard J. Elderton, BDS, LDSRCS, PhD
The public places its trust in dental professionals because these professionals possess dental knowledge and expertise. However, dental professionals do not always strive to achieve the expectations of the patients and provide the services and information they require.
A very real problem lies in the fact that, traditionally, dentists have had a preoccupation with “restoring” teeth. Therefore, the “cutting and filling” response to any departure of a tooth from absolute normality is inherently strong. A diagnosis of caries, the finding of an imperfect restoration, or the discovery of a blemish on a tooth to which the word “cosmetic” can be applied, all too readily results in the dentist leading the patient into believing that operative treatment is essential. The diagnosis of caries typically fails to take into account the activity status of the lesion and its potential activity status in the future. Further, operative treatment still holds the moral high ground, and the dentist’s advice tends not to be questioned.
But should we be questioning operative treatment? After all, we are the experts who know all about oral diseases and dental treatment, including the pros and cons of operative intervention. As far as the cons are concerned, it is possible to assemble an evidence-based model of the cycle of very real possible events that embrace the many shortcomings of traditional dentistry. I refer to this as the “Repeat Restoration Cycle,” and it is outlined in the Figure.
Since all these factors (Figure) are liable to influence potential treatment, restorations are often not very durable, many surviving only a few years. In any case, restorations do not cure caries. Dentists need to understand these characteristics of outdated restorative treatment.
We are in a litigious world where informed consent is not just a preventive tool against being sued. It is a requirement of the health care professional to explain openly to the patient the potential downsides of any proposed treatment just as much as to explain any potential benefits — or to not explain at all. Do you explain the Repeat Restoration Cycle to your patients? I do.
A proper appreciation of the situation markedly strengthens the case for moving wholeheartedly to a philosophy based upon preventive management of dental caries as far as possible. After all, caries is a bacterial disease that can be controlled only by an appropriate influence on the bacteria themselves. The aggressive restorative approach, which powers many dentists and drives the Repeat Restoration Cycle, must now be seen as absolutely untenable and unjustifiable. Ethically, we cannot continue to live in the past and turn a blind eye to it; we must take the responsibility and face the facts squarely.
The difficulty with which we have to grapple lies in the profession having for so many years considered restorations as constituting a legitimate “treatment” for caries, which, of course, they are not. By continuing to perpetuate the Repeat Restoration Cycle, we have allowed ourselves to depart from the evidence-based road to the detriment of ourselves and our patients. The dental schools in particular must carry the standard and provide leadership in this concept.
We all know, or certainly should know, that caries management in 1998 is all about identifying the primary etiological factors and then causing our patients to make relevant adjustments. We know that patients don’t have to become angel-like in so doing. Often a subtle nudge in the right direction is enough to effect the desired outcome and place the dentition into an equilibrium with the forces that would otherwise cause deterioration. But having caused the patient to bring about these changes, the dentist must then hold back with invasive intervention, where appropriate, so as to allow the altered lifestyle measures to take effect and thereby maximize the chances of invasive intervention never having to take place at all.
QUESTIONS WE NEED TO ASK
With respect to every potential operative intervention, we should ask ourselves, and answer, a series of questions as follows. I have written the questions in the first person, as if the dental problem were in my, ie, your, mouth:
Question 1. What actually is the lesion or condition I am considering? For example, is it:
• A brown area on my tooth, perhaps cavitated?
• A dark region on a radiograph?
• A ditched restoration margin?
Question 2. Is it detrimental to my long-term oral health or well-being?
Question 3. Is it tending to deteriorate, and does it matter if it does?
Question 4. If so, can I influence, to my advantage, the environmental factors that effect it? For example:
• Are there dietary factors that I can alter favorably?
• Am I using fluoride optimally, and if not, how can I upgrade my fluoride usage?
• How may I focus bacteriological control (my oral hygiene) more effectively?
Question 5. Should I introduce other agents into the system, eg, chlorhexidine, xylitol, etc?
Question 6. Which course of action would be the wisest choice for my long-term oral health?
• Having a dentist restore (or re-restore) my tooth now?
• Adjusting the appropriate environmental factors and then monitoring the situation over time, aware that a restorative intervention can always be instituted in the future if circumstances warrant it.
• Doing nothing.
When confronted with a diagnosis of caries, dentists have traditionally exhibited a tendency to institute invasive restorative measures. Clinicians are regarded as the authorities on treatment, but we should be cautious about automatically subjecting the dentition to operative procedures. Once these measures are established, the “Repeat Restoration Cycle” readily contributes to a gradual reduction of oral health. Only by modifying our thought processes can we prevent the perpetuation of the cycle. Adoption of preventive measures, eg, dietary modifications, fluoride treatment, and bacterial control is the key element contributing to the minimal invasive dentistry to which our patients aspire.
*Visiting Professor of Preventive and Restorative dentistry, Department of Oral and Dental Science, University of Bristol, Bristol, England.