This month, Dentistry33 highlights Dr. Vineet Dhar, clinical professor and chair of orthodontics and pediatric dentistry at the University of Maryland School of Dentistry. He is a member of the American Dental Association’s (ADA) Council on Scientific Affairs and the lead author of the ADA’s new Tooth Decay Treatment Guideline, published in July 2023 in the Journal of the American Dental Association.
Dhar said that the recommendations encapsulate restorative dentistry’s two main objectives: maintaining healthy tooth structure and protecting the soft tissue inside the tooth. In this interview, he talks about dental caries, what it took to create the new guidelines and how, if at all, it might change dentistry.
Q: You’ve been studying this topic and dental caries for years – what are some of the major advancements that have occurred since you worked on your doctoral thesis, “Cariology and its Prevention in Pediatric Dentistry”?
Dhar: The greatest advancement over these years has been in the understanding of dental caries as a disease process and its clinical presentation as a caries lesion (cavitated or noncavitated) that could affect both primary and permanent teeth. This has helped researchers and clinicians identify evidence-based strategies to manage the disease process and to treat caries lesions.
The current clinical practice guideline provides much-needed, evidence-based recommendations on managing cavitated caries lesions in non-endodontically treated primary and permanent teeth.
Q: What was the process like in terms of timing to produce final recommendations?
Dhar: It took three years to develop and publish this guideline. An expert panel of dentists from the ADA Council on Scientific Affairs and the ADA Science & Research Institute conducted an extensive review of approximately 300 published studies and randomized clinical trials on carious tissue removal approaches and caries restoration.
Q: How, if at all, will this change dentistry in the average practice? Will any specialties be more affected than others?
Dhar: We have moved away from “drill and fill” dentistry to an era of evidence-based, patient-centered care. Most dentists are currently trained to remove all decayed tissue in an infected tooth, and it may not be necessary.
Evidence suggests that using conservative caries tissue removal approaches, along with appropriate direct restorative materials, is effective and decreases the risk of adverse events, such as pulp exposure.
While the panel conditionally recommended various direct restorative materials, some materials were prioritized over others depending on different clinical scenarios. All dentists, including specialists, who provide restorative care in their offices can use these guidelines to inform their clinical practice.
Q: What else would you like dentists and the public to know about the new tooth decay guideline?
Dhar: It is important for dentists and the public to know that the new guideline used the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) Evidence to Decisions Framework to contextualize data for our patient population. GRADE is a recognized and respected systematic approach used to rate and present summaries of existing evidence to help develop clinical practice recommendations.
The panel considered factors such as desirable and undesirable effects of the studied interventions, feasibility, resources (including costs), acceptability and patient values and preferences to formulate recommendations and obtained consensus on it.
The recommendations are conditional with low to very-low certainty of evidence, which highlights the need for high quality research to further substantiate our findings. Meanwhile, it is important that clinicians continue to engage their patients in the shared decision-making process as they make evidence-based choices to guide their caries tissue removal strategy and choose from a wide range of restorative materials indicated for the specific clinical scenario.
Dental pain management, other guidelines to come from the ADA
The ADA Clinical and Translational Research group — part of the association’s Science & Research Institute — produces one clinical practice guideline per year. According to the ADA, the new restorative caries treatment guideline is the second in a series of four caries management clinical practice guidelines.
ADA published a previous guideline on nonrestorative caries treatment in 2018. Two additional guidelines on caries prevention and caries detection and diagnosis are in the preliminary stages of development. Guidelines on acute dental pain management for children, adolescents and adults are also in progress. An ADA spokesperson said that these guidelines should be published later in 2023.
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