The last thing we want to tell our patients (and patients want to hear) is that decay has returned to a place we have already spent time and money filling. What can we do to help mitigate risk and work together as patient and practitioner to keep the disease at bay?
The restorative material of choice becomes a primary 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 anti-caries 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.