1Why restore teeth?
with the surface plaque-free after home cleaning. Ifthis isconsistently not achieved, consideration should be given toﬁssure sealing the surface with a resin to obliterate thegroove fossa system, thus aiding plaque control.Where a bitewing radiograph shows an approximal lesionin the outer enamel, the patient should be shown how to usedental ﬂoss.Root surface lesions are just as amenable to control bymechanical plaque control as coronal lesions. Pay particularattention to the approximal surfaces ofteeth next to a den-ture. Patients need to be shown how to angle the toothbrushto reach these areas or, alternatively, use strips ofcottongauze or cloth in a similar manner to ﬂossing to remove thegross plaque from these hard-to-reach areas (Fig. 1.18).
Use of ﬂuoride
The dentist should check that the patient is using a ﬂuoridetoothpaste. Some products formulated for sensitive teeth andsome herbal toothpastes do not contain ﬂuoride. The pasteshould be used twice daily and cleared from the mouth byspitting rather than vigorously rinsing. A ﬂuoride mouth-rinse (0.05% sodium ﬂuoride) used every day is a usefulﬂuoride supplement in a high risk patient, although the costofthe product may preclude its use by some patients.Surgery application ofﬂuoride varnish is a sensible pre-ventive measure and particularly valuable in those unlikelyto comply with a daily mouthwash regime.
Dietary advice should be given based on a diet sheet. Figure1.36 shows a diet sheet completed by a middle-aged patientwith a high incidence ofcaries. The sugar attacks have beenhighlighted. Note the frequency ofsugar intake. This gives thedentist the opportunity to explain the Stephan curve (Fig. 1.2)and the importance ofdecreasing the frequency ofsugarintake. The dentist should try to get the patient to suggestchanges. This approach helps the patient to set realistic goalsand enables the dentist to see whether the relationship betweendiet and caries has been understood by the patient. The dentistshould check that the main meals are adequate, and a list of foods that are safe for teeth may be helpful here. The negotiat-ed dietary change should be recorded on paper so that thepatient can take this away and ponder at leisure. The dentistshould record the goals agreed in the notes so that speciﬁcenquiry can be made at the next visit. A reasonable aim for thispatient would be to try to conﬁne sugar to mealtimes.
Salivary ﬂow should be measured because a feeling ofa drymouth may be subjective rather than actual.When the salivary glands are capable ofsecreting, chew-ing gum stimulates salivary ﬂow. A chewing gum with anartiﬁcial sweetener (sorbitol or xylitol) should be chosen inpreference to a sugar-containing gum. Ofthe two artiﬁcialsweeteners, xylitol seems the better as this product may sup-press counts ofsome acidogenic micro-organisms.Sometimes patients with a dry mouth suck sweets or sipsweet drinks to alleviate the problem. This is obviously veryunwise in patients who are already at high risk to cariesbecause they are short ofsaliva.
The role ofoperative dentistry in the management ofden-tal caries is to facilitate plaque control. Tooth restorationalso restores:•appearance•form•function.
Caries in pits and ﬁssures
Uncavitated lesions can be controlled by mechanical plaquecontrol with a ﬂuoride-containing toothpaste. Where apatient cannot or will not remove plaque, a ﬁssure sealant isa wise intervention to prevent plaque stagnation.Cavitated lesions should be visible in dentine on a bitew-ing radiograph and should be treated operatively becausethe patient will be unable to clean plaque out ofthe hole inthe tooth.
The diagnosis ofcavitation was discussed on p. 14.Cavitated lesions need operative treatment because even themost fastidious ofﬂossers cannot clean plaque out ofthehole – the ﬂoss simply skates over the top.In anterior teeth, approximal lesions may be unsightlybecause the demineralized dentine appears black or brown.This would be a reason to restore, even ifno cavity waspresent.
Smooth surfaces and root caries
Many smooth surface lesions, including cavitated ones, canbe arrested by preventive, non-operative treatment. Lesionswhich are plaque traps or unsightly should be restored.
Tooth wear is deﬁned as the surface loss ofdental hard tis-sues other than by caries or trauma, and is sometimes called‘tooth surface loss’ (TSL). This distinguishes it from earlyenamel caries that is characterized by
loss ofmin-erals beneath a relatively intact surface zone. The term‘tooth wear’ is preferred to ‘tooth surface loss’ because it iseasily understood by patients and because the extensively