For the past three years, an expert panel consisting of members from the American Dental Association (ADA) Council on Scientific Affairs and Science & Research Institute (ADASRI) have been systematically analyzing literature and conducting clinical trials regarding carious tissue and caries restoration. That panel of experts, led by lead author Vineet Dhar, B.D.S., Ph.D., chair of orthodontics and pediatric dentistry at the University of Maryland School of Dentistry, have now released new clinical practice guidelines on restorative treatments that suggests more conservative approaches to removing carious tissue may decrease the risk of adverse effects (Evidence-Based Clinical Practice Guideline on Restorative Treatments for Caries Lesions).
“This particular guideline is part of a series of guidelines the American Dental Association has been working on and the focus is management of tooth decay,” Dr. Dhar said. “We have realized that the management of tooth decay has two distinct parts to it – one is we have to manage the disease process and the second is we have to treat or manage the decayed tooth, the caries lesion, or cavity. “
Prior to these new guidelines, most dentists are trained to completely remove caries lesions, but this new research shows that no longer has to be the case.
“You no longer have to remove all the tooth decay, you just have to remove enough and put in the right restoration materials on top of it,” Dr. Dhar explained.
Why the change in technique and process? As Dr. Dhar noted, when managing a cavitated lesion that is of moderate or advanced depth, trying to remove all of it can sometimes expose the nerves, the pulp, and that can lead to the need for pulp therapy and even a root canal. But now the research shows that risk can be avoided by utilizing a conservative caries removal method instead.
At UMSOD, Mary Anne Melo, DDS, MS, PhD, clinical professor and chair of the Department of Comprehensive Dentistry, noted that, “We emphasize evidence-based dentistry aimed at less-invasive carious tissue removal and highlight the effectiveness of various direct restorative materials in the management of deep carious lesions on both primary and permanent teeth.”
These new guidelines also present two steps to managing cavitated lesions – how much decay to remove and what materials to use to restore it.
“Just treating the cavities is known to not be effective long-term in preventing new decay from happening, even recurring decay on the same tooth, so the purpose has been for some time to understand how we can manage the decay process, and how can we manage the cavitated lesions,” Dr. Dhar said. “One aspect of that is preventing tooth decay, the other is managing tooth decay by non-restorative methods, not necessarily taking a drill and filling the tooth but using other techniques and strategies to arrest the existing decay and manage it that way, and the third piece of it is restoring the existing caries lesion.”
To create these new guidelines, a systematic review was conducted following a structure known as the GRADE Framework for formulating recommendations. From collecting the evidence to making the final clinical decision, the panel looked at the evidence, analyzed it, put it into context by looking at the desirable or undesirable effects of the interventions, looking at aspects such as patient values and preferences, resources, costs, feasibility, and acceptability, and then making a recommendation.
“If you look at the recommendations they say two things after every statement – the strength and the certainty,” Dr. Dhar noted. “It might note a strong or conditional recommendation and then it will have varying degrees of certainty. When we note we have high certainty of evidence, it means we have very high confidence in whatever results we have seen, that it’s based on solid science and unlikely to change. We’ll almost never give strong recommendations based on weak evidence. But even when we make a strong recommendation, recommendations are never a cookbook, it’s not saying you should do this only. It’s saying that if you take our evidence-based recommendation, it’s likely to be successful. But in today’s time you still have to always engage the patient, or the patient’s parents, to make that decision.”
“These new guidelines give clinicians a wide range of materials to choose from for the restorative process, but they still need to include the patient in the shared decision-making process. As a patient, I have the right to know there are other materials that are equally good and the clinician should offer them to me as equal choices,” Dr. Dhar added.
As for being the lead author, Dr. Dhar said he was humbled by the decision.
“Everybody on that panel is a subject matter expert of national and international repute,” he said. “I believe I was chosen because of my subject matter expertise and because of my know-how on the methodology side, but I’ve been working with ADA for some time, and they are very selective about the whole process as to who can lead such a panel and honestly any one of those individuals could have done just as a good a job. It was my pleasure and honor to work with them all.”
As for the main takeaway from these new guidelines, Dr. Dhar said he hopes clinicians, students, and patients are all aware that, “Selective and conservative caries tissue removal is very effective in preserving tooth structure when used with appropriate restorative materials.”
“Our readers, the clinicians, our patients, should all have the knowledge to understand what the recommendations mean and how clinicians can use them to guide their practice on a daily basis and make decisions that are more focused on prevention, non-restorative strategies, and managing the disease process while using the right process for treating the caries lesion,” he added.