Asking for a Friend: How can I explain to my patient that a small cavity is a big deal?

Do patients fully understand the consequences of tooth decay when discussing preventive methods, or do they say things like, "I'll just pull them all out when that happens," as if that's a simple solution? Or have you ever gotten the impression that your patient assumes getting a crown or filling would be the last investment they’d ever need for that tooth? Action to preserve healthy enamel and counteract the signs of decay is imperative, since nothing compares to our natural dentition. But how can this be effectively relayed to the patient—especially when getting them on board with easy and low-investment solutions, such as good home-care aids, fluoride treatments, and remineralization therapies?

Asking for a Friend: Am I still a top-tier clinician without top-tier dental equipment?

The magnificent structure of teeth

Our natural, intact teeth possess the ideal combination of enamel and dentin properties, with enamel serving as a rigid outer shell and dentin acting as a highly mineralized layer between the enamel and the pulp. An architectural bond joins these layers, creating the dentinoenamel junction (DEJ), which provides the perfect balance of stiffness and flexibility in a tooth structure.¹ This natural structure can withstand heavy mechanical loads without leading to cracks and fractures.

When carious activity and the subsequent need for restorative treatment occur, it threatens this perfect harmony due to the need for removal of healthy tooth structure and a reduction in original strength, rigidity, and flexibility. A small filling can be the initiation of a cycle leading to restorative failure and tooth loss.² Preserving healthy enamel is key to preventing this cycle, with therapies such as guided biofilm removal and fluoride varnish or fluoride-alternative treatments.

Demineralization marks the beginning of decay

Educate patients that these demineralized areas may appear as a white line mark that is soft and chalky, or stained and sticky, and that they require immediate intervention to preserve the enamel structure. Fortunately, teeth do not make a direct progression from demineralization to cavitation. Instead, the tooth may demonstrate periods of regained strength or remineralization when fluorapatite crystals replace lost calcium, phosphate, and fluoride ions. The interplay between demineralization and remineralization highlights the need to significantly enhance oral hygiene methods and implement therapies that counteract decay and subsequent treatment. Ask your patients to invest in tools that can better interrupt biofilm colonization and commit to using them with adequate frequency, duration, and technique every day.

Why it’s not worth the ”watch and wait”

In most cases, demineralized areas left untreated will eventually require more invasive restorative treatment. As preventive health specialists, we help patients achieve remineralization with early intervention methods like fluoride varnish or treatments such as silver diamine fluoride (SDF), nanosilver fluoride (NSF), sealants, resin infiltration, and peptide technology. In the case of decay with an International Caries Detection and Assessment System (ICDAS) score of 1-2, SDF and NSF may aid in restoring a lesion to remineralized health.³

Dental caries requires intervention

When decay is beyond early intervention treatment, we recommend restorative intervention to treat the affected tooth structure, preventing further damage and subsequent tooth loss. When restoring a tooth with a filling, reducing the tooth into a retentive shape is necessary. Achieving this mechanical retention means losing enamel structure, which permanently reduces the tooth's original strength. Even a well-done restoration does not compare to the biomechanics and strength of natural teeth. Patients must understand that a filling may not be the end of the story, and that the filling may break down over time via occlusal force or marginal leakage. The tooth may require more preventive care than before to support its strength and ability to resist decay.

Cavities that extend into the dentin often require more invasive restorative procedures, such as a crown, to restore the stiffness and strength. In preparation for a crown, more than 75% of the coronal tooth structure is lost, significantly increasing the likelihood of tooth failure in the future. If the remaining tooth structure can't meet the minimum requirements of a crown, or if secondary decay occurs under an existing crown, the final option for tooth preservation is a root canal.

Asking for a Friend: Should I be treating patients with hypertensive crisis readings?

The effects of pulpal damage

If pulpal damage is a factor, a root canal may be necessary to keep the tooth and retain a restorative crown. The resulting structure is very stiff and rigid, without any of the flex found in natural tooth structure. The tooth can no longer withstand occlusal forces like it once could, and the risk of root fracture is significant. Clinical signs of fracture include observation of new significant changes in probing depths, new mobility, and suppuration due to the formation of an abscess.

Left undetected, microbes infecting the pulp may result in an abscess. When this happens, the tooth must be extracted to preserve oral and systemic health. At this final stage, tooth replacement options are reviewed—none of which compare to their original healthy, natural tooth, and come with their own set of elevated maintenance requirements. Even dentures have maintenance requirements. Unfortunately, patients are often surprised that the restorative investment made in a tooth could lead to the point of failure or tooth loss, as they often do not realize the likelihood of future problems with a tooth that has suffered from decay.

Crystal ball therapy

When facing noncompliance with preventive measures in treating incipient lesions, this is what gazing into a crystal ball would look like. That would look cool in the op, right? We know that in many cases, demineralization is the first sign of structural decomposition and can be avoided or delayed by implementing collaborative preventive measures. Topical application of sodium fluoride varnish is one effective intervention for treating incipient lesions, arresting the decay process, and preventing future carious lesions by reducing the incidence of decay by up to one third.⁴ Therapeutic measures may not prevent decay in all cases. Still, it is proven to hasten the progression of caries and avoid initial restorations at an early age. Educating patients on the big picture of tooth decay initiation can motivate their collaborative efforts in preventive care.

Verbiage: “The best time to treat a tooth problem is before you have a tooth problem. Every time a tooth is treated for a cavity, the structure becomes weaker, and if your daily habits put you at a higher risk for decay, the likelihood of needing further treatment on that tooth or losing the tooth increases.”

Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

1. Kuczumow A, Chalas R, Nowak J, et al. Novel approach to tooth chemistry. Quantification of the dental-enamel junction. Int J Mol Sci. 2021;22(11):6003. doi:10.3390/ijms22116003
2. The tooth cycle of death. Nejad Institute for Biomimetic Dentistry. https://www.nejadinstitute.com/blog/traditional-dentistry-the-tooth-cycle-of-death/
3. Surendranath P, Krishnappa S, Srinath S. Silver diamine fluoride in preventing caries: a review of current trends. Int J Clin Pediatr Dent. 2022;15(Suppl 2):S247-S251. doi:10.5005/jp-journals-10005-2167
4. Lenzi TL, Montagner AF, Soares FZM, de Oliveira Rocha R. Are topical fluorides effective for treating incipient carious lesions?: A systematic review and meta-analysis. J Am Dent Assoc. 2016;147(2):84-91.e1. doi:10.1016/j.adaj.2015.06.018