Does the cycle of rerestoration lead to larger restorations?

CF Brantley, JD Bader, DA Shugars and SP Nesbit J Am Dent Assoc 1995;126;1407-1413 The following resources related to this article are available online at jada.ada.org ( this information is current as of September 16, 2011):
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ARTICLE 3

LEAD TO LARGER RESTORATIONS?

C. FRANK BRANTLEY, D.D.S.; JAMES D. BADER, D.D.S., M.P.H.; DANIEL A. SHUGARS, D.D.S., PH.D., M.P.H.; SAMUEL P. NESBIT, D.D.S., M.S.

DOES THE CYCLE OF RERESTORATION

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Qrocedures relating to the replacement of existing restorations

The common practice of

rerestoring teeth has been

termed the "cycle of rerestora-

tion." Some researchers and

clinicians have speculated that
this cycle results in teeth receiv-

ing progressively larger restorations. In this study involving

1,337 decisions to replace existing restorations in posterior

teeth, the authors noted that 70

percent of all recommendations

resulted In an increased number of restored surfaces. This observed Increase in restoration

size raises questions about the

effects of the rerestoration cycle

on the health of a tooth and sug-

gests that practitioners should

attempt to avoid premature rerestoration since it could hasten the cycle.

make up a significant portion of the restorative dental care provided in the United States and elsewhere. Rerestoration occurs with such regularity that researchers have described a "cycle of rerestoration"'5 whereby once a restoration has been placed, the tooth is relegated to a lifetime of re-evaluation and subsequent rerestoration. Consequently, rerestoration involves additional operative insult to the tooth and the potential for ever-enlarging restoration size. One may confidently hypothesize that the risk to the health of the tooth and the cost of restoring it increase as the cycle progresses. Over the last two decades, investigators have questioned traditional practices in planning the rerestoration of teeth. In the absence of overt caries or restoration failure, decisions to replace restorations are typically the result of a clinical evaluation of the quality of the existing restoration and an assessment of the risk factors for undetectable caries or future recurrent caries.126 In effect, decisions to replace existing restorations are frequently based on a subjective determination rather than a definitive diagnosis. Evidence exists that raises concern about the accuracy7 and consistency8 of dentists' assessments leading to a diagnosis and decision to replace a restoration. As a result, some dentists believe that accepted rerestoration practices may unduly increase health care costs 4910 and diminish the appropriateness of treatment.2'4'11'12 Although previous studies have focused on general issues related to the rerestoration of teeth, tooth-based analyses that quantify increases in the number of restored surfaces during rerestoration procedures have not been reported, to our knowledge. We analyzed existing data to determine the effect of treatment planning decisions on the size of replacement restorations compared with that of existing restorations.
MATERIALS AND METHODS

From December 1991 through June 1993, we collected the data used in these analyses. Sixty-six dentist volunteers, recruited from the four-county area surrounding the dental school at the
JADA, Vol. 126, October 1995 1407

CLINICAL PRACTICETABLE
I

New

caries

Caries diagnosed, niot associated with restoratioxn

Caries suLspected, not associated with restoration

Caries risk, niot associated with restorationi

cruited 66 dentists for participation in the study; 80 percent of them were male. The mean year of dental school graduation was 1978 (range, 1951 to 1991), and 83 percent of the dentists graduated from the same dental school. General dentists made up 98 percent of the participants (one participant was a prosthodontist). Ninety-four percent of the dentists were in private practice and the remainder were dental school faculty members who had private
practice experience.

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Other

University of North Carolina at Chapel Hill, examined 62 adult volunteers who had come to the dental school clinic for treatment. Groups of four to six patients were examined individually by groups of four or five dentists during half-day sessions. Some dentists and patients participated in multiple sessions, but no patient participated for longer than three months, thus minimizing the possibility that changes in clinical conditions had occurred. We selected patients on the basis of three pertinent characteristics: numerous previously restored teeth, few missing teeth and no local or systemic
1408 JADA, Vol. 126, October 1995

conditions that might necessitate modifications in treatment

recommendations. The mean age of subjects was 41 years (range, 25 to 66 years); 59 percent were female and 88 percent were white. All patients underwent an initial standard visual-tactile caries examination13 by the same experienced examiner in a dental school operatory. These examination findings were used to initially classify teeth by restoration status. We did not determine intraexaminer reliability. The primary criterion for dentist participation was active general practitioner status in the four-county area. We re-

During each of 14 sessions, a panel of four or five dentists each examined four to six patients in dental school operatories equipped with an operating light, an air/water syringe, a high-speed evacuator, a frontsurface mirror and an explorer. A total of 333 dentist-patient interactions were carried out. We obtained full-mouth radiographs, health histories and periodontal data for all patients. Trained recorders used a standard protocol for noting dentists' treatment recommendations during the clinical examination. We instructed dentists to assume that patients were visiting their practices for the first time. They were urged to proceed in a manner as similar as possible to that usually occurring in their practices, including discussing treatment alternatives with patients before making a recommendation, if appropriate. For each tooth, the recorder noted the dentist's decision
about whether to recommend treatment. If treatment was

recommended, the recorder noted the specific surfaces to be restored, the restorative material to be used and the principal reason for the recommenda-

CLINICAL PRACTICE
mendations overall and for each of the four mutually exclusive reasons for rerestoration.
RESULTS

QA I R

Overall, 70 percent of all recommendations to restore resulted in an increase in the number of restored surfaces.

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The Figure shows the proportion of Figure. Percent of restorations for which replacement with an increased number of sur- restorations for faces was planned, according to tooth type and reason for replacement. which dentists planned replacement with an increased tion of those teeth with crowns. tion. Dentists also had the opnumber of surfaces. The reaWe did not include recommention of establishing a "watch" sons "new caries" and "other" dations to restore that did not notation on the patient's record involve an existing restoration. (for example, fracture, fracture rather than recommending risk, abutment, contact/contour The 62 patients had a total of treatment for any given tooth. problems) led to the greatest 974 posterior teeth, 648 of When the recommended proportion of increased surfaces which had been restored. A treatment involved rerestorafor premolars. The reason mean of 5.8 dentists assessed tion of a posterior tooth, the "other" was cited most freeach of these restored posterior recorder wrote down the numteeth, for a total of 3,758 assess- quently by dentists who recomber of surfaces of the existing mended replacement of restoraments. Of these assessments, restoration (one, two, three, tions in molars with larger 1,337 (36 percent) resulted in a four [plus] or a crown). The restorations. However, "recurrecommendation to rerestore. number of surfaces in the recof these recommen- rent caries" and "faulty restoraThe percent ommended restoration was dations that involved additional tion" also led to increases in the recorded similarly and the reasurfaces (that is, those previnumber of surfaces for approxithe existing son for replacing mately one-half of premolar and ously unrestored surfaces) is restoration was classified and the subject of this report. molar restorations. recorded as one of four specific Tables 2 and 3 show the proWe calculated percentages "new caries," "recurdiagnoses: portion of restorations for which rent caries," "faulty restoration" separately for premolar and molar teeth and further categoplanned replacement resulted and "other." We presented genin an increased number of surrized them by the number of eral descriptions of these diagsurfaces involved in the existing faces. However, calculations nostic categories to the dentists based on 10 or fewer teeth may (Table 1), but requested them to restoration. Teeth with four or five restored surfaces were com- not be stable. Our results indiinterpret and apply these diagbined. We considered a recomcate that restorations with more noses based on their individual surfaces will likely result in an mendation for a crown to be an training and experience. increase in the number of reincrease in the number of reThe analyses presented stored surfaces for any tooth. stored surfaces in the rerestorabelow are based on all recomtion process. The percentages were determendations to rerestore premoWhile the data set includes lars and molars, with the excep- mined for re-treatment recomJADA, Vol. 126, October 1995 1409

C KCLINICAL PRACTICETABLE 2

New caries

Failty restoration

*Number of restorations with increased surfaces/total number of restorations to be replaced (percent).

lrm~ ~ - 14/14 (100)

20/33 (61)

6/8

(75)

1/1 (100)

3/9

26/70

37/78

12/12

(33)

(37)

(47)

(100)

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TABLE 3

I''IS L|! . !||.;|!.S

New caries

||iI!
One4
49/64

Two
22/52 (42)

Trhree
(38)
3/8

Four (plus)
18/20 (90)

(77)

Fanity restoration

22/47 (47)

38/70 (54)

33/49 (67)

109/122 (89)

*Number of restorations with increased surfaces/total number of restorations to be replaced (percent).

multiple observations of the same teeth by different dentists, each assessment can be considered independent for these analyses. Dentists were not aware of others' recommendations when they conducted their examinations. Thus, to the extent that dentists, patients and individual restored teeth in our study represent dentists, patients and individual restored teeth elsewhere, the results can be generalized to larger populations. Of course, this generaliza1410 JADA, Vol. 126, October 1995

tion is limited to the type of patient recruited for this study, that is, patients with multiple restored teeth.
DISCUSSION

cases of amalgam restorations is performed to replace existing

restorations.9'14 Elderton and Osman2 suggested that a negative factor in replacing restorations is the likelihood of increasing the size of the new restorations. Anusavicel5 agreed that rerestoration tends to result in larger restorations. Further, he also alluded to the

Despite a decrease in caries incidence, improved restorative materials and an increased focus on preventive education and procedures, rerestoration represents a significant proportion of expenditures for oral health services.4'59 Treatment in approximately 72 percent of

potential damage to adjacent teeth and an increased risk of amalgam breakdown and tooth fracture with an increase in

CLINICAL PRACTICE
isthmus width as potentially negative factors in rerestoration. The results of this study support concerns regarding increases in restoration size upon rerestoration. Although the data in the present study relate exclusively to treatment planning and not actual clinical procedures, it is clear that practicing clinicians in this study anticipated an increase in restoration size on rerestoration of most posterior teeth irrespective of the diagnosis or the tooth under consideration. When we combine the evidence that the cycle of rerestoration leads to larger restorations with the documented inaccuracy and inconsistency among practitioners in diagnosing and planning treatment, concerns are heightened regarding the biological and structural consequences for teeth and the costs of dental care. Thus, knowledge of the factors associated with the rerestoration cycle is very important. Frequently, dentists base their decisions to replace restorations on clinical findings related to the perceived quality of the restoration, which is often largely subjective. The two most frequently cited reasons for replacing restorations are recurrent caries and defective restoration margins.49'14"16'17 Nonetheless, studies have shown that there is poor agreement among dentists in diagnosing recurrent caries,7, 12,18 and that clinicians' diagnostic accuracy is low when measured against the verified presence of
an individual tooth when assessing an existing restoration for serviceability. This assessment may be tainted by the use of dated knowledge and/or bias introduced during dental school training. Definitive diagnosis of recurrent caries or a leaking restoration may be impossible using non-destructive techniques. In the absence of overt caries or restoration failure, assessment is frequently inexact. It generally entails a judgment regarding the quality of marginal adaptation, the potential for caries activity, an assessment of the size of the exist-

marginal breakdown is a predisposing factor for recurrent caries.2'22 However, Goldberg and colleagues23 contended that this concept only operates for restoration margins that are near or below the gingiva and is not valid for defects on occlusal surfaces. Other researchers suggest that the correlation between defective margins and the actual presence of secondary caries is low and they believe that the clinical presence of a marginal defect alone is insufficient to replace a

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restoration.24-26 Clinically, the diagnosis of secondary caries tends to occur

in situations in which the explorer catches at the margin of a restoration and visual inspection of the site is impossible; thus, a differentiation between true secondary caries and a non-carious crevice at a marginal defect is difficult or impossible.' Hewlett and colleagues20 observed that 86 percent of teeth with defective restorations did not have radiographic evidence of secondary caries. Espelid and Tveit27 demonstrated that radiography coupled with a clinical examination produced a 3 percent falsepositive diagnostic rate of secondary caries. Based on the evidence from these studies, the use of margin defects as the sole criterion for restoration replacement may result in considerable overtreatment. Elderton3 speculated that many restorations continue to function adequately despite several unsatisfactory clinical factors or characteristics. A longterm study of predictors of restoration deterioration28 supported this position; in that study, most of the curves for restorations that had unsatisJADA, Vol. 126, October 1995 1411

In the absence of overt caries or restoration failure, assessment is frequently inexact.

ing restoration relative to the integrity of remaining tooth structure and a subjective interpretation of the functional stress that the restoration is likely to experience. Surveys of dental practitioners have shown that clinical evidence of defective restoration margins is a commonly used indication for replacement of restorations.459'6'9 Traditionally, the presence of clinically detectable defects in restoration margins has been linked to an increased risk of secondary caries, and this risk has been used to justify replacement. The perceived benefits of replacement are an opportunity to access and remove any caries present and to place a new restoration with improved adaption to reduce the subsequent risk of secondary caries.20 Several studies have supported the concept that

carnes.
Dentists are often forced to rely on clinical experience and intuition to predict the risks for

CUlNICAL PRACTICEfactory scores did not closely match the actual restoration survival curves. These researchers concluded that a number of clinical factors used to assess restorations may have little relevance to the long-term survival of the restorations. Elderton and Osman2 contended that dentists who adopt an aggressive, invasive-oriented approach to caries treatment may place too many new or replacement restorations and unwittingly fail to allow existing restorations to achieve their full potential. In a longitudinal study, Elderton and Davies29 noted that, in general, the more frequently a patient visited a dentist, the more restorations he or she was likely to receive over a fixed period. Furthermore, the more restorations a patient had, the more he or she was likely to receive in the future. Additional research shows that patients who changed dentists were more likely to receive an increased number of restorations over a specific period, indicating that some dentists may be inclined to replace restorations they did not insert.30 Some investigators sense that a tendency toward an overly critical evaluation of existing restorations and an aggressive approach to intervention may have its genesis in dental school training programs. Dental schools emphasize perfection, and as a result some restorations may be replaced primarily because of their failure to meet teaching standards for quality. In a study of differences among dental school faculty members regarding replacement decisions for amalgam restorations, Nuckles and colleagues31 found
1412 JADA, Vol. 126, October 1995

that marginal breakdown was the indication cited in 69 percent of decisions to replace. These data conflict with other studies32"33 that found caries to be the primary reason for amalgam replacement and may suggest a bias on the part of dental school faculty members toward being more critical of the margins of old restorations, especially when there is no treatment history. Maryniuk'2 asserted that because of variations in faculty members' opinions, many students may leave school unsure of the appropriate standards for clinical acceptability of restorations. Clinical judgment begins with dental training. Boyd34 contended that decisions to replace restorations are still based on tradition rather than fact, and quality restorations are equated primarily with the smooth margins and polished restorations emphasized by G. V. Black.
CONCLUSION

Our study findings support the view that the cycle of rerestoration leads to an increase in restoration size. When placed in the context of a growing body of work that points to diagnostic inaccuracy and considerable variation in treatment decisions among practitioners, some may question the view that the degree of variation in diagnosis and re-treatment is not problematic or may argue that such variation is inherent to the artistic component of dentistry. No consensus exists among dentists concerning diagnosis and treatment in the rerestoration of teeth. This is directly related to the paucity of information about the outcomes of treatment and an incomplete

understanding of the differences in dental disease progression and the variation in risk factors among patient populations. More specific studies are needed on the biological and structural outcomes for teeth as a consequence of the rerestoration process. To be maximally informative, outcomes studies must have breadth and depth; investigations must include consequences for individual teeth and should include some consideration of patient preferences. This information will provide a reliable basis for developing treatment guidelines. Useful parameters, developed through an assessment of outcomes, should assist practitioners in raising their level of accuracy in making a diagnosis and identifying which treatment, if any, is likely to be most effective in any given clinical situation. Finally, we must look more closely at the clinical decisionmaking process in dentistry. The clinical experience of the practitioner and the influence of role models appear to be important factors exerting considerable influence on decision making. Nonetheless, we would be wrong to promote a particular theory regarding current decision-making practices in dentistry. To a significant degree, our knowledge, or lack of knowledge, about how decisions are made is reflected in the variability in treatment decisions among practitioners. A better understanding of what information is required, what is realistically attainable and how this information should be used to make decisions is integral to developing treatment guidelines that have appeal and applicability to busy dental practices. o

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CLINICAL PHACTICEI
Dr. Brantley is a clinical associate professor and director of the Advanced Education in General Dentistry program, Department of Dental Ecology, School of Dentistry, University of North Carolina at Chapel Hill, CB 7450, Brauer Hall, Chapel Hill, N.C. 27599-7450. Address reprint requests to Dr. Brantley. Dr. Bader is a research professor, Sheps Center for Health Services Research and Department of Operative Dentistry, School of Dentistry, University of North Carolina at Chapel Hill.

Dr. Shugars is a professor, Sheps Center for Health Services Research and Department of Operative Dentistry, School of Dentistry, University of North Carolina at Chapel Hill.
Dr. Nesbit is a clinical associate professor, Department of Diagnostic Sciences and director of Patient Admissions/Emergency Service and the Diagnosis and Treatment Planning Service, School of Dentistry, University of North Carolina at Chapel Hill.

This research was supported by grant HS06669 from the Agency for Health Care Policy and Research. The authors thank the practicing dentists in the greater Chapel Hill, N.C., area who participated in this study.
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