Dr. Hamilton and his co-investigators have composed an elegant paper, but its results are suspect and its conclusion is not clinically applicable by a conscientious dentist.
Regarding the results:
The element of air abrasion seems to be somewhat of a distraction in this study. It appears that the results would have been the same whether the faulty pits and fissures were cleaned with air abrasion or small round burs.
The differential between 44 percent dentin decay in the experimental group and 11 percent in the control group is too great to be accounted for by anything other than faulty randomization between the experimental and control groups or inadequate criteria for treatment of teeth in the control group. There is no discussion in the article about how teeth in the control group were selected for treatment, and the need for treatment in the experimental group was not predictable. Undertreatment of teeth in the control group is likely.
The suggestion that increased remineralization due to greater availability of fluoride seems inappropriate. Monitoring interproximal enamel lesions that have not reached the dentin is one thing. Postulating remineralization of pit-and-fissure caries that may have invaded the dentin and is not easily visualized radiographically is quite another.
Regarding the conclusion, given the unreliability of the results, the conclusion that early treatment is not justified is not warranted. The conclusion that questionable lesions should not be treated suggests these clinical implications:
- – Sealants are not advisable. Early dentin decay might be found that would prompt the placement of an unnecessary filling.
- – Restoration of decay in dentin should be delayed until the most cost-effective point in time.
Even though the study’s panel of experienced clinicians could not accurately predict by examination which lesions extended into dentin, dentists should maintain confidence in their ability to delay treatment of lesions in dentin without jeopardizing the structural integrity and pulpal health of individual teeth.
Patients who request, "Doc, just fill the bad ones," will be in tune with current evidence-based dental science.
