Decay and Abfractions

Philosophies About Decay

There are 2 classifications of decay. Incipient, which is defined as interproximal decay that is still within enamel, and dentin decay (decay past he DEJ) which is decay that needs to be addressed. Dentinal decay is considered urgent treatment. 

We would classify incipient as preventative and anything further as very important treatment. 

How much does it bother both you and the patient to treatment plan a B or L on a tooth, only to look up at the patient’s electronic chart and see that an O, or MOD was just done on the same tooth 1 year ago? Now the patient has to go through the emotional stress, get shots again, etc. Not to mention insurance likely will not cover if it has been within 24 months. Wouldn’t it have been better to just have been thorough and cleaned out those grooves while the patient was already numb and getting treated for that tooth last year? When treatment planning fillings for decay, remember how unfortunate it is for a patient to have MO placed on a tooth, then a B is added to the same tooth next year, and then L the following year.  By treatment planning the MOBL from the beginning, if you think the other grooves will need to be filled in next couple years, it is better service to the patient to get done in 1 appointment. Additionally, insurance will typically only allow a tooth to be worked on once every couple years. So if you didn’t take care of everything at the first appointment, then they will likely deny the procedure at future appointments.

If you began treating the tooth and realize, the cavity will be less than originally thought, great!   Patients love it when they get money back, and it makes them trust you more.  This is part of our “Worse Case Scenario” treatment planning philosophy.

Another example: small occlusal filling on lower molars that only extends half way through the occlusal grooves, then leaks at each of the 4 groove points within 3 years… not good for the patient, not good for the dental office. If those grooves had been completely cleaned out, often times through lingual and buccal line angles slightly, this tooth may not need treatment again for 20 years. Sometimes we think we are being conservative and we are actually doing more harm. 

Note: Check the lingual of maxillary anteriors.  These teeth often have decay that goes undiagnosed

The only time an older restoration that was not placed in our dental office should not be 100% removed is if the dentist has agreed to perform compromised care for the patient after the patient declined ideal care. An example of this would be a patient presenting for recall and recurrent decay way detected under the mesial of a large MOD filling on tooth #3. The dentist correctly treatment plans a build up and crown. For whatever reason the patient declines the optimal treatment recommendation and asked for this decay to be removed via a compromised/patch option. If the dentist agrees to perform this compromise, leaving the distal portion of the large existing MOD restoration makes sense. Make sure this is documented well in the chart notes 

Based on these pictures, our philosophy is to treat grade 1 with prevention and to treat grade 2-5 with restorative dentistry