When parents see something not quite right with our children, be it a sore throat, a fever or a hole in the tooth, we want to do whatever we can to make things better for our children, right?
So when a dentist tells parents, “Your child’s dental decay cavity does not need to be filled just yet” and "Actually, fixing the tooth won't cure dental decay." It is reasonable that we respond with some doubts. Afterall at some point in our lives, we have likely been told that, to treat a dental decay cavity means a trip to the dentist for a filling.
Yet, history has shown time and time again, that filling a hole in the tooth does not cure dental decay. If nothing else changes, more dental decay cavities typically arise in the same mouth over time and old fillings breakdown to reveal more decay. The vicious cycle of tooth problems and costly fillings or teeth replacements then continues for life.
So, Why Doesn’t Fixing Cavities In Our Teeth Cure Dental Decay?
This is because the traditional “drill and fill” treatment for dental decay cavities does not address the underlying factors causing the dental decay disease.1
In “drilling away the dental decay”, the dentist is removing part of the tooth which has been most badly affected by the dental decay process and enabling better adaptation and retention of the filling material.
The filling restores the shape of the tooth, which helps improve comfort and appearance. Filling could be viewed as “cosmetics / make up” for the tooth. The tooth filling camouflages the destruction caused by decay.
The filling can also protect the damaged tooth area e.g. from irritants, debris and bacteria.
However, the tooth filling cannot reverse the destruction caused by the dental decay disease process and the tooth filling cannot prevent future dental decay from happening in the same tooth.1
The Dental Cavity Is Still There Under the Filling.
The dental cavity – the tooth hole – the blemish, whatever you like to call it, is not the root of the problem. The dental cavity is not the disease itself.1 It is the outcome.
The underlying causes of dental decay disease, such as the decay causing bacteria (also called dental plaque), the sugars in our diet that feed and activate bacteria to produce tooth destroying acids and the imbalance between demineralisation and remineralisation processes occurring at the microscopic level in the mouth environment, have not been addressed.1
The “What We Know” vs. “What We Do” Gap
A big “know-do gap” exists. What we know from scientific research does not align with what we do in clinical practice in dentistry.1 The modern day “drill and fill” treatment offered for dental decay dates back to the 18th century. Current scientific research has provided much evidence supporting dental decay as a chronic disease and not just “holes in teeth” as well as demonstrating the reversibility of early dental decay and the importance of preserving dental tissues.1-6
There is a call for action by many dental experts for clinical practice to move away from a surgical approach that manage only the hole in the tooth, which focuses on a short term “fix”, to a more biological approach that identify and manage the causes, thereby promoting long term improvement to the dental decay problem.1,4,6,7,17
In addition, there is a shift away from extensive tooth preparation before a tooth filling, to a minimally invasive approach, with the aim of preserving the vitality of the decayed tooth.1,8-10
The aim of the biological approach is to "preserve dental tissues and promote oral health over a lifespan” and “restore only when indicated”.1,6,11,12
Early Stages of Dental decay Is Reversible
Scientific research has shown that early dental decay, especially when decay has not progressed to result in “a hole in the tooth”, is reversible.,1,5,11 Evans and co-authors (2016)12 concluded in their study that, “As restorative care is not appropriate for non-cavitated lesions, the persistence of a restorative approach to caries control results in unnecessary invasive procedures, and brings into question the ethics of continuing this practice”.
Even when a dental decay cavity is visible to the eye but not symptomatic (e.g. sensitive, painful), dental decay can become arrested and inactive, thus rendering restoration not necessary from a biological point of view.1,6,9 Similarly, when looking at dental decay in radiographs, even when the dental decay lesion is determined to have progressed into the dentine layer of the tooth, immediate restoration may still not be required according to current scientific evidence.6,13,14
Tooth Fillings Alone Will Not Cure Dental decay
This does not mean tooth fillings have become obsolete. Tooth fillings are still necessary in many cases.14-17 Tooth fillings can improve comfort and function, as well as aesthetics – all important for overall health and well-being.14 However, tooth fillings alone will not cure dental decay.1,14
To manage dental decay successfully using a biological approach requires effort from both the dental professionals and the patients:
- A similar understanding of the dental decay disease process shared by dental professionals and the patients.
- The risk factors contributing to each individual’s dental decay problem identified through thorough patient interview and clinical diagnosis.
- Patient’s commitment to make lifestyle changes and implement at home prevention strategies supported by the dental professionals.
- Patient’s commitment to regular professional targeted prevention therapy and regular disease monitoring, as well as risk assessment by the dental professionals.
- Patient risk level (high risk vs. low risk of dental decay) together with extent of the dental decay cavity must be taken into account when determining if restorative management is indicated.
- Minimally invasive surgical techniques and biomaterials to be used when restorations are indicated and always coupled with intensive, risk-based prevention at home and professionally.
- Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, Tagami J, Twetman S, Tsakos G, Ismail A. Dental caries. Nat Rev Dis Primers 2017; 25; 3: 17030. doi: 10.1038/nrdp.2017.30
- Axelsson P, Lindhe J, Nystrom O. On the prevention of caries and periodontal disease. Results of a 15-year longitudinal study in adults. J Clin Periodontol 1991; 18: 182-189.
- Baelum V. Caries management: technical solutions to biological problems or evidence-based care? J Oral Health Rehabil 2008; 35: 135-151.
- Fejerskov O, Kidd EAM. (Eds). Dental Caries – The Disease and Its Clinical Management. Oxford: Blackwell Munksgaard, 2003.
- Featherstone JD. Remineralization, the natural caries repair process – the need for new approaches. Adv Dent Res 2009; 21: 4-7.
- Ismail AI, Tellez M, Pitts NB, Ekstrand KR Ricketts D, Longbottom C, Eggertsson H, Deery C, Fisher J, Young DA, Featherstone JDB, Evans RW, 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: e12-e40.
- Sbaraini A, Evans RW. Caries risk reduction in patients attending a caries management clinic. ADJ 2008; 53: 340-348.
- Banerjee A, Domejean S. The contemporary approach to tooth preservation: minimum intervention (MI) caries management in general practice. Prim Dent J. 2013 Jul;2(3):30-7.
- Kidd E, Fejerskov O. Changing concepts in cariology: forty years on. Dental Update 2013; 40(4): 277-278, 280-282, 285-286.
- Kidd E, Fejerskov O, Nyvad B. Infected dentine revisited. Dental Update 2015; 42(9): 802-806, 808-809.
- Fontana M, Gonzalez-Cabezax C. Noninvasive caries risk-based management in private practice settings may lead to reduced caries experience over time. JEvid Based Dent Prac 2016; 16(4): 239-242.
- Evans RW, Clark P, Jia N. The Caries Management System: are preventive effects sustained postclinical trial? Community Dent Oral Epidemiol 2016; 44(2): 188-197.
- Mejare I, Kallestal C, Stenlund H, Johnansson H. Caries development from 11 to 22 years of age: a prospective radiographic study. Caries Res 1998; 32: 10-16.
- Innes NPT, Schwendicke F. Restorative thresholds for carious lesions: systematic review and meta-analysis. J Dent Res 2017; 96(5): 501-508.
- Baynes SC. Dental biomaterials: where are we and where are we going? J Dent Educ 2005; 69(5): 571-585.
- Baynes S, Petersen SE, Piper D, Schmalz G, Meyer D. The challenge for innovation in direct restorative materials. Adv Dent Res 2013; 25(1): 8-17.
- Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal intervention dentistry for managing dental caries - a review: report of a FDI task group. Int Dent J 2012; 62(5): 223-243.