The other day, I had a conversation with someone I just met, about her experience of taking Little Miss 5yo to 3 dentists in 3 weeks a while ago. My new friend shared that she toothbrushes her daughter's teeth every day, and allows juice and lollies only at parties. When I asked why 3 dentists in 3 weeks, my new friend explained, “The first dentist said Miss 5yo has dental decay and needed 2 fillings. Wanting a second opinion, we went to the second dentist, who took x-rays and recommended no treatment, just monitoring. Not sure who to believe, we went to a third dentist, who recommended fissure sealants.”
It is difficult to decide what is best for our children when it comes to dental treatment. Most of the time, we respect the dentist’s expertise and trust their decisions. What happens when there are differences in opinions? It is not necessarily a right vs. a wrong. Instead, sometimes treatment philosophies may differ. There are afterall, “many ways to skin a cat”.
So, if dental decay is diagnosed, is a dental filling always the treatment of choice?
Dental decay (or dental caries as dentists like to call it) is often taken as being synonymous with dental cavity, tooth cavity or hole in the tooth. However, dental decay starts way before a cavity is visible.
Dental decay is not simply “a cavity in the tooth”.(1) Dental decay is a chronic disease. Dental decay is related to an imbalance in the oral environment, a disproportionate number of acid-loving, acid-producing bacteria and greater demineralization than remineralization.(2) Dental decay results in progressive, localized destruction of the tooth structure by acids produced by oral bacteria fermenting dietary carbohydrates, in particular, sugars.(1-3) A cavity is formed only after a prolonged period of oral imbalance. A cavity indicates that dental decay has been allowed to progress over time, from damage to the tooth structure that is reversible to damage that is not reversible.(2,4)
That’s right. The current available scientific evidence supports that beginning stages of dental decay are reversible. Ismail and co-workers put it this way: “The detection of a caries lesion by itself must not automatically lead to a decision to restore it.”(5)
Not only is dental decay reversible if detected early. It is now recognized that many dental decay lesions do not progress.(6) Moreover, dental fillings as the only treatment for dental decay cannot cure the problem. Once filled, teeth are at risk of entering a vicious cycle of broken fillings and recurrent decay, requiring repair and retreatment.(7)
Before getting a dental filling to fix dental decay, it probably doesn’t hurt to check with your dentist:
1. Where is the dental decay in the mouth, is there a visible cavity?
If dental decay has not progressed to the stage of a visible dental cavity yet, it may not require dental filling as treatment. It is worth taking xrays to verify and also as baseline for future comparison. The ICDAS foundation has developed a contemporary system for determining if a particular dental decay lesion actually requires treatment or not by assessing the tooth visually and radiographically.(8)
2. What does the dental decay look like on intraoral dental x-rays?
Intraoral dental x-rays (e.g. bitewing films) are helpful diagnostic aids for checking for the absence or presence of dental decay and the extent of dental decay. The Academy of Pediatric Dentistry recommends intraoral dental xrays especially for “proximal surfaces that cannot be examined visually or with a probe”.(9)
Dental decay may affect the enamel, dentine or pulp of the tooth. On the xray film, the outer whitest layer of the tooth is the enamel, the greyish layer in the middle of the tooth is the dentine and the dark core in the middle of the tooth is the dental pulp. Decay will also appear dark on xray film.
If the dental decay is visible on xray but the decay is limited to the enamel layer or the demarcation between enamel and dentine layers of the tooth, it may be reversible.(8)
If the dental decay is shown to have extended to the deeper dentine area of the tooth, dental decay is likely irreversible and require dental filling as treatment.(8)
3. What risk factors are contributing to dental decay progression in the mouth?
Many risk factors contribute to the development and progression of dental decay. Specific risks vary from person to person. Some risk factors are age-specific. Some risk factors are community-specific. To ensure the factors at play are identified and managed, caries risk assessment is advisable, regardless of whether dental filling is indicated or not. There are different caries risk assessment systems e.g. CAMBRA, CAT and Cariogram but essentially, they all achieve the same goal of identifying caries risk factors. (6,10,11) Recently, a patient-orientated caries risk online tool - iCaresCare has become available via the Alliance for a Cavity Free Future – it’s worth a look.
4. Can the dental decay affected area be treated non-invasively?
Dental decay treatment may be invasive i.e. involves cutting away tooth structure or non-invasive i.e. does not involve cutting away tooth structure.
Non-invasive treatment may include remineralization using sodium fluoride varnish, silver diamine fluoride solution or casein phosphopeptide-amorphous calcium phosphate and non-restorative caries treatment (where decay is not removed but the cavity is shaped to allow easy cleaning, so that the oral microbes can be constantly disrupted).(12-14)
Micro-invasive treatment such as pit and fissure sealants, may be an option for arresting initial dental decays detected on the occlusal or biting surfaces of a tooth.(15) Micro-invasive treatment such as resin infiltration may be an option for the proximal surface of a tooth. A recent Cochrane systematic review suggests that micro-invasive treatment may be more effective than non-invasive treatment such as fluoride varnish.(16,17)
5. If dental filling is required, what approaches are available for minimizing destruction to existing tooth structure?
Traditionally, dental decay requires complete removal of the damaged tooth structure before the placement of a dental filling. Current evidence suggests that deliberate partial decay removal or stepwise decay removal, followed by optimal seal via dental filling or crown, may be preferable in some cases – less destructive to tooth structure and more protective of the dental pulp.(4, 18)
The success to dental decay management depends not only on comprehensive diagnosis, sound clinical judgement regarding treatment, a plan for managing risk factors and regular dental reviews, but also clear communication between dentist and patient. So if in doubt, do ask. Most dentists are only too happy to explain. Afterall, "communication and trust are the key ingredients to a successful relationship".
- Fontana M, Douglas AY, Wolff MS, Pitts NB, Longbottom C. Defining dental caries for 2010 and beyond. Dent Clin North Am 2010; 54(3): 423-440. DOI: http://dx.doi.org/10.1016/j.cden.2010.03.007
- Innes NP, Frencken JE, Bjorndal L, Maltz M, Manton DJ, Ricketts D, Van Landuyt K, Benerjee A, Campus G, Domejean S, Fontana M, Leal S, Lo E, Machiulskiene V, Schulte A, Splieth C, Zandona A, Schwendicke F. Management carious lesions: consensus recommendations on terminology. Adv Dent Res. 2016 May;28(2):49-57. doi: 10.1177/0022034516639276.
- Takahashi N. Oral microbiome metabolism from “who are they?” to “what are they doing?” J Dent Res 2015; 94(12): 1628-1637. doi: 10.1177/0022034515606045.
- Schwendicke F Frencken JE, Bjorndal L, Maltz M, Mandton DJ, Ricketts D, Van Landuyt K, Banerjee A, Campus G, Domejean S, Fontana M, Leal S, Lo E, Machiulskiene V, Schulte A, Splieth C, Zandona AF, Innes NP. Managing caries lesions: consensus recommendations on carious tissue removal. Adv Dent Res. 2016 May;28(2):58-67. doi: 10.1177/0022034516639271
- Ismail AI, Tellez M, Pitts NB, Ekstrand KR, Ricketts D, Longbottom C, Eggertsson H, Deery C, Fisher J, Young DA, Featherstone JD, Evans W, Zeller GG, Zero D, Martignon S, Fontana M, Zandona A. Caries management pathways preserve dental tissues and promote oral health. Community Dent Oral Epidemiol 2013; 41(1): e12-40. doi: 1111/cdoe.12024.
- American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children and adolescents. Clinical Practice Guideline 2014. Accessed online: http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment7.pdf
- Moraschini V, Fai CK, Alto RM, Dos Santos GO. Amalgam and resin composite longevity of posterior restorations: A systematic review and meta-analysis. J Dent. 2015 Sep;43(9):1043-50. doi: 10.1016/j.jdent.2015.06.005.
- ICDAS Foundation. ICCMSTM Quick Reference Guide for Practitioners and Educators. 2014. Accessed online: https://www.icdas.org/downloads.
- American Academy of Pediatric Dentistry. Guideline on prescribing dental radiographs for infants, children, adolescents and persons with special health care needs. Endorsement 2012. Accessed online: http://www.aapd.org/media/Policies_Guidelines/E_Radiographs1.pdf.
- Gao X, Di WI, Lo EC, Chu CH, Hsu CY, Wong MC. Validity of caries risk assessment programmes in preschool children. J Dent 2013; 41(9): 787-795. doi: 10.1016/j.jdent.2013.06.005.
- Hansel Petersson G, Twetman S, Bratthall D. Evaluation of a computer program for caries risk assessment in schoolchildren. Caries Res 2002; 36(5): 327-340.
- Kidd E. Should deciduous teeth be restored? Reflections of a cariologist. Dent Update2012; 39:159-162, 165-166.
- Santamaria RM, Innes NPT, Machiulskiene V, Evans DJP, Splieth CH. Caries management strategies for primary molars: 1 year randomized control trial results. J Dent Res 2014; 93(11): 1062-1069.
- Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries remineralisation and arresting effect in children by professionally applied fluoride treatment – a systematic review. BMC Oral Health. 2016 Feb 1;16:12. doi: 10.1186/s12903-016-0171-6.
- Wright JT, Tampi MP, Graham L, Estrich C, Crall JJ, Fontana M, Gillette EJ, Novy BB, Dhar V, Donly K, Hewlett ER, Quinonez RB, Chaffin J, Crespin M, Iafolla T, Siegal MD, Carrasco-Labra A. Sealants for preventing and arresting pit-and-fissure occlusal caries in primary and permanent molars. Pediatr Dent 2016; 38(4):282-308.
- Tinanoff N, Coll JA, Dhar V, Maas WR, Chhibber S, Zokaei L. Evidence-based update of pediatric dental restorative procedures: preventive strategies. J Clin Pediatr Dent 2015; 39(3): 193-197. doi: 10.17796/1053-4628-39.3.193.
- Dorri M, Dunne SM, Walsh T, Schwendicke F. Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth. Cochrane Database Syst Rev 2015; 11:CD010431. doi: 10.1002/14651858.CD010431.pub2.
- Hayashi M, Fujitani M, Yamaki C, Momoi Y. Ways of enhancing pulp preservation by stepwise excavation – a systematic review.J Dent. 2011;39(2):95-107. doi: 10.1016/j.jdent.2010.10.012.