Grey areas in restorative dentistry: introduction

This is the first of a series of articles considering the ‘grey’ areas in restorative dentistry. Their origins lie in the book: Grey Areas in Restorative Dentistry – Don't Believe Everything you Think! by the present author.¹ This series will look at the often-difficult decisions that have to be made every day in general dental practice to answer the ‘who, how, why, when and where’ questions about intervention that arise when looking inside a patient's mouth. There isn't a probe that we can put on a particular tooth that will tell us what to do. Fill this one. Watch this one. Repair this filling. Put a post in that tooth. These are all decisions that are ultimately subjective and are, therefore, the reason for the variations that we see in care plans between different dentists and even between the same dentist on different days and at different times. As human beings, we are not as consistent and reliable as we would like to think. As Kahnemann states:² ‘The extent of the inconsistency is often a matter of real concern. Experienced radiologists who evaluate chest X-rays as ‘normal’ or ‘abnormal’ contradict themselves 20% of the time when they see the same picture on separate occasions. A study of 101 independent auditors who were asked to evaluate the reliability of internal corporate audits revealed a similar degree of inconsistency. A review of 41 separate studies of the reliability of judgments made by auditors, pathologists, psychologists, organisational managers and other professionals suggests that this level of inconsistency is typical, even when a case is re-evaluated within a few minutes. Unreliable judgments cannot be valid predictors of anything’. Like it or not, our decisions are going to vary.

There are several factors that contribute to these variations: undergraduate training; postgraduate training; time available; financial pressures; gender; age; and the environment that one is working in – be it general or private practice, hospital or academic. All of these will influence our choice or preference for treatment even when discussing the options with the patient before us. And, of course, the actual care plan that is implemented must be one that is agreed and acceptable to both the practitioner and the patient.

The aim of this series is to explore the issues surrounding a variety of situations that are often met by dental practitioners carrying out restorative dentistry. Situations to which there are no right answers and only the passage of time will tell whether the decisions were right or not.

Then again, what does ‘right’ mean? Success may be measured in several ways and will vary according to the circumstances. What we hope to achieve for one patient may not be appropriate for another. Readers are encouraged to think about what they are doing and to be able to answer the most important questions: What am I doing? Why am I doing this? Where am I going? Whose interests are being served? In other words, become reflective practitioners. ‘Good judgment comes from experience and much experience comes from bad judgment.’

In many respects, clinical dentistry is an art form rather than a science and, as a result, there are very few, if any, black or white situations where there will be general agreement on their management. So many areas rely on the judgement of the individual, the so-called ‘grey areas’. This series will cover topics such as: what are the aims of treatment; clinical decision making and care planning; diagnosis; radiolucencies under restorations; restorations with deficient margins: direct or indirect restorations; and management of teeth with suboptimal root fillings

It is hoped that the clinical conundrums presented at the end of each article will encourage debate among dentists as to why they would choose a particular course of action. There can be only one correct diagnosis, but there may be several ways of dealing with it. Furthermore, it would be gratifying if these articles stimulated dentists to be more confident in their prescription of treatment for their patients. After all, a satisfactory care plan is one that is based on current thinking, as per the dental literature, the clinician's experience, and one which can be justified before an independent third party should the occasion arise. In addition, for the care plan to be effective, it must have the cooperation of the patient. So as not to be prescriptive, the author does not present options in the clinical conundrums sections of each article.