by Shirley Gutkowski, RDH, BSDH and Larry Burnett, DDS
It is an often repeated phrase that dentists are in the business to put themselves out of business. The wide use of fluoride, insistence on brushing and using dental floss to remove biofilms (plaque), biannual dental visits, and X-rays to detect decay at its earliest stages bear this out. The sad truth is that if decay were eradicated today, dentists would still have decades of dentistry to do. Addressing the existing decay and replacing existing restorations would keep dentists busy for a long time. Keeping teeth caries-free is an enormous challenge for tooth owners and oral health-care providers.
In the old days, teeth were considered to be disposable. Teeth would decay and the owner of the tooth would live with it until the pain became unbearable. Then the local tooth-puller extracted the tooth. Or physiological death ensued, precipitated by the tooth or some other malady. During the 19th century, teeth was listed as the number one cause of death for more years than not.
Dentistry advanced at breakneck speed along with everything else during the 20th century. Decay was detected and treated early. Endodontics replaced extractions. Cast or indirect restorations saved teeth. Dentures were not a part of a person's life until they were very old, if at all. Prevention of decay grew in importance to patients and as an industry. Fluoride, advanced filament design for toothbrushes, floss advancements and dental hygienists all helped keep people in teeth for longer and longer.
Today, we have decades of statistics to help us determine what's best for our charges. Science and history show us that healthy teeth, not restored teeth, is the most economical way to go.
The debate over restorative materials
Surprisingly, there is an ongoing debate over which material is best for restoring teeth. The amalgam camp has history behind it. A literature review in Pediatric Dentistry in 2002 concluded that amalgam was an excellent restorative material. Placing a resin sealant on top of the amalgam increased its effectiveness.
The composite camp has esthetics and constant upgrading behind it. Cast restorations have longevity over the other two options. Nothing lasts forever; nothing man-made works forever.
The cost effectiveness of no restoratives
What's missing from the debate is the notion of no restoration at all. Avoiding the first surgical intervention at all costs is the safest and only cost-effective method for maintaining health.
Let's use an erupting first molar to illustrate. The first molar is notoriously cavity-prone. Dexterity and motivation of a child at the time of first molar eruption is lacking. There are no masticatory forces removing food and biofilms from the tooth as it makes its way into the oral cavity. Ordinary oral care is not achieved often enough to save this tooth. Most decay sets in on the first molar before it is fully erupted.
Alvin, Boysen, Charlie, and Devin are quadruplets. Their six-year molars all arrived at about the same time. For the next 14 months or longer, these teeth will slowly erupt into the mouth. During that time, we know those teeth will be under a constant acid challenge. They are normally hypocalcified or under-mineralized as they erupt. The teeth are uncleaned by natural and unnatural means. Since they are not in occlusion for the duration of time they're erupting, they are collecting five to 10 times more plaque than their fully erupted neighbors. Also, since six-year-old little boys are notoriously bad at self-care, these teeth are in supreme danger of decay. If their mother carries cariogenic bacteria, the chances that these teeth will become decayed is even higher.
Although the children are quadruplets, small differences are noted in the occlusal anatomy of each. The fissures in each child are a little different. Alvin has fissures that are narrow at the top and expand at the base. Using imaginary super goggles we can see that an explorer cannot reach the bottom of the fissure; it cannot detect this anatomy at all. Explorers have been shown to be somewhere between 30 to 60 percent specific in locating decay; light sources like the DIAGNOdent are 92 percent specific.
Boysen's fissures are defective at the base. There is virtually no enamel there and acids have a nearly direct route to the dentin. Charlie has fantastic fissures, wide and shallow. There are no mysteries there. And Devin's fissures look great with ordinary loupes; the special imaginary goggles though, show a different story. Like a figure eight with the top one-fourth chopped off, Devin's fissures are shallow on top and have a second bubble of a fissure underneath.
Alvin is the first to get decay on the occlusal surface of No. 30. The dentist employs only an explorer and X-rays to detect decay, so it's advanced enough to require surgery. The doctor chooses amalgam to restore the biological dimensions of the tooth because it has been proven by the test of time to be the best option in tooth restoration at this level. Alvin has a smaller area of decay on the occlusal of No. 19. Since it is so small, the doctor decided on a tooth-colored composite resin. The mother is happy about that. She hates all of her own black and silver fillings. She will do what she can to spare her babies the embarrassment of all that restorative work showing during a belly laugh. Because of his decay on the lower teeth, the doctor decides to use a new technique on his other six-year molars. He'll use air abrasion to open the grooves a little bit and apply resin sealants to protect those teeth from occlusal decay. The doctor makes sure the hygienist shows the child how to brush.
Boysen is caries-free by traditional detection methods. Most of his teeth are still covered by an operculum — not good candidates for resin sealants yet. Charlie is also caries-free today. There is no operculum, so he's scheduled for resin sealants. Devin is caries-free too, by the methods employed by the dentist to detect decay. The doctor doesn't know that the anatomy of the fissures is allowing acids to seep down to the true base of the fissure, demineralizing the inside of the tooth. It is undetectable by explorer or radiograph, and commonly known as a fluoride bomb once detected.
Poor Alvin — his relationship with dentistry is set.
That first amalgam will likely cost him $4,000 by the time he's finished using that tooth. Replacing that first amalgam with another one when he's 25 at $150, then a third one when he's 40 for another $200 or more is the sequence of events he's in for. After that is the inevitable recurrent decay or fracture of the tooth, and he'll realize the benefits of root canal therapy, and a cast restoration before he's finished. Often another indirect restoration is in his future after that.
If only the dentist could do something else at this earliest stage.
Avoid the first surgery
The problem with restorations — any restoration — is at the margins. They are the weakest point in any renovation attempt. Current estimates are that secondary caries account for nearly 60 percent of all amalgam replacements and studies report a median survival of just over seven years for a single-surface amalgam. Dentists spend approximately 70 percent of their time replacing restorations! There is a vast number of reasons that restorations fail. Avoiding the first surgery is crucial. Poor Alvin.
The doctor's decision to open the grooves as an extension for prevention move is setting Alvin's other teeth up for a similar fate.
During the 1980s, when dentistry started to adopt the wearing of gloves for all procedures, a resistant few started talking about the overuse of latex gloves. They said that intact skin was an excellent barrier — better than gloves with a government standard of allowable holes. When they started to realize that hands don't have intact skin, they started to move toward the way of the pack. It's true — intact skin is the best barrier to pathogens, and intact enamel is the best barrier to decay. Enamel can have microscopic channels that allow acids to penetrate, so sealants are indicated — much like gloves on the hands of a health-care provider.
Opening grooves with a special burr or air abrasion to put a sealant in place is like using steel wool to dry hands before donning gloves. The creation of tiny micro-cuts is like a vast black hole, allowing bacteria into the closed system of the body, thereby creating a higher chance for disease and rendering the gloves ineffective. Intact enamel is the same as skin, in that it functions best when whole.
Boysen's molars are in danger of becoming decayed because of their unusual anatomy. Using an explorer and X-rays, the doctor can only guess that the teeth are sound. Using today's technology of laser density detection or qualitative light fluorescence, the doctor could see the early decay happening on Boysen's molars. The doctor recommends sealants, but not for another six months, once the operculum is gone. A glass ionomer sealant placed at this stage will save Boysen untold hours in the dental chair.
Glass ionomer sealants such as Triage have evolved to a stage where they flow easily, and contain six times the available fluoride that the earlier generations had. They can also be applied in a wet field under an operculum, removing the need for laser or other surgery to remove it. Glass ionomers bond directly to the tooth without etchant. Once applied, a glass ionomer sealant will fill that under-mineralized area in the fissures and act as a fluoride battery, causing the enamel to become more and more resistant to decay. The physical barrier of the sealant will also help decrease the chance of the tooth becoming decayed before it erupts fully into the mouth. One study showed that only 2 percent of glass ionomer restorations failed because of secondary caries, compared to 10 percent of amalgam restorations over six years.
Devin would also benefit from this sealant technology. Without benefit of today's detection technology, the dentist cannot fathom the concept of a second bubble under the first fissure. Devin may or may not have decay today. Using the hundred-year-old technology of an explorer, this dentist is very limited in his diagnostic abilities.
Do the math
Locating and arresting decay in its earliest forms are paramount in today's world. People are living longer, and in order for teeth to last the duration, it's better for the owner of the teeth to put off surgery.
Alvin is in for a long life of paying for dental care once this first restoration is foisted upon him. Hours of lying in the chair are before him. No matter what kind of spa dentistry becomes available, it's still surgery — even if the air is full of the smell of chocolate chip cookies and he's getting a foot massage at the same time. Preventing that first filling is key.
If dentistry or dental hygiene as an industry doesn't do it soon, medicine will take over. There are already states where pediatric nurses apply fluoride varnish to children's teeth during their well-baby check, while dental hygienists in most states are restrained from doing so. Massachusetts is one of the few states that does allow dental hygienists to work under the authority of a physician. The Healthy People 2000 final review shows that too many children in the six- to eight-year-old range have untreated dental caries. That measurement shows the trend is going backwards.
Educating parents on the use of xylitol to decrease the numbers of transmitted cariogenic bacteria is the genesis of a minimally invasive technique of dentistry. Using smaller burs and difficult access points is up the ladder a few rungs. Topical fluoride at home as the teeth erupt — cute and vulnerable — is the second step in the protocol. Professional intervention in the form of dental hygiene visits is the final step, unless one of the previous steps isn't followed. In the ideal world, dentists never pick up a drill. This ideal was written about nearly 80 years ago.
"Not filling teeth but preserving the necessity for filling teeth should be the dentist's work. Let him consider himself successful who can show a clientele where his patients boast that never from babyhood to the grave have they had a stain or hole in any tooth. That is true dentistry, not this tiresome, painful plugging of holes. It is an ideal possible for the majority of people. Why is our profession permitting sixty percent to suffer needlessly?"
M. Evangeline Jordan, DDS, wrote the above in the third chapter, "Operative Dentistry for Children," in the 1925 book, Oral Prophylaxis.
We didn't have the tools then to do what we now can do to address decay at its earliest. We can detect caries with lasers and other light, digital radiography, and dyes. We can adjust the microflora with xylitol and chlorhexidine. We can remineralize early decay with casein products and fluoride. The first filling, at an enormous end cost in time and money can be avoided in all but the most aggressive forms of the disease.
Larry Burnett, DDS, has authored numerous articles and lectured extensively on conservative periodontal therapy throughout the United States and Canada. A frequent speaker at the ADA annual scientific session, Chicago Midwinter, and Academy of General Dentistry meetings, Dr. Burnett is featured in the video-based study program "Advanced Ultrasonics in General Practice." He can be contacted at [email protected]. Shirley Gutkowski, RDH, BSDH, has been a full-time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].References• Murdoch-Kinch, McLean: "Minimally invasive dentistry," JADA Jan 2003: 87-95
• Mjor: "Problems and Benefits Associated with Restorative Materials: Side Effects and Long Term Cost," Advanced Dental Restorations Sept 1992: 7-16
• Healthy People 2000 Final Review
• Axelsson, Paulander: "Integrated Caries Prevention: Effect of a Needs-Related Preventive Program on Dental Caries in Children," Caries Research 1993 (suppl 1): 83-94.
• "Fluoride-releasing restorative materials and secondary caries" J Calif Dent Asso March 2003
• Mandari, Frencken: "Six-Year Success Rates of Occlusal Amalgam and Glass-Ionomer Restorations Placed Using Three Minimal Intervention Approaches," Caries Research 2003: 246-253