When should a dentist restore a cavity?

Abstract

At the start of this book it was commented that some dentists see restorative dentistry (fillings) as the treatment of dental caries. These dentists see prevention of caries as a separate issue. The authors profoundly disagree with this. The previous chapters have shown how dental caries develops and what it is, so in this chapter it is important to ask the question ‘with this knowledge in mind, what is the role of restorations (restorative dentistry) in caries control?’ Are restorations required or can the problem be solved by sealing all surfaces in the oral cavity—or at least those parts where surface irregularities (occlusal fissures, grooves, pits, etc.) may favour biofilm stagnation? Therefore, this chapter starts with a discussion of so-called fissure sealants. On occlusal surfaces, caries lesions may form at the entrance to the fissure because this complex morphology may be difficult to clean, particularly in the erupting tooth that is below the level of the arch and tends to be missed as the toothbrush swings by. Fissure sealants cover the fissures with a flowable resin or highly viscous glass ionomer cement, so that they are easier to clean. Their effectiveness has been proved in many studies. When first introduced in developed nations, all molar surfaces were recommended for sealing to avoid caries development and the need for fillings. This ‘sealing all teeth’ policy would now be totally incorrect for two reasons: ◆ Caries can be controlled by cleaning alone. ◆ Many of these surfaces will never develop lesions, and this automatic sealing approach is over treatment and not cost-effective. The indications for fissure sealing are: ◆ Active fissure caries has been diagnosed, but attempts at caries control have not arrested lesion progression. ◆ Occlusal surfaces are often highly irregular, and filled with grooves and fissures, and the patient or parent either cannot, or will not, remove plaque effectively. This is particularly important in the erupting molar. This surface is particularly at risk of lesion development and progression because permanent teeth can take 6–12 months to erupt; indeed, third molars may take several years.