Partial caries removal: justified?

 Provisional restorations

There are several situations where dentists should opt to partially excavate decayed dentin, according to Dr. Browning.

"Dentists should use this approach wherever complete caries removal is likely to leave less than 1 mm remaining of dentin thickness or expose the pulp," he explained. "They should use this approach in situations where a direct restoration will be sufficient; i.e., where the prognosis for a direct restoration is at least fair."

He also outlined several ways that dentistry can use the concept to its advantage. First, it is OK to seal in some incipient decay as long as the occlusal pit-and-fissure system is well-sealed.

"This also means that there is little reason to remove enamel for the sole purpose of investigating the fissure system to determine if caries is present," Dr. Browning said.

The approach can benefit both a patient who has multiple moderate to large carious lesions and financial constraints and also the practitioner. "Sometimes the pace at which patients can afford to pay and the pace at which some lesions will involve the pulp and/or make the tooth unrestorable are often incompatible," Dr. Browning explained. The dentist can opt to arrest the decay with a well-sealed restoration.

"In this situation, grossly unsupported enamel and peripheral decay only are removed and a provisional is placed — my recommendation is a glass ionomer," he added. "Several of these provisionals can be placed in the time it would take to place one definitive restoration. Accordingly, a much smaller fee can be charged, yet the dentist is still appropriately compensated."

After the lesions are successfully arrested, the dentist can circle back and place definitive restorations.

"These provisionals result in an extra fee to the patient, but are far less costly than the cost incurred if even one of these lesions necessitates endodontic treatment," Dr. Browning said.

Patients who present with large carious lesions on one or more teeth may also have symptoms suggesting reversible pulpitis, making a precise treatment plan and accurate estimation of associated fees challenging.

"Here again, a provisional restoration can simplify the situation greatly," Dr. Browning advised. "Removal of caries at the dentin-enamel junction helps to establish whether or not the tooth is even restorable, and whether a direct or indirect restoration is needed. Removal of most of the deeper caries provides a good estimate of whether or not the pulp may be exposed."

Patient comfort, lasting results

In addition, a well-sealed provisional will initially make the patient more comfortable and promote the long-term vitality of the pulp, Dr. Browning noted. Over the next three months, the pulp’s vitality or need for endodontic treatment will be clear.

"This provides an opportunity for the patient to become comfortable and the dentist to become much more confident about the long-term pulpal prognosis and the restorative needs of the patient," he said. "As a result, the dentist can provide a much more accurate treatment plan and fee estimate."

While the authors hope that this approach spreads in dentistry, there are roadblocks.

"Currently, our profession is rewarded by treatment," Dr. Chan said. "We would like dentists to think about risk assessment and tailor treatment according to the patient’s risks. It is moving that way now, but it’s not moving fast enough."