A 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 these developments, as well as the dentist’s conflict with third-party payers, who may be reluctant to provide reimbursement for both sealant and minimally invasive restorative treatment.
A shift is occurring in dentistry that involves a change from reliance on gross mechanical instrumentation of dental caries to early diagnosis and treatment.
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21ST-CENTURY APPROACHES TO DENTISTRY
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The streamlined language of Current Dental Terminology, fourth edition, or CDT-4, is consistent with the straightforward diagnostic and treatment protocols adopted by many dentists who have embraced the concepts of conservative 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 débridement is completed, he or she may place a sealant. This is consistent with the CDT-4 descriptor for the sealant procedure, which states that 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 débridement of the typical pit or fissure (when the organic plug is removed), if the clinician discovers veins of decay that penetrate the DEJ, he or she should continue the process of mechanical preparation until all infected dentin has been removed.3 The dentist then can restore the tooth using the adhesive material of choice. Such treatment constitutes a one-surface restorative procedure.
Radiographic documentation is unnecessary for sealant therapy; in addition, one-surface restorative procedures frequently can be performed without radiographic evidence of caries.4,5 Radiographs might not reveal lesions that lie within heavily fluoridated and noncavitated enamel, or those that have barely penetrated the DEJ. However, the dentist can make the diagnosis through use of a relatively sophisticated armamentarum. In fact, conservative mechanical instrumentation of occlusal pit-and-fissure defects can serve both diagnostic and restorative roles. Within this new paradigm, clinicians are able to investigate suspicious defects in an exploratory process that can lead to identification and elimination of disease in one integrated approach.
Within this new paradigm, clinicians are able to investigate suspicious defects in an exploratory process that can lead to identification and elimination of disease in one integrated approach.
Minimally invasive dentistry.
This may create a problem for those who have not embraced the principles of conservative care, now widely characterized as minimally invasive dentistry. They consider themselves to be reasonable diagnosticians, but they often do not understand how unpredictable it can be to rely on a mouth mirror and explorer to identify caries.6–8 Several studies9–11 have demonstrated the inability of dentists using the traditional dental explorer to diagnose carious lesions within pit-and-fissure defects. In addition, the explorer may create cavitation in a demineralized surface and may spread Streptococcus mutans (the caries infective agent) from one fissure to another.
Bacterial infection.
Some clinicians have yet to recognize dental caries as a bacterial infection and treat it accordingly. Although the caries resulting from the infection must be diagnosed and treated as an integral part of the process, the infection itself also must be treated. Some within the profession have voiced concern12,13 about overtreatment of incipient lesions, but I believe that failure to diagnose disease and ignoring an ongoing nidus of bacterial infection are more grievous omissions. Diagnosis requires a basic knowledge of cariology; otherwise, dental professionals are reduced to the status of crude surgeons treating symptoms of a disease they cannot comprehend, have failed to diagnose and can neither control nor cure.
Performing cultures and assessing caries risk are thorough and accurate methods of diagnosing the disease. The technology exists to perform cultures of S. mutans (in colony-forming units) and lactobacilli, while monoclonal antibody tests for S. mutans are in the process of development.
Diagnostic tools.
Dental caries is a gross manifestation of disease that can be diagnosed comprehensively with caries detection dye, or CDD, magnification, transillumination and laser fluorescence caries detection. These tools can take much of the guesswork out of diagnosis, guiding dentists from accurate clinical descriptions through effective treatments.14 When a pit or fissure is stained naturally, or stains with CDD, it can be investigated with laser fluorescence (DIAGNOdent, KaVo America, Lake Zurich, Ill.). If the probability of caries is high, clinicians can perform conservative mechanical instrumentation with a high-speed handpiece and a fissurotomy bur, with air abrasion or with a hard-tissue laser. Thus, sound diagnostic principles merge seamlessly with treatment protocols.
As the clinician explores suspicious pits or fissures, he or she removes hypoplastic, demineralized and aprismatic enamel from the walls. If caries has not extended to the DEJ, the dentist places a sealant on the tooth. However, if caries does extend past the DEJ, the dentist removes all caries as conservatively as possible, and uses a resin-based composite to restore the tooth. The protected margins of such restorations lie within the steep inclines of the buccal and lingual cusps, bonded to prismatic enamel, and out of harm’s way from occlusal forces.15
In general, a resin-based flowable composite can be used either as a sealant or as a restorative material. Sealants and minimally invasive Class I restorations can mimic each other, rendering it virtually impossible for a third party in a post-treatment insurance audit review to visually determine which procedure had been performed. Generally, one cannot differentiate between a sealant and a conservatively prepared resin-based composite restoration on the basis of the clinical appearance of the resin surface. Pre-treatment radiographs rarely help in the determination.16
In both of the above scenarios, the treatment will have been driven by the same protocol. However, when the evidence confirms the presence of potentially defective pits or fissures harboring caries-producing bacteria wholly within the enamel, or confirms the presence of irreversible hard-tissue pathology that has penetrated the DEJ, the treatment objective is either minimally invasive preventive or restorative dentistry that addresses the patient’s needs with precision.17
Third-party payers.
This creates problems for dentists as they deal with third-party payers, who are reluctant to pay for the treatment of teeth that they believe do not yet warrant attention.18 For reasons that have not been clearly articulated, many insurance companies resist the philosophy of early intervention.19,20 They do not view the treatment of incipient caries as restorative care but, rather, view it as a variant of a sealant procedure. Therefore, they judge such minimally invasive restorations to be nonreimbursable.21 Such a position may serve the financial interests of the insurance industry, but it is in direct conflict with available published scientific data.22–26 In addition, it may create an ethical dilemma for the treating dentist, who is pressured to forgo treatment he or she deems appropriate, provide treatment that the insurance carrier deems appropriate, or provide nonreimbursable treatment that may place a financial burden on the patient.
In order to successfully defend an insurance carrier audit of patient treatment records, there must be meticulous diagnostic and treatment documentation.
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ETHICS AND THE NEW PARADIGM OF CONSERVATIVE CARE
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Dentists have both an ethical and a legal responsibility to provide their patients with the best available care, regardless of cost-control mechanisms that third-party payers may have put in place to discourage the treatment of incipient lesions.27,28 Conflicts with dentists inevitably arise when dental consultants for insurance companies do not acknowledge early intervention as a viable paradigm.29 At the same time, overzealous dentists have confused the restoration of occlusal defects that do not penetrate the DEJ with those that do, and they continue to identify and treat enamel lesions as Class I lesions. They fail to understand that, in most cases, treatment of enamel lesions, unlike Class I lesions, is not reimbursable under the terms of most insurance contracts.
Dentists must be aware that even if they mechanically remove hypoplastic aprismatic enamel from the walls of defective pit or fissure lesions to facilitate a sealant/resin bond to etched prismatic sound enamel, the preventive service they have rendered is not equivalent to the single-surface restorative procedure that involves the occlusal surface and penetrates the DEJ (for which there is a CDT-4 code).
Diagnostic and treatment documentation.
However, practitioners must be aware that, in order to successfully defend an insurance carrier audit of patient treatment records (when the third party is questioning the necessity of treating incipient lesions), there must be meticulous diagnostic and treatment documentation. Because such restorations typically do not require preauthorization from third-party payers, and since defects may not be radiographically demonstrable, the best justification for treatment is a clinical photograph of the opened lesion, DIAGNOdent readings or both.
Laser fluorescence.
In 1999, KaVo America introduced laser fluorescence caries detection, and it has U.S. Food and Drug Administration marketing clearance (510[k] clearance K9835658, Feb. 22, 2000) for the diagnosis of occlusal caries. Multiple studies have demonstrated its effectiveness via selectivity and sensitivity testing, and Clinical Research Associates has correlated the depth of caries to the numerical reading displayed by the instrument.30 In the CRA study, more than half of the teeth with a numeric reading of 8 or greater had caries penetration of at least 2 millimeters into the tooth structure.
In addition to confirming the diagnosis from different perspectives, clinicians can use additional diagnostic tools to provide supporting documentation that increases the likelihood that the procedure will be reimbursed by a third party. These might include detailed narrative descriptions of the clinical appearance of the pathology,31 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 air-abrasion 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 patient’s 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
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THE FUTURE IS NOW
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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 non-invasive 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 today’s 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 diagnostic vocabulary. It is time for dentists to join ranks with their medical colleagues, who rarely, if ever, choose to monitor bacterial infection in their 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 high-speed 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.
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CONCLUSION
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Paradigm shifts are inevitable. As new evidence emerges, existing belief systems evolve. Even dogmas that are entrenched in the profession’s 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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21ST-CENTURY APPROACHES TO...
