Conservative treatment of the Class I lesion: A new paradigm for dentistry PHILIP HUDSON J Am Dent Assoc 2004;135;760-764

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ABSTRACT
Background. A shift is occurring in dentistry that involves a change from reliance on gross mechanical instrumentation of dental caries to early diagnosis and treatment of the bacterial infection that causes caries. Types of Studies Reviewed. The author explores the topic of minimally invaA 1 RT sive dentistry, and cites several studies that E ICL offer scientific evidence of the effectiveness of this approach. The author also examines the role of third-party payers, who are reluctant to provide reimbursement for sealants or treatment of incipient caries. Conclusions. As dentists embrace a new paradigm in the treatment of the Class I lesion, they are beginning to acknowledge their role as clinical cariologists with the means to accurately assess the extent and threat of existing disease, determine the appropriate clinical response, provide minimally invasive treatment and unambiguously describe services rendered. Clinical Implications. As evidencebased protocols become more widely accepted, dentistry will have the necessary tools to interact with third parties, which also are struggling to cope with and adapt to an emerging standard of care.

Conservative treatment of the Class I lesion

A new paradigm for dentistry
PHILIP HUDSON, D.D.S.

paradigm shift is occurring in dentistry that involves a change in focus from reliance on gross mechanical instrumentation of dental caries to early diagnosis and treatment of the bacterial infection that causes caries. A number of tools now exist to aid in the process of early intervention. In this article, I explore A shift is these developments, as well as the dentists conflict with third-party payers, occurring in who may be reluctant to provide reimdentistry that bursement for both sealant and miniinvolves a mally invasive restorative treatment. change from 21ST-CENTURY APPROACHES TO reliance DENTISTRY on gross The streamlined language of Current mechanical Dental Terminology, fourth edition, or instrumentation CDT-4, is consistent with the straightforof dental caries ward diagnostic and treatment protocols to early adopted by many dentists who have diagnosis and embraced the concepts of conservative treatment. dental care. These clinicians support the efforts of the American Dental Association that encourage its members to place protective sealants on the occlusal surfaces of teeth at risk of developing caries.1 Applying the principles of conservative care dentistry, clinicians should remove plaque and masticated food debris from unrestored developmental pits and fissures and should place sealants or resin-based composite, depending on the presence and depth of caries found. Light mechanical instrumentation, including elimination of the organic plug, allows direct visualization of the pit or fissure defect. If the dentist does not identify caries after dbridement is completed, he or she may place a sealant. This is consistent with the CDT-4 descriptor for the sealant procedure, which states that

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before placement, the enamel surface may be mechanically and/or chemically prepared.2 In the absence of caries removal and with no violation of the dentinoenamel junction, or DEJ, during mechanical preparation, such treatment constitutes a sealant, according to CDT-4. In a practice setting, the key element in diagnosis and treatment is the professional judgment of the dentist regarding a specific patient at a specific time. For example, on sites containing known enamel lesions, practitioners may place sealants as preventive measures after identifying, quantifying and eliminating these lesions via the most conservative approach available. During dbridement of the typical pit or fissure (when the organic plug is removed), if the clinician discovers

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veins of decay that penetrate the DEJ, he or she knowledge of cariology; otherwise, dental professhould continue the process of mechanical prepasionals are reduced to the status of crude surration until all infected dentin has been removed.3 geons treating symptoms of a disease they cannot The dentist then can restore the tooth using the comprehend, have failed to diagnose and can neiadhesive material of choice. Such treatment conther control nor cure. stitutes a one-surface restorative procedure. Performing cultures and assessing caries risk Radiographic documentation is unnecessary for are thorough and accurate methods of diagnosing sealant therapy; in addition, one-surface restorathe disease. The technology exists to perform cultive procedures frequently can be performed tures of S. mutans (in colony-forming units) and without radiographic evidence of caries.4,5 Radiolactobacilli, while monoclonal antibody tests for S. graphs might not reveal lesions that lie within mutans are in the process of development. heavily fluoridated and noncavitated enamel, or Diagnostic tools. Dental caries is a gross those that have barely penetrated the DEJ. Howmanifestation of disease that can be diagnosed ever, the dentist can make the diagnosis through comprehensively with caries detection dye, or use of a relatively sophisticated armamentarum. CDD, magnification, transillumination and laser In fact, conservative mechanical instrumentation fluorescence caries detection. These tools can take much of the guesswork out of diagnosis, guiding of occlusal pit-and-fissure defects can serve both dentists from accurate clinical diagnostic and restorative roles. descriptions through effective treatWithin this new paradigm, ments.14 When a pit or fissure is clinicians are able to investigate Within this new suspicious defects in an stained naturally, or stains with paradigm, clinicians exploratory process that can lead are able to investigate CDD, it can be investigated with to identification and elimination of laser fluorescence (DIAGNOdent, suspicious defects in disease in one integrated approach. KaVo America, Lake Zurich, Ill.). If an exploratory proMinimally invasive denthe probability of caries is high, clincess that can lead to tistry. This may create a problem icians can perform conservative for those who have not embraced mechanical instrumentation with a identification and the principles of conservative care, elimination of disease high-speed handpiece and a fissuronow widely characterized as minitomy bur, with air abrasion or with in one integrated mally invasive dentistry. They cona hard-tissue laser. Thus, sound approach. sider themselves to be reasonable diagnostic principles merge seamdiagnosticians, but they often do lessly with treatment protocols. not understand how unpredictable As the clinician explores suspiit can be to rely on a mouth mirror and explorer cious pits or fissures, he or she removes to identify caries.6-8 Several studies9-11 have hypoplastic, demineralized and aprismatic enamel from the walls. If caries has not extended demonstrated the inability of dentists using the traditional dental explorer to diagnose carious to the DEJ, the dentist places a sealant on the lesions within pit-and-fissure defects. In addition, tooth. However, if caries does extend past the the explorer may create cavitation in a deminerDEJ, the dentist removes all caries as conservaalized surface and may spread Streptococcus tively as possible, and uses a resin-based composite to restore the tooth. The protected margins mutans (the caries infective agent) from one fisof such restorations lie within the steep inclines sure to another. of the buccal and lingual cusps, bonded to prisBacterial infection. Some clinicians have yet matic enamel, and out of harms way from to recognize dental caries as a bacterial infection occlusal forces.15 and treat it accordingly. Although the caries resulting from the infection must be diagnosed In general, a resin-based flowable composite and treated as an integral part of the process, the can be used either as a sealant or as a restorative infection itself also must be treated. Some within material. Sealants and minimally invasive Class I the profession have voiced concern12,13 about restorations can mimic each other, rendering it overtreatment of incipient lesions, but I believe virtually impossible for a third party in a postthat failure to diagnose disease and ignoring an treatment insurance audit review to visually ongoing nidus of bacterial infection are more determine which procedure had been performed. grievous omissions. Diagnosis requires a basic Generally, one cannot differentiate between a
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sealant and a conservatively prepared resindefects that do not penetrate the DEJ with those based composite restoration on the basis of the that do, and they continue to identify and treat clinical appearance of the resin surface. Preenamel lesions as Class I lesions. They fail to treatment radiographs rarely help in the understand that, in most cases, treatment of determination.16 enamel lesions, unlike Class I lesions, is not reimIn both of the above scenarios, the treatment bursable under the terms of most insurance will have been driven by the same protocol. Howcontracts. ever, when the evidence confirms the presence of Dentists must be aware that even if they potentially defective pits or fissures harboring mechanically remove hypoplastic aprismatic caries-producing bacteria wholly within the enamel from the walls of defective pit or fissure enamel, or confirms the presence of irreversible lesions to facilitate a sealant/resin bond to etched hard-tissue pathology that has penetrated the prismatic sound enamel, the preventive service DEJ, the treatment objective is either minimally they have rendered is not equivalent to the invasive preventive or restorative dentistry that single-surface restorative procedure that involves addresses the patients needs with precision.17 the occlusal surface and penetrates the DEJ (for Third-party payers. This creates problems which there is a CDT-4 code). for dentists as they deal with third-party payers, Diagnostic and treatment documentation. who are reluctant to pay for the However, practitioners must be treatment of teeth that they believe aware that, in order to successfully do not yet warrant attention.18 For defend an insurance carrier audit In order to reasons that have not been clearly of patient treatment records (when successfully defend articulated, many insurance compathe third party is questioning the an insurance carrier nies resist the philosophy of early necessity of treating incipient audit of patient intervention.19,20 They do not view lesions), there must be meticulous treatment records, the treatment of incipient caries as diagnostic and treatment documenthere must be restorative care but, rather, view it tation. Because such restorations as a variant of a sealant procedure. meticulous diagnostic typically do not require preauthoTherefore, they judge such minirization from third-party payers, and treatment mally invasive restorations to be and since defects may not be radiodocumentation. nonreimbursable.21 Such a position graphically demonstrable, the best may serve the financial interests of justification for treatment is a clinthe insurance industry, but it is in ical photograph of the opened direct conflict with available published scientific lesion, DIAGNOdent readings or both. data.22-26 In addition, it may create an ethical Laser fluorescence. In 1999, KaVo America dilemma for the treating dentist, who is presintroduced laser fluorescence caries detection, sured to forgo treatment he or she deems approand it has U.S. Food and Drug Administration priate, provide treatment that the insurance carmarketing clearance (510[k] clearance K9835658, rier deems appropriate, or provide nonreimFeb. 22, 2000) for the diagnosis of occlusal caries. bursable treatment that may place a financial Multiple studies have demonstrated its effectiveburden on the patient. ness via selectivity and sensitivity testing, and Clinical Research Associates has correlated the ETHICS AND THE NEW PARADIGM OF depth of caries to the numerical reading displayed CONSERVATIVE CARE by the instrument.30 In the CRA study, more than Dentists have both an ethical and a legal responhalf of the teeth with a numeric reading of 8 or sibility to provide their patients with the best greater had caries penetration of at least 2 milavailable care, regardless of cost-control mechalimeters into the tooth structure. nisms that third-party payers may have put in In addition to confirming the diagnosis from place to discourage the treatment of incipient different perspectives, clinicians can use addilesions.27,28 Conflicts with dentists inevitably arise tional diagnostic tools to provide supporting docuwhen dental consultants for insurance companies mentation that increases the likelihood that the do not acknowledge early intervention as a viable procedure will be reimbursed by a third party. paradigm.29 At the same time, overzealous denThese might include detailed narrative descriptists have confused the restoration of occlusal tions of the clinical appearance of the pathology,31
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use of binocular magnification, use of surgical microscopes,32,33 clear intraoral radiographs,33 oral transillumination,19 use of CDD34 and additional intraoral photographs at progressive stages of cavity preparation.35 Even hard-tissue lasers (that is, erbium:yttrium-aluminum-garnet; erbium, chromium:yttrium scandium gallium garnet and neodymium:yttrium-aluminum-garnet) and airabrasion devices can be used in discriminating ways as diagnostic instruments.36 With comprehensive diagnostic protocols in place, the characterization of occlusal treatment as either preventive or restorative becomes unambiguous. In the past, much of what has been done in dentistry ultimately has harmed the patient. One need only witness the progression of treatment endured by many teeth over a patients lifetime. This is unacceptable in the face of compelling scientific evidence that supports early and accurate diagnosis, coupled with minimally invasive treatment focused on the elimination of pathology without damage to adjacent healthy tissues.37
THE FUTURE IS NOW

There is a paradigm shift occurring in dentistry.38 As we learn to differentiate bacterial pathogens from those that are harmless, we will be able to treat the infectious agents themselves, rather than address only the physical complications of the disease. Will we continue to be dental surgeons or will we become clinical cariologists? Will treatment of the incipient lesion be mechanical or chemotherapeutic or both? Many viable treatment options are available. Some are noninvasive, some are minimally invasive and some are quite invasive. The course of dentistry is at a crossroads. Will we fail to consider the merits of certain interventions only because they might initially appear to be unnecessarily sophisticated, technologically confusing or prohibitively costly? To dismiss noninvasive or minimally invasive treatment options without first probing their advantages and limitations would be a mistake. The appeal of minimally invasive dentistry is that it proposes a viable evidence-based standard of care.39 Dentists with many years of experience sometimes are startled when they come face to face with the high-technology world that exists in todays clinical environment. The paradigm shift to magnification loupes, microscope-assisted precision dentistry, hard-tissue lasers, laser fluorescence caries detection, air abrasion and other

diagnostic tools can be challenging. But these tools can reveal disease long before it has destroyed tooth integrity, and can provide the means for eliminating the word watch from the Dr. Hudson is in private diagnostic vocabulary. It is time practice at the Center for Advanced for dentists to join ranks with Technology, 123 W. their medical colleagues, who Cascade Way, Spokane, Wash. 99208, e-mail rarely, if ever, choose to monitor DrPhilHudson@Qwest. bacterial infection in their net. Address reprint requests to Dr. Hudson. patients. Early diagnosis can be combined with initial conservative treatment of the bacterial infection that is surrounded by healthy tooth structure. Thus, the practitioner has the power to incorporate conservative preventive and restorative techniques that do not eliminate significant landmarks with one swipe of the highspeed bur, but rather allow greater discrimination between carious defects and intact DEJs. In the hierarchy of clinical decision making, that is where theory is put to the test.33 Ultimately, these new evidence-based standards provide the benchmark by which clinical dentists assign sealant or restorative treatment codes to the particular minimally invasive procedure being performed on occlusal surfaces.
CONCLUSION

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Paradigm shifts are inevitable. As new evidence emerges, existing belief systems evolve. Even dogmas that are entrenched in the professions mainstream thinking need to be tested continually. If they require revision, forward-thinking dental professionals will embrace new approaches to old challenges, even if the process is difficult. As John F. Kennedy declared, Change is the law of life. And those who look only to the past or present are certain to miss the future.
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