Too Much Drilling? Not All Early Tooth Decay Needs a Filling

Columbia

Some dentists are using newer technologies to help detect the beginnings of decay. The aim is to find out when the tooth begins to lose some of its minerals, before it develops a hole (cavity).

But if you have early decay, what should be done? Do you need a filling right away?

Not necessarily.

These days, dental decay is "a slowly progressing disease," says David A. Albert, D.D.S., M.P.H. Dr. Albert is an associate professor of clinical dentistry at the Columbia University College of Dental Medicine.

"From start to finish in the general population, it can take about three years to go from early decay on the surface of the tooth to a large cavity that reaches the pulp," Dr. Albert says. The pulp is the center of the tooth, where the nerves and blood vessels are.

Early in the 20th century, decay could reach the pulp in a matter of months, Dr. Albert says.

Today, early decay doesn't always mean you need a filling. In fact, the decay often can be reversed. A tooth starts to decay because acid in your mouth causes minerals to leach out of the enamel. This makes the enamel break down, and a cavity then forms.

In some cases, a filling is a no-brainer. If you're in pain or have an obvious cavity, you need a filling. But, says Dr. Albert, "If there's no cavity and no pain, the tooth can fix itself."

New technologies can help dentists find early decay. At this stage, decay can be reversed with home and dental office fluoride treatments, better oral hygiene and changes in your diet, Dr. Albert says. Minerals can build up in the tooth again, making the enamel stronger.

In theory, then, finding decay early should lead to fewer fillings. However, the reality may be different.

"Dentists may actually do more fillings because they find early decay and decide to treat it," Dr. Albert says.

"For the general population, that's wrong," he says. "For some individuals at high risk for dental decay, it's good to find decay early and treat it early. But if you're in a low-risk group for dental decay, the treatment of choice is to apply fluorides in the dental office and at home to repair the tooth. In other words, don't drill."

"If I saw 100 patients [who had early decay and no cavity] and decided to wait 6 months before treating them, it would be the right decision for 95 of them," he says. "I think we do more harm by overtreating, because there will always be complications of treatment."

For example, there is always a chance that a filling will crack, break or fall out. The space between the filling and the tooth is a hot spot for further decay. Eventually, the tooth may need root canal treatment. It may even need to be extracted. If a filling can be avoided, the tooth will be stronger.

Another concern is that the new devices being used to help detect decay aren't always right, Dr. Albert says. "Some things look like cavities, but they're not. For example, a dark discoloration does not mean a cavity."

So why don't most dentists watch and wait? They may be worried that the person won't return in six months for another checkup. Or they may worry that patients will think they don't know what they are doing or can't make a decision.

Newer technologies can help diagnose early decay and help a dentist monitor a tooth. But Dr. Albert says dentists need to be cautious with treatment. If your risk of dental decay is low, he says, it is best to "watch and wait" rather than "drill and fill."

06/27/2014

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