particular carious lesions.
8.3.1 Reasons not to treat
These can be divided into several distinct categories.
- The damage done by treatment to:
(a) The affected tooth. However conservative the technique it is inevitable that
some sound tooth tissue has to be removed when operative treatment is undertaken.
This weakens the tooth and makes it more likely that problems such as cracking of the
tooth or loss of vitality of the pulp may occur in the future.
Key Point
- Every time that a restoration is replaced more sound tissue has to be removed,
putting the tooth at further risk.
(b) The adjacent tooth. It is almost inevitable when treating an approximal lesion
that the adjacent tooth will be damaged. The outer surface has a far higher fluoride
content than the rest of the enamel so that even a slight nick of the intact surface will
remove this reservoir of fluoride. Additionally, it has been shown that early lesions
that remineralize are less susceptible to caries than intact surfaces and these areas of
the tooth are all too easily removed when preparing an adjacent tooth.
Key Point
- Early lesions that remineralize are less susceptible to caries.
(c) The periodontal tissues. Dental treatment can cause both acute and long-term
damage to the periodontium. It is virtually impossible to avoid damaging the
interdental papillae when treating approximal caries. The papillae can be protected by
using rubber dam and/or wedges and if well-fitting restorations are placed the tissues
will heal fairly rapidly, but long-term damage can be more critical. Many adults can
be seen to be suffering from overenthusiastic treatment of approximal caries in their
youth; and while the relative import-ance of poor margins compared to bacterial
plaque can be debated, the potential damage from approximal restorations is sufficient
reason to avoid treatment unless a definite indication is present.
(d) The occlusion. Poor restoration of the teeth can, over time, lead to considerable
alteration of the occlusion. It is tempting when restoring occlusal surfaces to leave the
material well clear of the opposing teeth to avoid difficulties, or to be unconcerned if
the filling is slightly 'high'. However, this can allow the teeth to erupt into contact
again or the interocclusal position to change and alter the occlusion. Often this is felt
to be of little concern, but there are a large number of adults where the cumulative
effect of many poorly restored teeth has severely disturbed the occlusion, thus making
further treatment difficult, time consuming, and expensive.
- The difficulty of diagnosis. It is well known that it is difficult to diagnose dental
caries accurately. Even when coarse criteria such as those developed for the United
Kingdom Child Dental Health Surveys are used, there is wide variation between
examiners. It is not just variations between examiners that need to be considered as