- Dr. David Alfaro
Why do I need to replace it?
Wow! It has been a mega long time since I have sat down and blogged away! I have to blame the beautiful weather that we have been having. This is the first cloudy weekend we have had in weeks and when it is sunny, the last thing I want to be doing is reading and writing nerdy dental stuff.
But it is a cloudy Saturday so I may as well write something.
Last week a patient of mine presented to the office for his cleaning appointment and finally after various visits of my informing him of some problems, he finally agreed to have fillings replaced that were beginning to have decay around them.
Of course, his questions were:
1) Why do they need replacement?
2) Why weren't they done properly? (ie why did the fillings fail)
These are questions that always come up when I see work that needs replacement, so I figured that it would be a good topic to write about.
Let us talk about the replacement of dental fillings.
Why would someone require a dental filling in the first place?
There are pretty obvious reasons why someone may require a dental filling, such as a chipped or worn down tooth, so patients don't really question why the treatment would be recommended in those scenarios.
Dental caries, however, is a process that patients may not even be aware is happening, so they often question me if or why a filling is required.
And dental caries truly is a process. The mouth is full of bacteria; some good, some bad. And people have different strains of the good and the bad, making their mouths more or less susceptible to oral diseases than others. Then there are personal habits, such as brushing, flossing and diet, which are also highly variable, and often neglected.
It amazes me when so many people complain about how expensive dental care is, that so many still do not brush their teeth and floss properly, and they continue to drink sugary drinks and foods. Getting people to change habits is the hardest part of my profession, and I take on extreme challenges of manual dexterity on a daily basis. People get free floss, free toothpaste, free brushes, and free advice (there is actually a billable code for oral hygiene instructions that I do not often use), so it is really a matter of time and effort......a people still show up with inflamed gums and teeth covered in plaque. Not my fault by that point.
When you consume sugary foods and beverages, the bacteria eat it up and make acid as a waste product. The acid eats away at the minerals of the teeth, weakening them. Furthermore, when the bacteria gobble up sugar, they also use the byproducts to make themselves a nice little environment to live in as one big happy family (plaque and calculus). If not removed with a daily frequency, the amount of bacteria multiply rapidly and they become very effective acid forming colonies, causing tooth demineralization.
This demineralization, when it gets severe enough, can be visible on an x-ray, and has some clinical signs as well. If sugar intake is minimal and infrequent, the teeth are able to take up minerals from the saliva and fix themselves up. But, like is too often the case, people do not brush and floss well enough, and they keep poor diets, and the bacteria win the battle, and the teeth begin to decay. Once the demineralization is severe enough, a hole can form on the surface of the tooth: a cavity.
There was a time, and I am sure that there are some aggressive dentists still practicing this way, where any evidence of dental caries was treated immediately with a large amalgam filling.
"Extension for prevention"
This antiquated approach really caused more destruction to tooth structure than protection, but it was due to a limitation of the restorative materials that were available at the time (dental amalgam). Today, it is pretty much consensus that a tooth only requires a filling if there is a cavity, meaning we can try to remineralize the teeth in mild cases of tooth decay.
In my office, I prefer to not have to drill a hole, unless their is clear evidence that there already is one, or if there is evidence of progression of the decay, or if the person is at high caries risk. We have multiple non-surgical approaches to the management of dental caries: behaviour management, FLOURIDE, and remineralization agents. I always give these a try first. And if I have to drill a hole, I am as conservative as possible, and select my materials based on the clinical scenario.
Why would a filling need replacement?
Again, there are obvious reasons as to why a filling would require replacement, such as broken fillings, loose fillings, or loss of aesthetics (primarily for front teeth).
Dental caries, however, is the most common reason that dental fillings need replacement. And this is where the blame game begins.
The first thing that some patients say when I tell them that a filling needs replacement due to tooth decay is, "well, why wasn't it done properly in the first place?"
Ok, yes there are times when a filling is just not placed right. Dentistry is difficult and sometimes things just don't work out ideally. And if it doesn't...it should be redone.
But, dental caries is a process. Placing a filling does not stop this process, it just patches up the results of tooth decay. Dental fillings do not cure dental caries; they treat tooth decay.
In order to fight dental caries, more than just the mechanical filling of the cavity is required. Reductions in sugar intake, improvements in oral hygiene, the incorporation of fluoride and remineralization agents, and frequent dental visits, are all recommended in order to truly combat dental caries, especially in someone with a history of tooth decay and dental fillings.
For the gentleman who I recommended that we replace his fillings, once we removed the old composite, there was decay everywhere, causing him to ask the question of why things were not done properly in the first place.
It is hard to explain to someone the dental caries process, and that a dental filling itself had not failed and was placed well in the first place, and that it was actually the tooth around the filling that was failing.
Dental caries is strong enough to destroy perfectly intact dental enamel. No matter how good a dentist is, or how high quality of a material we use, there will always be a junction between the tooth and the filling, and this is a weak spot where tooth decay often attacks, just like grime sticking to the grout between bathroom tiles. If people are not brushing away plaque and bacteria, the acid attacks the junction between the tooth and the filling, and the filling remains fine, but the tooth begins to fail.
Dental caries is a process.
Isn't this just one big "racket"?
Whenever there is an article online about dentistry, I love seeing all the anti-dentite trolls piping up about how it is just one big racket, and that dentists are all rich and taking advantage of patients.
When we dentists tell our patients that a treatment that they paid a lot of money for will not last forever, I can see why people would get upset. It is an expensive endeavour patching up years of tooth decay, but we are fighting a disease process, which in the end is often the winner, so we cannot say that something will last forever.
And there is such an unreasonable expectation for dental work to last forever. I mean, who still has an Iphone 3? Or a CRT television? Or has worn the same shoes everyday for ten years? But a filling needing replacement after a decade of neglect, extreme temperature changes, ridiculous bite forces, and exposure to acids.......that is unacceptable! And it usually isn't even the filling, but the tooth around the filling, that fails first.
Yes, there is a segment of my profession that is profit driven, and there is some pretty shady stuff happening right now in Vancouver (and probably across North America), but I know and work with many honest dentists who are truly concerned with the oral health of their patients. If you think dentistry is a racket, you are going to the wrong place.
In my practice, I try to be as conservative as possible. The reality is that there is so much dental work that is needed out there, and as a specialist I spend so much of my time providing very complex dental treatments, that there is no reason for me to be aggressive and to drill holes for something that might be tooth decay, or to recommend "cosmetic dentistry" to someone with pretty nice, natural looking teeth.
I am in the business of helping people keep their teeth healthy, for longer, especially having the experience of treating extremely damaged dentitions on a daily basis. It may be hippy of me, and I definitely could pay off my student loans faster if I was pushing veneers and botox on everyone, but I am happy having someone come in for a check up and a cleaning and seeing them off with nothing further until their next cleaning.
There is nothing more cosmetic than a healthy, natural smile.
Thanks for reading!!!
Dr. Dave
drdave@alfaropros.com
