I wish to compliment Dr. Philip Hudson for his June JADA article, "Conservative Treatment of the Class I Lesion: A New Paradigm for Dentistry." The diagnosis, prevention and treatment of the early carious lesion are perplexing, and create both professional and ethical dilemmas for the practicing dentist.
Dr. Hudson’s observation of a "paradigm shift" from "gross mechanical instrumentation of dental caries to early diagnosis and treatment of the bacterial infection that causes caries" is, in my opinion, accurate. I also agree with his assessment of diagnostic tools available.
Studies have demonstrated the unreliability of the explorer, as well as the inconsistent diagnoses resulting from its use. Current research also supports the potential efficacy of laser fluorescence, although the technology cannot distinguish between active and inactive lesions. Clearly, dental caries is a bacterial infection, and I fully agree with Dr. Hudson’s statement about performing cultures and assessing caries risk. I particularly appreciate his application of caries risk in caries diagnosis.
Not uncommon to dentistry, I agree with all these "facts," yet come to a differing conclusion. Specifically, I disagree with Dr. Hudson’s recommended "early intervention" with early lesions.
Let me first state my appreciation for his clarification regarding lesions confined to enamel, and those that penetrate the dentinoenamel junction. The first does not constitute a "restoration" according to the Code on Dental Procedures and Nomenclature, while the second does. Studies have shown sealants to be an effective caries prevention procedure.
A study reported by Dr. James Hamilton and colleagues in December 2002 JADA that is still in progress, "Early Treatment of Incipient Carious Lesions: A Two-Year Clinical Evaluation,"1 concluded after two years that "conservation of tooth structure was not substantiated by early treatment."
Further, studies abound that support the caries prevention properties of fluoride, as well as the ability of fluorides to re-mineralize enamel. Clearly, inexpensive, noninvasive, scientifically sound preventive measures should prevail over expensive, minimally invasive procedures that may not conserve tooth structure, yet create an environment that will "require continuing maintenance,2,3 because of possible wear, microleakage or fracture of the restorative material."1
It is for this reason that most third-party payers are "reluctant to pay for the treatment of teeth that they believe do not yet warrant attention." Dr. Hudson implies that the rationale for such nonpayment is the financial interests of the insurance industry. If one follows the money, it will be found that the dollars come from business and industry that pay the premiums for dental benefits. And, yes, for them money is an object. More and more, they are concerned about paying for procedures—diagnostic, preventive and treatment—that have little or no value.
I believe there is a paradigm shift, as described by Dr. Hudson. Further, I believe there is a challenge for the dental benefits industry as it relates to early detection, prevention and/or treatment of dental caries. Dental benefit designs are archaic—unchanged since their very beginnings. Diagnosis, prevention and treatment of dental caries should be based on risk factors. It should be treated, as suggested by Dr. Hudson and many others, as a bacterial infection.
The removal of tooth structure should be a last resort. Lesions that are arrested, and are not progressing, need not be treated surgically, but should be monitored for progression. This is the medical model to which Dr. Hudson suggests dentists subscribe. I agree that our medical colleagues "rarely, if ever, choose to monitor bacterial infection." However, they also rarely, if ever, remove tissue that has been subjected to an infection.
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