Where Does Restorative Care Fit in the CAMBRA Protocol?

Dental caries is a disease that leads to net mineral loss of the teeth and, in many instances, cavitation and lesions of the teeth. Early mineral loss will display as white spot lesions, and more advanced mineral loss will present as cavitated lesions. The research is clear that noncavitated or white spot lesions need not and should not be restored. What used to be considered the “ideal board exam lesion,” an E2 lesion, is not cavitated 85% of the time, and the first approach to therapy should be remineralization of the lesion.[1] Smooth surface white spot lesions need to be categorized into active and inactive or remineralized lesions. The surface of an active smooth surface white spot lesion is dull or chalky in appearance when air from a three-way syringe is blown across it. The inactive or remineralized smooth surface white spot lesion remains shiny in surface appearance when air is similarly blown over it. All active noncavitated white spot lesions should be remineralized with professional/prescription therapy, including fluoride (such as CTx4 Gel 1100). Cavitated smooth surface lesions need to be restored. This leads to the question, when in the overall therapeutic process should cavitated lesions be restored, and what materials should be used?

The research is not clear on whether it is best to restore the cavitated lesions first and then treat the patient with antimicrobial/anticaries therapy if indicated, or if it is best to treat the patient with anticaries therapies first and then restore the cavitated lesions. Ultimately, to reduce the cariogenic pathogens successfully, the lesions act as a source of this infection and need to be eliminated. It makes sense to both accomplish the anticaries therapy and restore any cavitated lesions simultaneously, recognizing that it may take staging multiple restorative appointments over the span of a month, while the anticaries therapy may be ongoing for 3–6 months or more.

The restorative material of choice becomes the next issue. For high/extreme risk patients, placing expensive final restorative materials such as crowns, veneers, or final composites at the time of initially removing the cavitated lesions comes with the risk that these restorations may fail, depending on the patient’s adherence to the anticaries therapy. Additionally, depending on the size and the extent of the lesions, combined with the patient’s overall risk status and severity of risk factors and disease indicators, the clinician and patient might be better off by restoring the lesions initially with GIC (glass ionomer cement )materials until the patient is at lower caries risk for a period of a year or more. The GIC material provides the added benefit of acting as a fluoride reservoir in the mouth and will transport fluoride ions into the enamel and dentin. Then once the patient has been low/moderate risk and decay free for a period of a year or longer, definitive final restorations can be placed with reduced risk of failure due to secondary decay. If the patient has dental insurance, this creates an additional dilemma. While the teeth will essentially be restored twice in the span of a couple of years, the insurance plan may only provide a benefit for restoring them once. In most situations like this, it is common practice for the practitioner to give the patient the option of utilizing their insurance benefit for the provisional (short-term) restorations or the final restorations and recognize that the patient will be paying for one set of restorations.

A patient may opt to have the final restorations placed at the initial decay removal stage, but needs to be fully informed of the risk of recurring decay around these newly placed restorations during the process of creating a healthy balance in their mouth. If the patient chooses this option, they need to be willing to assume the responsibility of any restoration failure, recognizing that restoration failure due to recurring decay is not the fault or responsibility of the dental practitioner.

N. B. Pitts and P. A. Rimmer, “An In Vivo Comparison of Radiographic and Directly Assessed Clinical Caries Status of Posterior Approximal Surfaces in Primary and Permanent Teeth,” Caries Res 26 (1992):146–152.