The treatment plan should also address how to manage aging dentitions. People are living longer and fewer are becoming edentulous. However, complete denture teaching may be lacking in dental schools, resulting in new dentists who do not have the necessary skills, education, or confidence to provide complete dentures. As a result, they will have to depend on secondary care providers. Expanding the role of clinical technologists could help to address the issue, providing skills sets in both technical and clinical aspects. Edentulousness can have an adverse effect on oral health quality of life, which can often be managed using implantretained mandibular overdentures. An issue that must be addressed in this regard is funding for these restorations provided to hospital delivery systems. Future workforce planning must address the opportunities presented in caring for older patients, which may be supported through the use of joint team planning between restorative and other specialties, including oral surgeons and special care providers. The provision of care must also address hospital delivery. With inherently complex cases, the best treatment may be planned and delivered through a multidisciplinary team of primary and secondary care members. The lack of recognition of restorative dentistry specialists in primary treatment and future maintenance has significantly altered the ability of patients with complex disease to access dental care after age 18 years and the funding and resources needed for such treatment. Patients with an increased incidence of periodontal disease and structural tooth defects may be treated inadequately through
traditional surgical and endodontic approaches and may require a comprehensive approach. A special case involves patients with head and neck cancer, who have both acute and chronic problems that need restorative management. Such patients require a thorough assessment and delivery of treatment to avoid subsequent complications. Often just a short time span is allotted for such restorative care, making this a special case that must be managed appropriately.
Clinical Significance.—Providing restorative dentistry in today’s economic and demographic environment must seek to maintain efficiency while optimizing resources. The current challenges can be met by restorative dentists who continue to refine their primary and secondary care capabilities, but efforts are needed to further develop the specialty so that patients benefit from the results. Other specialties are also probably facing such challenges.
Alani A, Bishop K: Contemporary issues in the provision of restorative dentistry. Br Dent J 213:163-170, 2012 Reprints available from A Alani, Specialist Registrar in Restorative Dentistry, Newcastle Dental Hosp, NE2 4AZ; e-mail: [email protected]
Repaired restorations Background.—Increasingly, there is support for repairing rather than totally replacing defective, clinically unacceptable restorations. A repair that includes only preparation and restoration of the defective part of the tooth and/or restoration limits the amount of tooth substance sacrificed as well as the amount of exposed dentin surface. Repairs require a simpler treatment procedure, have less risk for pulpal complications, and cost less. Surveys of practitioners reveal substantial differences in the choice of whether to replace, repair, refurbish, or monitor dental restorations with deficiencies. As a result of these factors, some dental schools are increasing their instruction in repairs. Issues remain concerning the longevity of dental restorations with repairs. It is expected that a repaired restoration will have a shorter life than a total replacement, with the connection between old and new material, a possible point of weakness. A retrospective study was undertaken to determine the influence of repair on
Table 1.—Reasons for Repair of Failed Amalgam and Composite Restorations Reason for repair
Tooth fracture Cracked tooth syndrome Restoration fracture Caries Endodontic intervention Aesthetic reasons Marginal fracture Unknown Repaired restorations (total)
76 4 3 31 7 3 7 2 133
57 3 2 23 5 2 5 2 100
11 0 7 70 24 0 0 1 113
10 0 6 62 21 0 0 1 100
(Courtesy of Opdam NJM, Bronkhorst EM, Loomans BAC, et al: Longevity of repaired restorations: A practice based study. J Dent 40:829-835, 2012.)
restoration longevity and to assess the longevity of repaired restorations.
Fig 1.—Repair procedure of an existing amalgam restoration in tooth 16 with a new cavitated caries lesion at its mesial surface. A, Failed restoration due to mesial caries lesion. B, Preparation of the defect: Cavitated caries lesion visible. C, Finished repair preparation. D, Repaired restoration. (Courtesy of Opdam NJM, Bronkhorst EM, Loomans BAC, et al: Longevity of repaired restorations: A practice based study. J Dent 40:829-835, 2012.)
Methods.—Twelve hundred two amalgam and 747 composite resin restorations were placed. Of these 407 failed, with 293 of them done in amalgam and 114 in composite material. Two hundred forty-six restorations were repaired with composite resin using an etch-and-rinse technique. The data collected for the repaired restorations included reason for failure, number of surfaces in the original restoration, repair date, and date of patient’s last visit. If new treatment was needed, the restoration was considered a failure. The accumulated data were analyzed statistically.
Results.—One hundred thirty-three amalgam restorations were repaired; 57% of them had failed because of fracture (Table 1). One hundred thirteen composite restorations were repaired; 62% had failed because of caries. Figure 1 shows the steps involved with repairing a molar amalgam. After 4.8 years, 61% of the repaired restorations were still in service without further interventions (Fig 3). The annual failure rate (AFR) after 4 years was 9.3% for repairs to amalgam restorations and 5.7% for repairs to
Fig 3.—Tooth 16 with an 8-year-old composite resin restoration that was successfully repaired 2 years ago with a distal box type restoration due to secondary caries. (Courtesy of Opdam NJM Bronkhorst EM, Loomans BAC, et al: Longevity of repaired restorations: A practice based study. J Dent 40:829-835, 2012.)
composite restorations. Repaired composite restorations had a significantly superior performance (Fig 4). In addition, restorations repaired because of fracture had a significantly lower survival than those repaired because of caries. After 12 years, the AFR for the amalgam restorations never repaired was 3.0, whereas that for those that were still clinically successful including the first repair was 2.5%. Similarly, the 747 composite restorations never repaired had an AFR of 1.8% and that for restorations clinically acceptable with the first repair was 0.7% after 12 years. Factors associated with survival included patient factors, material used, number of surfaces in the original restoration, and repair reason. Gender had a significant influence, with the risk for failure of the repair twice as high for women as for men. Age, material, and number of surfaces also had significant influences on survival. Discussion.—Repairs can enhance the longevity of dental restorations. When a restoration fails because of
Fig 4.—Kaplan Meier survival graphs of repaired amalgam and composite resin restorations with annual failure rate at 4 years. (Courtesy of Opdam NJM, Bronkhorst EM, Loomans BAC, et al: Longevity of repaired restorations: A practice based study. J Dent 40:829-835, 2012.)
fracture, the repaired restoration has a worse prognosis than when the restoration fails because of caries.
Clinical Significance.—Composite restorations can be repaired more successfully than amalgam restorations. In addition, repairs caused by fracture are less likely to be successful than repairs caused by caries. Overall, repairs of restorations function very well, considerably extending the lifetime of the restoration.
Opdam NJM, Bronkhorst EM, Loomans BAC, et al: Longevity of repaired restorations: A practice based study. J Dent 40:829-835, 2012 Reprints available from NJM Opdam, Dept. of Preventive and Restorative Dentistry, Radboud Univ, Nijmegen Medical Ctr – PO Box 9101, NL 6500, HB Nijmegen, The Netherlands; fax: þ31 24 354 0265; e-mail: [email protected]
Amalgam or composite? Background.—Indirect restorations have greater longevity, but direct restorations continue to be the primary choice of dentists for managing posterior decayed teeth. These teeth have less need for sound tooth removal, there
have been advances in direct restorative materials technology associated with greater material survival, and the lower cost of direct restorations makes them more attractive than indirect restorations. Dental amalgam offers the advantages