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To Restore or To Remineralize? The Gray Area of Operative Dentistry

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As everyone knows, if you ask three different dentists for their opinion on how to treatment plan a patient you will get three different answers! Which brings me to the point of this article; there are a lot of different philosophies that can be considered when determining whether a patient’s lesion can be remineralized or if it should just simply be restored. Furthermore, with the ethics of live patient boards being scrutinized lately I believe that this topic is something that needs to be discussed and investigated nationwide. Some dentist may say they only restore when the lesion is cavitated, while others may say if it’s into the dentin then they will restore. However there are also dentist who believe that anything that is not cavitated can be remineralized. On the other hand, the “ideal” lesion for the live patient board examination is thought to be a lesion that is only 2/3 into enamel, which a lot of dentist would say could be fixed with remineralization. I personally do believe that remineralization can be done in many cases however, I also feel that there is no standard guideline as when to restore or not. I believe that the treatment plan should be patient dependent and should vary from patient to patient. For instance, a 14 year old Medicaid recipient with poor oral hygiene and a high sugar diet walks into the office and upon examination it is determine that the child has borderline E3/D1 lesions on almost every posterior tooth in the mouth. For this patient, considering his/her caries risk, I would more than likely just go ahead and restore the lesions because they will most likely progress into bigger ones.  On the other hand, if a 14 year old from a high socioeconomic background with good oral hygiene and a rather healthy/balanced diet presents for examination with E3 lesions I may choose to just review oral hygiene instructions with the patient and bring them in for regular cleanings and fluoride varnish/ gel trays, and possibly even prescribe a prescription fluoride toothpaste. The point that I am trying to make is that you simply cannot take the same approach with every patient as there are other factors other than the depth of the lesion that needs to be considered. On another note, there is beginning to be a rise in the use of silver diamine fluoride in the dental office. If you are unfamiliar with silver diamine fluoride it is a topical fluoride that can arrest active decay in the event that a patient cannot receive treatment right away. It works great in patients with multiple caries that will require several visits to restore, preventing the decay from going deeper towards the pulp before it can be taken care of. The consensus is that the disadvantage to using it as a treatment has to do with the technique sensitivity of its application. Silver diamine can stain almost anything leaving a black, very noticeable mark on countertops, dental chairs, and clothes if not placed carefully. Furthermore, its application may not be accepted well by a patient who is esthetically driven or has lesions on anterior teeth as it will also stain the carious lesions very dark and black sometime making them more noticeable than they were. With all that said, research is still being done on the risk/benefits of silver diamine fluoride application and its has not yet been approved by the ADA. So some institutions are providing the treatment for free since they cannot yet charge for it. Ultimately, the best way to avoid the dilemma of what to restore and/or not restore is to focus more on preventing aid. If we could minimize the occurrence of these “borderline” lesions it would be much easier to stay out of the “gray area”.