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ly subjective, such as differences in smoothness, color, contour or mobility. While progress has and is being made in objectifying such determinations as much as possible—for example, through use of The International Caries Detection and Assessment System (ICDAS) criteria for determination of caries stage1— some subjectivity inevitably will remain. Counterintuitively, it is likely that the introduction of diagnostic codes in general practice would help reduce this subjectivity by refocusing practitioners’ attention on definitions. Over the longer run, the information on outcomes of treatment—and, indirectly, appropriateness of care—will benefit all aspects of dental practice.
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James D. Bader, DDS, MPH Research Professor Department of Operative Dentistry School of Dentistry and Senior Research Fellow Cecil G. Sheps Center for Health Services Research University of North Carolina Chapel Hill and Associate Editor for Evidence-Based Dental Practice The Journal of the American Dental Association 1. Ismail AI, Sohn W, Tellez M, et. al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol 2007;35(3): 170-178.
I am writing regarding Dr. Valeria Gordan and colleagues’ December JADA article, “A Long-Term Evaluation of
Alternative Treatments to Replacement of Resin-based Composite Restorations: Results of a Seven-Year Study” (Gordan VV, Garvan CW, Blaser PK, Mondragon E, Mjör IA. JADA 2009;140:1476-1484). Is it obvious to anyone else that there has never been a cover story in JADA on repairing or replacing defective amalgam restorations after fewer than seven years of service? That the authors found 10 criteria to judge resin-based composites (RBC) defective, even before “repair,” is itself an admission that RBCs are inferior dental restorative materials. “Cycle of rerestoration” is a term never applied to amalgam restorations. It should be alarming to our profession that a popular filling material of choice has “limited
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longevity” with “failure rates higher than those of other materials.” While Dr. Gordan’s study included a majority of anterior RBC restorations, I am quite sure that posterior composite restorations compose the huge majority of clinical failures. A recent letter by Dr. W. Dan Sneed, published in ADA News,1 and numerous clinical studies2-5 are exposing posterior composite restorations as far less satisfactory than marketed. Is it time that organized dentistry admits that the emperor has no clothes? Philip F. Fabel, DDS Robbinsdale, Minn. 1. Sneed WD. Composites. ADA News. November 2, 2009;40(20):4-6. 2. Tyas MJ. Placement and replacement of restorations by selected practitioners. Aust Dent J 2005;50(2):81-89. 3. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. JADA 2007; 138(6):775-783. 4. Forss H, Widstrom E. Reasons for restorative therapy and the longevity of restorations in adults. Acta Odontol Scand 2004; 62(2):82-86. 5. Lucarotti PS, Holder RL, Burke FJ. Outcome of direct restorations placed within the general dental services in England and Wales (part 1): variation by type of restoration and re-intervention. J Dent 2005;33(10): 805-815.
MORE ABOUT COMPOSITES
As an endodontist who was a practicing general dentist for eight years before specializing, I read with interest Dr. Valeria Gordan and colleagues’ December JADA article, “A Long-Term Evaluation of Alternative Treatments to Replacement of Resin-based Composite Restorations: Results of a Seven-Year Study” (Gordan VV, Garvan CW, Blaser PK, Mondragon E, Mjör IA. JADA 2009;140:1476-1484). Moreover, as a long-time endodontic advanced education program director, I have seen, and continue to see, many en250
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dodontic treatments necessitated because of poorly designed and executed composite restorations that either impinged on the pulp or grossly leaked, allowing bacteria to gain access to deep areas beneath these restorations and cause irreversible damage to the pulp. I applaud the authors for their desire to identify ways to minimize subsequent invasive corrective treatments for patients with defective composite restorations. However, I would like to point out some critically important issues germane to this subject. First, there was no mention in the article of whether the original restorative procedure was performed with the use of a rubber dam. Even though the student used the rubber dam during subsequent reparative operative procedures, information about whether it was used during the initial restorative procedure is missing—and is critical. Without a rubber dam, moisture, along with resultant contamination, cannot be controlled in any objective fashion. Etching procedures cannot be optimized, and the composite material is placed in an undesirable environment of contamination and high humidity, at a minimum. Second, there was no discussion in the article of staining around the margins of the composite restoration indicating leakage and invasion by bacteria. How does a clinician know where the bacteria end when preparing a corrective restoration? It is not possible. The entire restoration should be replaced under the rubber dam, presuming that the design of the restoration is appropriate and that amalgam is not better indicated. March 2010
Third, composite restorations are frequently placed where they are not suited—for example, multisurface restorations in posterior teeth. Because of the differences in coefficients of thermal expansion and contraction, leakage is right around the corner, especially when coupled with the high occlusal forces generated on these posterior restorations. Because of these and other factors, composite restorations frequently are placed with failure as the only possible outcome. The current investigation could have gained much had it been conducted with the use of rubber dam in both the original and corrective procedures, and if the reader had been given more information about the design and location of the restorations being evaluated. James C. Kulild, DDS, MS Professor and Program Director School of Dentistry University of Missouri-Kansas City
Author’s response: Thank you for the opportunity to respond to Drs. Fabel and Klulid’s comments. They both query the quality of posterior composite restorations in general dental practice. And they may have misunderstood the purpose of the study, which was to assess the longevity of alternative treatments to the replacement of composite restorations. It was not the purpose of the article to assess the longevity of originally placed composite restorations. We agree, as pointed out by Dr. Fabel, that JADA should consider making “repair versus replacement of amalgam restorations” a cover story in JADA or invite several authorities to comment on the topic in a special issue of JADA.