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Dentistry/To what degree is it 'wise' to drill pits and fissures of molars out of cosmetic concerns only?

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QUESTION: Dear dr. Peck,

Very much so I would like my dentist to drill some of my molars as to remove the black/brown discoloration of some pits and fissures.
She advised me not to as it would not be preferable: once the 'cycle' of restoration has started there is no stopping it, the composite resin would have to be replaced every so many years and with every cycle some more dental material would have to be removed. Currently carious lesions have not been found so she best want to leave my teeth the way they are.

As I see it: my main concern is having teeth that I think are as beautiful as I want them to be, I can't honestly get myself to adhere to her advice. I just don't like the staining at all as I see it the staining indicates plaque is easily retained at the site of staining, so drilling and restoring that area would have as an advantage - apart from getting me the cosmetically desired result - there is less chance of carious lesions developing as plaque cannot easily be retained at the site any longer.

Do I understand this correctly, there is the advantage of easier cleaning of the molars and less chance of carious lesions when molars without present carious lesions but with staining are drilled slightly and restored?

Generally with slight drilling of the molars to remove staining, what restorative procedure is generally followed: sealing the molars or adhering composite resin?

Is it possible to use ceramics to restore a site that is very small only and will using ceramics generally lead to needing less 'replacement cycles' at the site?

How 'wise' would it be out of cosmetical concern only to drill the molars to remove staining and restore them either with composite resin, ceramics or sealing them?

Thank you so much for taking the time to review my concerns.

ANSWER: Dear Veronica, thanks for your question.

Your dentist is correct - as soon as a tooth is drilled, it immediately becomes weakened, unless there is a justifiable reason to do so, such as fracture or decay. The day and age we are currently focuses more on minimally invasive and conservative approaches, which has been shown to reduce long term problems later. What can be done, is that the fissure and pits could be thoroughly cleaned with pumice and water and the affected areas could be covered with a flowable fissure sealant, but as nothing lasts forever, these would need to be redone every few years as they wear down, chip or crack. As for drilling and replacing with bonded composite restoration without any signs or symptoms of active decay or other pathology, I would advise you against this because of the potential problems that could occur post-operatively, such as temperature sensitivity, altered bite and secondary decay later on. It is, of course, your body and you have full right to do with it as you choose, and could probably find a dentist who would oblige your request. As far as I'm concerned, that is the dentist that everyone should avoid as they do not have the best interest of their patient at heart. I hope this helps and wish you all the very further, take care.

Dr Craig Peck

---------- FOLLOW-UP ----------

QUESTION: Thank you very much for your detailed answer!

It has not been well researched what the chance is of decay later developing after a flowable fissure sealant has been placed - or so I thought - can decay be sealed in? I thought there is also the issue of detectability of secondary decay because the sealant obscures the meticulous visual inspection for decay.

I hope you can shed some light on these issues.

Answer
Hi Veronica and thanks for your follow up question.

Tooth decay can only develop under conditions when bacterial enzymes act on dietary food stuffs to reduce the local pH and cause demineralization of the tooth structure due to acid production. In theory, if these 2 elements are removed and the tooth is sealed off, decay cannot develop - which is the philosophy behind fissure sealants. So, if no decay is present in the fissures or pits and they are sealed off, no decay should develop. In reality, however, I have experienced decay under fissure sealants, but this more related to old and long standing sealants or ones which have fractured or been partially lost due to wear. The principle of treatment should always be applied to any treatment - the benefit of doing the procedure must out-weigh the risk of leaving the situation as is, untreated, taking into account the potential side-effects and problems related to the procedure. Because fissure sealants are minimally invasive, preventative treatments, they can be removed relatively easily with minimal damage to the tooth - if any at all - if pathology is suspected and the tooth further examined, and of course, there is the benefit of diagnosis with the aid of X-rays. I hope this helps and wholeheartedly apologize if my previous answer in any way offended you - that was certainly not my intention.

Kind regards
Dr Craig Peck

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Dr Craig W Peck ( B.Med.Sc., B.Ch.D., Clin. Botox, Cosmet. Derm.)

Expertise

I am a General Dental Practitioner, with special interests in Cosmetic Dentistry & facial aesthetics and Periodontology, placing a strong emphasis on the establishment and maintenance of a healthy periodontium (the support structure of the tooth) before cosmetic options are considered. I uphold all principles of prevention above interventional treatment and try as far as possible, to remain conservative in my approach. I believe in detailed, open and honest patient discussion, establishing what the patients expectations are and what the reality is of achieving this and involving the patient at every level of the treatment. I have strong principles on ethical treatment and appropriate patient management. I have chosen to treat and rehabilitate many nervous and phobic patients, who, for whatever reason, find it impossible to take part in the very important task of even a routine check-up. I will accept questions relating to general and cosmetic dentistry (in conjunction with the use of facial cosmetic procedures) and dental fears/phobias. I will be more than willing to answer any academic questions in dentistry, biology, physiology, psychology and health sciences in general. As most dentists will tell you, there is often not only one way of dealing with a dental issue - so very often, there is no precise right and wrong way of approaching the problem. All clinicians vary when it comes to treatments and what works best in their hands is often the treatment that is advised. Be understanding of this and bear in mind that nothing lasts forever! Patients are happy to accept only a one-years warrantee when buying a new car, but seem to expect that dental work is going to last them their lifetime.

Experience

I have worked for many years in the UK and RSA as a general dental practitioner - within the NHS, private practice and the government dental health services. I am certificated for the administration of Botox and Dermal Fillers for facial lines and wrinkles as I have attended further courses in minimally invasive facial cosmetic procedures. I started seeing an increasing number of patients who presented with severe to moderate dental fears, even with full-blown phobias, so I started with the slow and patient task of tackling this problem and have successfully rehabilitated many patients. The key is good, effective, concise and understandable communication, shifting control from the dentist to the patient in order to slowly, but confidently, regain their trust back in dentistry, thereby giving them the feeling of achievement and this self-empowerment which drives them to the next level of treatment.

Organizations
Academy of General Dentistry. American Dental Education Association. IAPAM (International Association for Physicians in Aesthetic Medicine). Professional Speakers, Writers and Managements Consultants in Dentistry. The British Dental Association. UK Aesthetics Group. ARC - Aesthetic Professionals. Botox. Aesthetics & Beauty. American Association for Dental Research. FDI - World Dental Federation. SOURCE1uk. World Dental Hygiene Forum. ProDentalCPD. Public Health Dentistry. Dentist Network. LinkedIn. Who's Who of South Africa.

Education/Credentials
B.Med.Sc. Degree (Medical Physiology and Medical Virology; Physiology Cum Laude; Stell 1994). B.Ch.D. Degree (Bachelor of Dental Surgery; Clinical Dentistry Cum Laude; Stell 1997). CPR and CPR-Advanced Courses (2000/2001; UK). Clinical Botox (UK, 2001). Cosmetic Dermatology (Botox and Dermal Fillers; RSA 2011).

Awards and Honors
Placed on the Dean's List at University for academic achievement (1994). Highest achievement in the subject Dental Materials. Medal from 3M and the Radiology Association of South Africa for highest achievement in the subject Dental Radiology and Imaging. Medal from The Periodontal Association of South Africa for highest achievement in the subject Periodontology. Highest achievement for Oral Medicine. Highest achievement in Oral Pathology. Received the DASA (Dental Ass. of South Africa) Gold Medal for highest achieving dental student across the 5 1/2 years of the Degree. Passed the subject, Clinical Dentistry with distinction in final year.

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