Which Comes First, Restoration or Treatment?

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 5000). 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.

 

  1. 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.

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