What is it about?
Historically deep cavities have been managed differently in different parts of the world. At present two methods are dominant. US dentists generally prefer to remove all decay even if that means exposing the pulp (complete caries removal or CR). Exposure dramatically increases the complexity and thus the expense of treatment, but US dentists believe it produces a more consistent result. In many parts of the world dentists choose to leave some decay (partial caries removal or PCE) in order to avoid exposure. Historically anecdote and opinion had been the only available evidence to support one over the other; evidence which unfortunately is of lower reliability. Over the last 30 years clinical studies have improved in quality and quantity. As of the date of this review several high-quality single studies and systematic reviews have been published. This Critical Appraisal chose several representative studies to review. Each article reviewed included a synopsis of the methodology, the results of the study and its conclusions. In addition, commentary was provided: 1) the strengths and weaknesses of the study; 2) comments which highlighted some of the more subtle technical aspects of a systematic review; and 3) a summary of the more important clinical points from the appraisal.
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Why is it important?
In my opinion evidence is growing to support PCE as more effective. The public health implications of this are tremendous and the benefits to patients on a personal level are difficult to overestimate. At present PCE is not in wide use among US dentists, very few dental schools use the technique in their student clinics and it is not widely taught even strictly as a lecture topic. Dissemination of new information is not a rapid process. Adopting new treatments is slower still. Historically, evidence based on clinical studies has been fairly rare. Dentists have been generally cautious about switching their present treatments, which appears from their experience with patients to be successful, given the weakness of this available evidence. With the more recent move to use evidence based treatments this is changing. With higher quality evidence available, dentists will become more comfortable switching to treatments supported by data to be more effective. Everyone wishes the process were faster, but caution is not unreasonable. Accordingly it is important to disseminate this information as widely as possible.
Perspectives
I have a unique background which I believe brings value to the reader. I spent my first 20 professional years in a private practice, earned a Masters Degree in Clinical Research Design and Statistical Analysis and spent the next 20 years in academics conducting clinical studies and teaching restorative dentistry. As a result, I think I understand evidence based treatment well and can fully appreciate the difficulty the practicing dentist has when evaluating which treatments are best. The natural tendency of dentists is to believe what you “see” in your own day-to-day practice. To change a dentist’s mind you must provide a strong incentive. During my years at the Medical College of Dentistry I was exposed to one of the early publication on this subject, the 1998 Mertz-Fairhurst, et. al. study. No study is perfect and, if one is intent on doing so, some issues can always be found. Without resorting to being overly critical, I found this study to have important drawbacks. And it should be noted that contemporary publications got contradictory results in terms of arresting decay. The fact that decay appeared to be arrested even in the group for which treatment guidelines called for no decay to be removed is most often cited as the breakthrough finding and focus of the Mertz study. My impression was that the authors were advocating leaving all caries on a routine basis. Based on my assessment of the risks and benefits of leaving all caries in routine cavities, I saw no compelling reason to discontinue removing decay on a routine basis. As a result I was not motivated at that time to adapt the recommendations put forth. Over the years the quality of the research on this topic has evolved to deal with many of the methodology concerns and the focus has switched to the management of deep cavities, which changes the risk-benefit assessment drastically. As a result, with more and stronger evidence available I have come to believe that PCE is the better approach for the treatment of deep cavities which threaten the pulp, and will allow our patients to minimize tooth loss.
Professor Bill D Browning
Indiana University School of Dentistry
Read the Original
This page is a summary of: 2015 Update: Approaches to Caries Removal, Journal of Esthetic and Restorative Dentistry, July 2015, Wiley,
DOI: 10.1111/jerd.12165.
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