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Minimally invasive management of caries

17 October 2018
A patient attended an appointment where the dentist’s examination and bitewing radiograph identified caries beneath a pre-existing amalgam filling. The patient returned two weeks later for an appointment for a filling to be placed at LL4. The patient’s notes record that the tooth was restored with a distal reinforced glass ionomer cement placed under local anaesthesia. The patient was warned of post-operative sensitivity and occlusion was checked. The patient was advised to return for a review six months later. 

The patient subsequently complained to the practice, reporting that they had experienced discomfort the day after the filling was placed. The filling had cracked and so the patient attended another practice and was told there was a dark shadow beneath the filling and that decay was present. The patient was concerned that the filling had failed and that decay had been missed. The dentist contacted Dental Protection for advice. 

The member was newly qualified and had been taught techniques of minimal intervention dentistry. This is a recognised, evidence-based approach that preserves tooth structure and allows removal of infected dentine with hand instruments and the placing of fillings over affected dentine. It uses reinforced glass ionomer cement (GIC) to allow remineralisation of the previously demineralised tooth structure. The approach requires focus on careful case selection, cavity design and control of risk factors. 

The member’s view was that all soft decay had been removed and clarified that, in circumstances where there was a risk of nerve exposure, it was her practice to use a stepwise technique for the removal of caries and leave a layer of discoloured dentine. The treatment plan was then to review the tooth at a later date once reparative dentine had been laid down, and replace the restoration at that point to reduce the risk of endodontic treatment being required. 

The member responded to the complaint, explaining the clinical procedure and advising that the filling would have been replaced free of charge had the patient returned to the practice. The patient responded that the approach taken to treating the tooth had not been explained to her and she was concerned that the filling had failed and required replacement so soon after being placed. 
A further response was made to the patient apologising for the lack of clarity in the advice given and the situation was resolved with the patient accepting a refund of the cost of the original restoration. The patient returned to see the dentist six months later and a definitive restoration was placed.
Learning points

This case emphasises the need to ensure clear communication with the patient, and to document the information shared with the patient in the patient’s records, along with the treatment plan and rationale. With a minimal intervention approach the records should document that the patient is made aware of the need for regular review, likely repeat bitewings, and the focus on preventing decay with fluoride, dietary advice and good oral hygiene. Patients should also be made aware that GIC fillings may need replacement and may not be recognised as a permanent restoration.

If the case had progressed to a clinical negligence claim and caries had been identified on the x-ray, and if the patient’s records had not demonstrated that a clear discussion had taken place with the treatment approach and the patient’s consent to this, then there may have been some vulnerability to the allegation of failure to diagnose and manage caries appropriately.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
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