Oral diagnosis and treatment planning: part 5. Preventive and treatment planning for dental caries

Oral diagnosis and treatment planning: part 5. Preventive and treatment planning for dental caries IN BRIEF • Highlights changes that have affected, PRACTICE and continue to affect, the practice of dentistry in relation to caries. • Stresses that the various preventive measures available will not be successful without the understanding and cooperation of a motivated patient. • Informs that studies of restoration failures have concluded that one in three restorations present at any one time is considered to be ‘unsatisfactory’. K. Yip1 and R. Smales2 VERIFIABLE CPD PAPER The practice of operative dentistry continues to evolve, to reflect the many changes occurring in society and in dental diseases and conditions. However, the belief that all questionable and early carious lesions should be restored still persists. This belief is largely based upon the concept that the removal of all carious tissue followed by meticulous restoration of the tooth is the treatment of choice for dental caries. Yet restorations are not permanent and do not cure caries, as the causes remain. On the other hand, preventive measures can remove or partially remove the causes, thereby reducing the risks for future caries recurrence at the same site or elsewhere in the mouth. INTRODUCTION Although operative dentistry can retain teeth and also restore function and aesthetics to improve the well-being of patients, it can be uncomfortable, time-consuming, repetitive and costly. But, as was shown ORAL DIAGNOSIS AND TREATMENT PLANNING* Part 1. Introduction to oral diagnosis and treatment planning Part 2. Dental caries and assessment of risk Part 3. Periodontal disease and assessment of risk Part 4. Non-carious tooth surface loss and assessment of risk Part 5. Preventive and treatment planning for dental caries Part 6. Preventive and treatment planning for periodontal disease Part 7. Treatment planning for missing teeth Part 8. Reviews and maintenance of restorations *This series represents chapters 1, 7, 8, 9, 14, 15, 16 and 19 from the BDJ book A Clinical Guide to Oral Diagnosis and Treatment Planning, edited by Roger Smales and Kevin Yip. All other chapters are published in the complete clinical guide available from the BDJ Books online shop. Adjunct Professor, School of Dentistry, Charles Sturt University, Orange, New South Wales 2800, Australia; ,2* Visiting Research Fellow, School of Den‑ tistry, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia Correspondence to: Roger J. Smales Email: 1 Accepted 7 June 2012 DOI: 10.1038/sj.bdj.2012.774 © British Dental Journal 2012; 213: 211-220 in the United Kingdom, patients who have regular dental care, including operative dentistry when necessary, are just as likely to require emergency dental treatment as those who visit a dentist infrequently. For all these reasons, the practice of preventive and minimal intervention dentistry or minimally invasive dentistry offers many advantages to patients and practitioners. There are many changes that have affected, and continue to affect, the practice of dentistry with increasing rapidity and with increasing demands on practitioners. FACTORS AFFECTING OPERATIVE DENTAL TREATMENT Changes in the population and dental workforce composition and numbers There are increasing numbers of elderly persons who want to retain their remaining dentitions, which are often periodontally involved, extensively worn, heavily restored and of poor appearance. Many of these elderly persons have deteriorating health and finances, and also sometimes unrealistic expectations of what dental treatment can accomplish. Imbalances between the demand for dental treatment and the dental workforce have resulted in the closing and then the later re-opening of many dental schools and colleges, largely in response to political pressure from the dental profession. However, changes in dental workforce composition and numbers seldom mirror the ongoing optimum current population and economic requirements. Changes in dental diseases and conditions Over many years, there has been a sustained world-wide decrease in coronal dental caries in younger persons, but this trend has been reversed in several countries over the last decade in both children and young adults. The prevalence and severity of root surface caries, tooth wear, pulp pathoses and periodontal disease also increase markedly in elderly persons who have retained their natural teeth. Deterioration in their general health is often accompanied by a severe deterioration in oral health. There has been a marked increase in the prevalence and severity of tooth erosion in younger persons in particular, affecting approximately 30% of children and adolescents. The reasons for these increases in dental disease may be related to a greatly increased consumption of hidden refined sugars and acids in various foods and beverages, an increased use of xerogenic medications and illicit drugs, a decreased fluoridated water exposure, and the natural effects of retaining more teeth into old age. Changes in patients’ access to information and expectations Increased access to the internet and the production of ‘reality television body BRITISH DENTAL JOURNAL VOLUME 213 NO. 5 SEP 8 2012 211 © 2012 Macmillan Publishers Limited. All rights reserved. PRACTICE makeover’ programmes have lead to an emphasis on improved dental appearance as part of social and employment expectations, and even as the basis for character judgements. There are increased expectations by some patients (of cosmetic procedures in particular) that may be unrealistic. The risks of iatrogenic damage, maintenance problems, failure and litigation increase with the costs and complexity of dental treatments. The cost of professional dental indemnity insurance has increased rapidly in recent years, and the need for documented case records and fully informed patient consent before treatment should be obvious. Patients with persistent unrealistic expectations should not be accepted for dental treatment. Changes in diagnostic and treatment methods Increasingly expensive equipment is being purchased by practitioners for dental diagnosis and treatments, and for patient education and practice management. The increased practice costs have not been matched by the benefits paid by third parties for dental treatments, despite the increased insurance premiums paid by patients. There is an increased need for diagnostic methods that are more accurate and predictive of early dental disease for individuals, and for evidence-based information on the cost-effectiveness of different treatment alternatives. Changes in dental treatments provided In recent years, there has been an increase in adult endodontic, periodontic, orthodontic, dental implant, cosmetic and complex restorative treatments provided in dental practice. Though restorative dentistry still accounts for approximately 75‑80% of the work and inco (...truncated)