Dentistry/from 0 to 7 cavities with new dentist
QUESTION: Hi - my husband recently took my son for his 6 month cleaning and the new dentist (taking over from retiring dentist) used a new laser "Diagnodent" to detect 7 cavities, all in different teeth (2,3,15,18,19,30 and 31) My son, who is 14, previously had no cavities. He got his braces off over a year ago. All the "cavities" are very small and on the chewing surface. The dentist wants to drill and fill with a composite resin. I hate having him drill into 7 of my son's teeth. None of these cavities showed up in the X-rays taken 6 months prior, but they tell me that X-rays don't show chewing surface cavities. The person I talked to on the phone at first said they were not through the enamel, but then called back to say they all were through the enamel. The dentist is suppose to call me back later. My questions are: 1) can you put a sealant overtop of these little "cavities" to see if they will remineralize? 2) Should I go to another dentist for a second opinion? 3) Can these 7 cavities really not be there? How accurate are these laser detectors? What should I do?
I don't know if it matters but my family has a history of very strong teeth, I have no cavities at age 43, my mother has only 1 cavity, and my sister has none.
ANSWER: Hi Laura,
These are important questions you ask. I get a number of questions like this that suggest possible over treatment. I will try to answer your Diagnodent question and then I will include a link to my previous answer to another questioner which says most of what I want you to know. Then I will be prepared to answer any further specific follow up questions. I think it is worth all of this for the sake of your 14 year old who i feel has a head start on a cavity free life.
The Diagnodent is a fairly accurate tool and can be helpful in helping a conservative dentist avoid drilling and filling and re-mineralizing early decay. But it can be a double edged sword in that in can help an aggressive dentist justify fillings when reversal of early decay would be a better choice. The latter use seems to be the case for your son.
I will copy the previous letter I wrote for another questioner because this is the information I think you need:
Larry Burnett DDS
Expert: Larry Burnett DDS - 9/13/2011
I am turning 47 years old, never had a cavity in my life, my dentist always called me "Mary Poppins" because my teeth are "practically perfect" in every way. Today during my routine cleaning and exam, I found out my dentist had spent a sleepless night with a very sick wife (she has MS) and was not his usual self, jolly and pleasant. He was doing that "stick" test on my teeth and the metal point "stuck" in one of my molars, he tried it again, it stuck again, and he declared it a cavity. I was devastated. He said I needed a filling, non-silver material, within a month. Nothing showed up on my past xrays 6 months ago, no sticking last exam, and I have no pain. All my other teeth are fine. I am afraid that he poked a hole in the tooth, but I have no way of knowing. I have no way of knowing if it really is a cavity, if it really needs a filling or not. My dentist is almost 60 years of age (old school?). What would you do if you were me? Fill? Wait? Try somthing else? Thank you.
Get the answer below
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Christine, I'm glad you asked about this. Hopefully this will be read by others who can save themselves and their children from unnecessary treatment.
Now lets look at your case specifically. Your record of never having a cavity up to the age of 47 puts you in the area of LOW Risk for ever having a new cavity. It would be very unusual for a person with your dental history to develop decay necessitating a filling.
I want to first tell you why it is so important to avoid an unnecessary filling. The reason is that no matter how skilled the dentist or what material he uses, once that first hole is drilled through the outer layer of the protective enamel and filled, that tooth is destined to a lifetime of breakdown and repair costing thousands of dollars PER TOOTH. This is true whether the filling was necessary or a mistake.
If early tooth decay is discovered there are now two choices. One choice is to drill and fill. This was the only choice before we knew better. Now we have a second choice which is re-mineralization (healing) of the early decay before it penetrates the enamel.
The choice to fill early decay or not, is always a judgement call. If the choice is a filling, you know the rest. If the choice is to treat non-surgically to restore the enamel, the result is an intact enamel layer which is at least as strong as the original which will probably last your entire lifetime.
The explorer which your dentist used to detect decay can easily turn a reversible enamel defect into a frank cavity that will need to be filled. Furthermore the explorer has been found to be at best inconsistent and at worst suggesting a cavity that is does not really exist.
I have copied a scientific explanation to dentists explaining why dentists need to change how they do the examination for cavities with that sharp instrument. It is long, but I post it in the hope that others may avoid over-treatment for themselves and their children.
My advice to you.
1. Ask the dentist to show you the decay he found on x ray. If it doesn't show, chances are it does not exist or is early enough to be re-mineralized.
2. A low risk person like yourself should put yourself under the care of a dental hygienist who is prevention oriented, preferably independent. The hygienist can make the judgement to drill and fill or to remineralize without monetary incentives to cloud that judgement. Dental Hygienists are the dental prevention specialists indeed.
3. Don't let anyone else put hard pressure onto your teeth with that sharp explorer.
The article below explains hazards of improper cavity detection and can save a lot of people from a lot of unnecessary dental work. After reading the article below the patient who has been thinking "I wish he wouldn't jam that sticker so hard into my tooth, it feels like he could make a cavity like that.", can now how have the knowledge and confidence to tell whoever the examiner may be, to refrain from stabbing his teeth with that instrument.
I would like to hear your final outcome, filling or not?
Larry Burnett DDS
George Stookey, Ph.D.
USE OF AN EXPLORER CAN LEAD TO MISDIAGNOSIS AND DISRUPT REMINERALIZATION.
For at least the past 50 years, the conventional procedure for the clinical detection of dental caries has involved a visual-tactile examination of the tooth surfaces supplemented with the use of radiographs. As described in 1968 by Radike,1 a critical factor supplementing the visual inspection was the tactile feel of tackiness and force of withdrawal associated with the insertion of the dental explorer into the suspicious area. Thus, dental students were taught literally to attack the suspicious area with the sharp explorer to determine if the area had the traditional feel of a carious lesion. Since many of the suspicious areas resisted the explorer, the clinician was expected to use pressure on the probe. However, an increasing amount of research is indicating that that long-standing approach may no longer be the best.
The results of several studies indicated that use of the dental explorer was of limited value for the detection of occlusal caries.
THE EXPLORER, REMINERALIZATION AND FALSE DIAGNOSES The caries process is a known continuum beginning with demineralization beneath dental plaque and progressing through various stages that include a so-called "white spot" and eventual cavitation. Since the 1966 report by Backer Dirks2 documenting that white-spot lesions could be reversed completely and "disappear" clinically, many scientists have investigated the physicochemical dynamics of the caries process. Among the conclusions from these numerous studies is the fact that even though the white-spot lesion reflects the loss of mineral through the outer one-half of the enamel thickness, the lesion may be remineralized as long as the surface layer remains in place. Once the surface layer is broken, plaque acids diffuse into the lesion and the extent of the lesion progresses much more rapidly. Thus, an intact surface layer is considered essential to the reversal of the caries process, and penetration of this surface with an explorer converts a subsurface lesion into a frank cavity.3,4
This realization, coupled with the observation that the use of the dental explorer in the historical manner resulted in an unacceptably high proportion of false-positive diagnoses on occlusal surfaces,1,3 led a number of clinical scientists to re-examine the value of the use of the dental explorer as a probe for caries detection.
Generally similar results of an unacceptably high number of false-negative diagnoses of fissure caries using the dental explorer have been reported by a substantial number of investigators.3,4,6 As noted by Anusavice,19 many clinical decisions to place occlusal restorations are based on the inappropriate use of the dental explorer to determine the softness or tackiness of the fissure or the amount of resistance to the removal of the explorer from the fissure. Thus, Anusavice concluded that there is strong evidence to support the elimination of the use of the dental explorer in the historical manner.
The tip of the explorer should be moved gently across the surface of any noncavitated area to determine the presence or absence of surface roughness.
However, as noted by Kidd and colleagues,20 the dental explorer continues to be an indispensable component of the caries diagnostic armamentarium. With the recognition that the caries process is a continuum and the caries process, if detected before cavitation, can be reversed or arrested with various professional and home-use fluoride measures, it is apparent that the mission of the clinical caries examination has changed from simply the identification of well-advanced lesions requiring restoration. Instead, the mission of the examination now includes the identification of lesions or demineralized areas at the precavitation stage that may be reversed or arrested if the thin surface layer covering the demineralized area remains intact. Thus, the use of the dental explorer in the traditional manner must be avoided, because it will fracture the surface layer and eliminate the possibility of reversing the caries process.
THE USES OF THE EXPLORER, PRESENT AND FUTURE The primary uses of the explorer are to remove dental plaque from the examination area and to determine the roughness of the surface of noncavitated lesions (white spots). Since dental plaque is essential for the development of dental caries, its presence is a clear indication that the area beneath the plaque needs to be examined carefully. The plaque biofilm may be removed gently with a scraping action of the explorer shaft or by the use of the explorer tip in fissures to expose the underlying enamel surface.
In addition, the tip of the explorer should be moved gently across the surface of any noncavitated area (white spot, brown spot) to determine the presence or absence of surface roughness as an indication of whether the underlying demineralized area reflects an active lesion. In the absence of imaging technologies, which still are evolving, the use of the explorer in this manner coupled with the visual examination appear in several studies to be the most effective means for the diagnosis of clinical caries and the identification of the most appropriate approach for caries management.4,9,21. These studies have demonstrated clearly that the use of the dental explorer in this manner does not diminish the clinician's ability to detect accurately more advanced lesions requiring restoration on both occlusal and smooth surfaces. Moreover, this procedure permits the detection of precavitation-stage lesions and the determination of whether these areas are active. This latter assessment of the precavitated lesion or demineralized area permits the clinician to identify the appropriate professional and home-use treatments to reverse or arrest the process and to monitor the success of the treatments at subsequent examinations. Thus, while the dental explorer continues to be a critical component of the clinicianiagnostic armamentarium, its use as a probe in the historical manner for a tactile examination of the tooth surface is contraindicated.
CONCLUSION There is an increasing body of scientific data indicating that noncavitated incipient lesions may be remineralized if the surface layer covering the demineralized area or lesion (the white spot) remains intact. Because the use of the probe generally has disrupted this surface layer and prevented the possibility of reversing the noncavitated area through remineralization, the use of the probe to determine the softness or tackiness of the noncavitated lesion is contraindicated.
Rating(1-10) Knowledgeability = 10 Clarity of Response = 10 Politeness = 10
Comment I got a great and interesting answer for my case; unfortunately, the damage may have already been done by a previous dentist, but now I know what to do for the future. Thank you so much for your help!!!
---------- FOLLOW-UP ----------
QUESTION: How do dentists decide whether the decay has broken through the enamel or not?
When can they put the ionomer sealant on, and when should they not?
Are the diagnodent numbers an indication of how deep the whole through the enamel are?
When the decay has gone far enough to where an actual hole in the enamel can be seen, that is the definition of a cavity. Early decay eventually advances far enough to cause the enamel to actually cave in a cause a hole(cavity). This is the point at which the enamel can no longer be remineralized. This is the point at which a filling becomes necessary. At anytime before the actual cavity appears, there is a good chance that you will halt the early decay and remineralize the enamel with the glass ionomer sealant plus reversal of any risk factors causing the initial decay. The penalty for failure is simply to do a filling in the future if serial x rays over time show the decay advancing slowly.
The Diagnodent numbers are not a good consistent indicator of depth of penetration into enamel. Matter of fact Diagnodent should never be the final decision maker on whether or not to fill. There is no substitute for a careful visual examination examination of the dry tooth surface, preferably with magnifying loops. If you are curious about the actual visual diagnosis, I post the following link which you probably must copy and paste into your browser. http://www.icdas.org/
I'd like to make another editorial important point for any patient wanting to avoid unnecessary treatment. As you can see, the decision whether to drill and fill or remineralize early decay is a judgement call. Social sciences have proven that incentives can seriously cloud the judgement of any person, often on a sub-conscious level. Therefore I feel more comfortable if the person making that judgement, to drill or not, has no financial interest in the outcome.
Larry Burnett DDS