class="bi x0 y0 w0 h1"
Proceedings of the International Conference on
Evidence Based Practice
in Dentistry
Kuwait, October 2–4, 2001
Faculty of Dentistry, Health Sciences Centre, Kuwait University
21 figures, 6 in color, 14 tables, 2003
Guest Editors
J.M. Behbehani,
Kuwait
E. Honkala,
Kuwait
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Vol. 12, Suppl. 1, 2003
1 Preface
Behbehani, J.M.; Honkala, E.
3
An Evidence-Based Approach to the Prevention of Oral Diseases
Spencer, A.J.
12 Preventive (Evidence-Based) Approach to Quality General Dental Care
Elderton, R.J.
22
Tobacco and Oral Diseases. Update on the Evidence, with
Recommendations
Reibel, J.
33 The Evidence for Prosthodontic Treatment Planning for Older, Partially
Dentate Patients

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This supplement is based on papers presented at the
Second International Conference of the Faculty of Dentis-
try, Kuwait University, October 2–4, 2001. The confer-
ence provided an ideal opportunity to exchange ideas and
discuss new developments in the field of dentistry, espe-
cially the latest trends in the evidence-based approach to
dental care. As the former President of Kuwait Universi-
ty, Professor Faiza M. Al-Khorafi, stated in her opening
remarks, ‘In science, we need to question continuously,
what is the evidence? We look to science for answers, but
quite often science can only give us the best estimate for
probabilities. Our research results need continuous re-
evaluation, and the evidence must be weighed according
to the strengths and weaknesses of the scientific methods
applied.’
The evidence-based approach has been widely dis-
cussed in various healthcare fields and has influenced
teaching throughout the world. With its emphasis on pre-
vention and its use of previous, analogous evidence to
design treatment plans, the evidence-based approach dif-
fers fundamentally from traditional methods of interven-
tion, which focus on clinical outcomes. The stages of the
approach, including the synthesis and assessment of evi-
dence, the application of that evidence to a particular
case, and finally the monitoring and reassessment of the

supplement, as is the issue of community health in Africa.
The dental curriculum at Kuwait University’s newly es-
tablished Faculty of Dentistry aims to promote oral health
in Kuwait through education, research and community
involvement. It incorporates recent trends in healthcare,
including the evidence-based approach which has become
an important component of comprehensive dental care
clinical work. In Iran, many new dental schools have been
established over the past 20 years, offering both under-
2
Med Princ Pract 2003;12(suppl 1):1–2
Preface
graduate and postgraduate training programs. The num-
ber of dentists and specialists in Iran is steadily increas-
ing, and just recently dental services have been incorpo-
rated into the public healthcare system. Efforts are also
underway in Africa to integrate oral health programs into
general health services, through the technical and finan-
cial support of WHO/AFRO. It is hoped that such pre-
ventive programs and new intervention strategies will
improve the level of oral health in many African coun-
tries.
As reflected in the presentations at this conference, the
vibrant research activity in the field of dentistry and the
efflorescence in dental education and oral health promo-
tion promise continued improvements in both dental
healthcare delivery and patients’ quality of life in the
coming years. It was an honor for the Faculty of Dentistry
at Kuwait University to host this conference and welcome
professionals and researchers from around the world, and

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Key Words
Evidence-based
W Prevention W Oral diseases
Abstract
The evidence-based approach has become the mantra of
health care and service delivery. But just what it means,
whether it is feasible, how to build it and the outcome of
its use are not well understood. The aims of this paper
are to provide an overview of an evidence-based ap-
proach to the prevention of oral disease, to examine the
assessment of clinical trial evidence, to examine emerg-
ing approaches to assessing population-wide interven-
tions and oral health promotion, and to illustrate some
principles and issues through examples from preventive
dentistry. The evidence-based approach to prevention is
presented using an evidence loop, which emphasizes
that the evidence-base should begin with an understand-
ing to the burden of oral disease and its determinants,
rather than a consideration of the efficacy or effective-
ness of interventions in clinical dental research. A sys-
tematic review of evidence from clinical dental research
is compiled and assessed, after which the intervention is
decided upon and implemented. The evidence loop is

programs and policies founded on less scientific evidence
4
Med Princ Pract 2003;12(suppl 1):3–11
Spencer
Fig. 1.
An evidence loop for the prevention
of oral diseases.
than is required or desired. Not only is more evidence
needed, but new ways of examining population-wide
interventions and programs for oral health promotion are
also needed to assist decision-making.
A number of levels of evidence and methods to assess
them are being developed. New concepts for an evidence-
based approach and a range of old and new methods for
the assessment of evidence seem to be gaining greater clar-
ity. This paper provides an overview of the evidence-
based approach to prevention, and points out some of the
limitations to applying evidence to population-wide inter-
ventions and some issues in oral health promotion.
Evidence-Based Approach to Oral Disease
Prevention
The evidence-based approach to prevention begins
with the identification and definition of an oral health
problem for which an objective for oral health gain can be
stated. Related evidence on the efficacy of interventions is
synthesized and assessed, after which an intervention
plan is decided upon and implemented. Finally, the oral
health outcomes among patients or populations are moni-
tored and the whole process reassessed over time. These
fundamental components might be expanded into a more

5
World Health Organization to inform health planning [2].
DALYs provide a way to link the cause and occurrence of
a disease to both short- and long-term health outcomes,
including impairments, functional limitations (disability)
and death. One DALY is a lost year of ‘healthy’ life.
DALYs are a combination of years of life lost (YLL) due
to premature death and equivalent years of life lived with
disability (YLD).
Such population-wide ‘summary health measures’
have been emphasized recently in the development of
health policies. A report on the burden of disease and
injury in Australia [3] identified oral disease as one of the
top dozen major disease groups for non-fatal burden of
disease. While mental and nervous system disorders were
of substantially higher burden than any others, oral dis-
ease ranked in a group of diseases/disorders that are con-
sidered highly preventable, such as injuries and infectious
diseases. The oral diseases included were dental caries,
periodontal disease and subsequent edentulism. Years of
life lived with disability were predominantly linked to
dental caries (56.2%), then to periodontal disease (30.3%)
and finally to edentulism (13.5%). Young and middle-
aged adults experienced more years of life lived with dis-
ability from dental caries than did older adults, while
the years of life lived with disability from periodontal dis-
ease were distributed among middle-aged adult groups.
The main challenge of using summary health measures
is ensuring that the burden of disease is appropriately esti-
mated, so current estimates of the burden of oral disease in

Determinants of Oral Disease
Preventive programs should be based on conceptual
and empirical evidence of the determinants of variation
in oral disease among patients or population groups in
order to identify more points of intervention in the pre-
vention of oral disease. The conceptual model illustrated
in figure 2 identifies three discrete yet closely interrelated
stages or levels of determinants: upstream, midstream,
and downstream [7].
Upstream level factors: The framework identifies so-
cial, physical, economic and environmental factors as
being the most fundamental determinants of oral health.
These include a range of interrelated factors such as edu-
cation, employment, occupation, working conditions, in-
come, housing, and area of residence. The framework also
indicates that these fundamental determinants are them-
selves influenced by even more upstream factors, namely,
government policies, globalisation, and culture.
Midstream level factors: Social, physical, economic
and environmental contexts throughout life influence
health either indirectly via psychosocial processes and
dental health behaviours, or more directly, for example
via injuries. The dental care system also plays some part
in determining oral health within a society. However, it
plays only a modest and moderating role.
Downstream level factors: Ultimately, oral diseases are
a consequence of adverse biological reactions to changes
or disruptions in various physiological systems. The
poorer health profile of some patients or population sub-
groups is due in part to longer-term adverse physiological

throughout a lifetime, but each life stage also has unique
contextual and behavioural aspects, and therefore partic-
ular strategies to reduce risk factors and strengthen pre-
vention are needed.
Integrated models are emerging that address the con-
tinuum of opportunities for prevention, such as the one
presented in figure 3, which was developed for Australia’s
chronic disease strategy [8]. In such models people are dis-
tributed across different target groups: the well popula-
tion, those at risk, those diagnosed with disease, and those
with controlled disease. Interventions are specific to these
stages and have different objectives, such as preventing
movement into the at-risk group, preventing progression
to established disease, or averting recurrence of disease
and loss of oral function. In such as approach to pre-
vention, the evidence-base on different interventions is a
key component of the support systems.
Synthesis of the Evidence-Base for Preventive
Interventions and Decision-Making
The evidence-based approach makes use of evaluative
research on the effects of an intervention to determine the
likely benefits or adverse consequences of intervention for
particular individuals or populations. When possible, evi-
dence of beneficial outcomes, rather than biological plau-
sibility or anticipated effects, is used [9]. Evidence of ben-
efits is derived predominantly from epidemiologic re-
search, which provides quantitative estimates of efficacy
or effectiveness. Summary estimates of effectiveness are
generated by a critical review of research data from two or
more studies using systematic review methods [10]. Sub-

hand searching and writing to experts are also essential.
The fate of all identified studies needs to be tracked,
whether included or excluded in the review.
Relevant studies are then summarized and the re-
search appraised. Numerous guides are available to assist
the process of abstracting information from selected stud-
ies and putting them in evidence table formats. Many
research publications, however, fail to include all the
information sought; this could be addressed by adhering
to a minimum set of information items that could reason-
ably be expected in research publications, such as those
suggested by the CONSORT statement [11].
Once the review is compiled, evidence is assessed to
determine the validity, reliability and precision of the
estimates of efficacy of the preventive intervention as well
as the size, importance and relevance of beneficial effects,
according to the following criteria:
E Strength of evidence: was the research good enough to
support a decision on whether or not to implement an
intervention?
E Size of the effect: what were the research results?
E Relevance: do they apply to the potential recipients of
the preventive intervention [12]?
The level of evidence indicates the validity of evalua-
tive research and takes into account the design of the
study, its potential for eliminating bias, and the methods
and analysis used [13]. An example of a classification of
the level of evidence based on study design is presented in
table 1.
As an illustration, we will apply the three above-men-

studies with historical control
IV Evidence obtained from case series
Excluded Evidence from expert opinion and
consensus of an expert committee
Source: [14].
The size of the effect has been expressed variously as
rates of retention of sealants over time or statistically sig-
nificant reductions in dental caries increment. Other
research has highlighted the intriguing potential for seal-
ants to prevent caries on adjacent non-sealed surfaces,
indicating that the effect may be larger than the pre-
vention of dental caries on sealed pit and fissure surfaces
[15]. However, there were more studies on the retention
of sealants than on caries increment, raising questions on
the appropriateness and relevance of outcomes. Reten-
tion is not the same as caries prevention [16].
In this example, it should be pointed out that different
studies may have used different measures of effect. Clear-
ly, only studies using the same measures are comparable.
It must be decided if studies using different measures will
be grouped together or if the type of effect measurement
will be a criterion for including the study in the evidence-
base or excluding it. Furthermore, the quality of individu-
al studies can vary even within a single level of evidence,
according to the study design; to address this potential
drawback, a quality score can be given to each study based
on methodological features like randomization, blinding,
and retention of subjects. Since this is a subjective judg-
ment, most systematic reviews are based on quality scores
given by two or more individuals. The level of agreement

dence to individuals, absolute benefits in target popula-
tions are predicted, and it is decided whether predicted
benefits outweigh any predicted harm.
While some guides to synthesis and decision-making
end here, the evidence-based approach to the prevention
of oral diseases includes a number of other important
issues, such as considerations of efficiency, public percep-
tions and side effects. Efficiency is determined by the rela-
tionship between the resources used and the outcome; it
includes economic analyses such as cost-effectiveness or
cost-benefit analyses. These techniques are also important
aspects of the evidence-base for prevention [17]. Percep-
tions of the public and side effects are covered briefly in
later sections.
Implementation, Monitoring and Reassessment
Once a decision on the appropriate oral health pre-
ventive intervention has been made, based either on a sys-
Evidence-Based Approach to Oral Disease
Prevention
Med Princ Pract 2003;12(suppl 1):3–11
9
tematic review of randomized clinical trials or an assess-
ment of observational studies, the intervention is imple-
mented. The last stage of the evidence loop is the monitor-
ing of patients or population groups and the reassessment
of the value and necessity of continuing the intervention.
While the importance of this final stage is readily ac-
knowledged, all too frequently resources and energy are
expended on the intervention and little effort goes into
monitoring the outcome. Without this reassessment at the

unknown. Instead, evidence on water fluoridation is gen-
erally derived from observational studies of discrete geo-
graphic areas with and without fluoridation, before and
after the water fluoridation was introduced. While these
designs may have been the most feasible, acceptable and
appropriate [21], they are considered to be at a lower level
in the evidence hierarchy [22]. The issue that emerges is
how to view a preventive measure where there is a large
number of studies which are all individually at a lower
level of evidence. A recent report argued that because of
the number of studies, the level of evidence should be
regarded as higher than that indicated by their study
design alone [23].
Another interesting evidence issue illustrated by the
case of water fluoridation is the public’s perception of the
intervention. An intervention will only be implemented if
there is general public support for its application. Despite
the successful implementation of water fluoridation pro-
grams in many countries, the public still does not know
much about it and expresses occasional concern about its
safety, while a sizeable minority of the population may be
undecided or opposed to it [24, 25]. Therefore, public per-
ception may assist or impede the implementation of an
evidenced-based preventive intervention, ultimately de-
termining whether the community will benefit from the
measure.
Evidence Issues in Oral Health Promotion
Health promotion programs which aim to improve
oral health often promote a mix of interventions, or a
‘portfolio’ [19]. These may be effective, but they do not fit

ing a portfolio or mix of interventions for oral health pro-
motion has recently been proposed as part of health pro-
motion planning and practice improvement [19]. Unlike
the approaches required for scientific, quantitative evi-
dence, such frameworks hope to ensure that the best avail-
able evidence, knowledge and expertise are brought to
bear on the problem at hand and that the portfolio ensures
a comprehensive approach to addressing the problem.
The distinct steps of the portfolio approach are:
E convene a decision-making group;
E specify the issue to be addressed;
E agree to the criteria against which to judge interven-
tions;
E weigh the criteria to be used to evaluate options;
E brainstorm a long-list of interventions likely to fulfil
the criteria;
E specify a short-list of interventions for more detailed
evaluation;
E evaluate the short-listed interventions against the
weighted criteria;
E score and prioritise the interventions;
E reflect on the outcomes of the exercise and refine if
necessary [19].
While such an approach uses the best evidence avail-
able, the disadvantages of these portfolios of interven-
tions are that they can never disentangle their component
effects, or might not be open to falsification.
Conclusion
Although the evidence-based approach is 30 years old,
just what it means, whether it is feasible, how to conduct it

appraisal, the evidence loop is completed by implementa-
tion, monitoring and reassessment. Too frequently an
intervention for which evidence has been found beneficial
is inadequately reassessed over time in target patients or
populations, but without reassessment it is difficult to
determine the value and necessity of maintaining a given
intervention. All of the stages of the evidence-based
approach are very important and taken together, they
offer a rational way forward to improve oral health and
dental care.
Acknowledgement
This paper is based on a presentation at the 7th World Congress
on Preventive Dentistry April 24–27, 2001, Beijing, China.
Evidence-Based Approach to Oral Disease
Prevention
Med Princ Pract 2003;12(suppl 1):3–11
11
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26 Jones CM, Tinanoff N, Edelstein BL, Schnei-
der DA, DeBerry-Summer B, Kanda MB, Bro-
cato RJ, Blum-Kemelar D, Mitchell P: Creat-
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low-income children. J Public Health Dent
2000;60:193–196.
27 Tinanoff N, Palmer CA: Dietary determinants
of dental caries and dietary recommendations
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Evidence Based Practice in Dentistry
Kuwait, October 2–4, 2001
Med Princ Pract 2003;12(suppl 1):12–21
DOI: 10.1159/000069841
Preventive (Evidence-Based) Approach
to Quality General Dental Care
Richard J. Elderton
University of Bristol, Bristol, UK
Richard J. Elderton, BDS, LDS RCS (Eng), PHD (Lond)
Visiting Professor of Preventive and Restorative Dentistry
University of Bristol, 83 Bell Barn Road
Stoke Bishop Bristol BS9 2DF (UK)
Tel./Fax +44 117 968 6234, E-Mail
ABC
Fax + 41 61 306 12 34

of each and every caries or periodontal lesion, with a
view to implementing specific preventive measures and
allowing the natural arrest of disease processes to occur.
The universal adoption of a preventive (evidence-based)
approach to making dental treatment decisions could be
by far the most powerful factor in reducing the restora-
tive burden of dental services. It is clear that dental edu-
cation and practice need to rise proactively to the chal-
lenge, or changes will be forced upon them while they
are in a defensive position. There is a need to move
wholeheartedly and contentedly into the preventive era.
Copyright © 2003 S. Karger AG, Basel
Introduction
Traditional restorative dentistry has had a strong in-
fluence on dental education and practice in many parts of
the world, and invasive restorative treatment has tended
to take precedence over non-invasive preventive mea-
sures. It appears that many dentists erroneously presume
that dental caries can be ‘treated away’ with restorations
and that periodontal diseases can also be ‘treated away’ by
regular scalings. Indeed, many dentists seem to believe
that traditional dental treatment automatically results in
oral health [1].
Dental caries and periodontal diseases, both bacterial
in nature, are largely preventable from the start. But they
are not always prevented; rather, the forces leading to the
diseases are allowed to remain out of balance with those
that lead to health. The situation prevails today whereby
the scientific basis of these diseases has largely been estab-
lished [2, 3], but the services providing appropriate dental

routines, social habits, and personal whims and fancies.
Consider the patient who has an active class II carious
lesion that has extended well into the dentine. Most clini-
cians would agree that when this stage of caries develop-
ment has been reached, it is necessary to excise the dis-
eased tissue and make good the defect with a restoration
[5]. But that is just one phase. It is also necessary to bring
about a change in the environment of the tooth and of the
rest of the dentition so as to prevent further caries, includ-
ing the development of new primary carious lesions [6].
Thus, proper caries management is all about identifying
the main aetiological factors, and selecting and targeting
specific efficacious preventive measures to help overcome
specific imbalances. It is also about causing patients to
make relevant adjustments, in a highly focused manner,
to their dietary patterns, oral hygiene habits and fluoride
(and chlorhexidine, xylitol, etc.) usage as appropriate. Fis-
sure sealants may also be necessary. The whole process
will need monitoring and perhaps fine-tuning over time
[7].
So, in addressing the question ‘How should the profes-
sion be managing caries?’ the answer has to be by estab-
lishing regimens with patients, such that the diseases are
arrested and prevented from recurring through environ-
mental and lifestyle measures (though backed up by pro-
cedures to restore form and function where appropriate).
It is essential that the regimens advised are tailored to the
individual, and that they are sympathetic to the individu-
al’s environmental and lifestyle characteristics.
Caries prevention works, so once a preventive philoso-

ment is to arrest attachment loss and cause a reduction in
pocket depth; indeed, the aim is normal-looking gingival
tissue with pocketing no greater than about 4 mm which
does not bleed or discharge pus on probing. The treatment
should take the form of effective daily oral hygiene carried
out by the patient, plus professional scaling and removal
of noxious elements in the periodontal pockets, including
the removal of the complex subgingival mass of bacteria
which may be adhering to the root surfaces. Other treat-
ment, such as the reshaping of restorations, may also be
necessary. As with caries, the prevention phase is critical.
However, whatever the patient does, plaque may return to
the deeper parts of the gingival crevice, so ongoing profes-
sional care may be needed at specific sites.
14
Med Princ Pract 2003;12(suppl 1):12–21
Elderton
It is necessary to ask, and where necessary address in
depth, some questions regarding the treatment and pre-
vention of destructive periodontal disease. For example:
(a) How well does the patient remove visible plaque on
an ongoing basis?
(b) Is the patient still using the non-favoured ‘roll’ tech-
nique of brushing as opposed to a method involving clean-
ing of the gingival crevice?
(c) Has the dentist or hygienist effectively taught the
patient a realistic method of plaque control, tailored to his
or her individual needs?
(d) Has the dentist unwittingly implied that multiple
daily toothbrushings are desirable or indeed a panacea for

outcome. And if the patient is a tobacco smoker, then
attempting to convince him or her to quit the habit should
be seen as an important component of the preventive den-
tal package, since smoking has a markedly adverse effect
upon periodontal inflammation and healing [16].
Dental professionals should appreciate that giving pre-
ventive advice in the form of oral hygiene instruction is
not of itself a preventive measure. The preventive mea-
sure succeeds when the patient actually achieves excellent
daily oral hygiene; it is this latter which must be the objec-
tive.
Why the Problem?
Why does evidence-based quality general dental care
constitute a challenge to the profession? Surely it should
naturally form the basis of all dentistry, shouldn’t it? After
all, dentists are professionals, and professionals should,
by definition, avow to offer the best for their patients. The
old adage ‘Prevention is better than cure’ is well known,
but if dental diseases do occur, it is important to treat
them as non-invasively as possible. Ask the World Health
Organization or any health minister whether or not it is
better to have diseases such as polio, yellow fever, cholera
or AIDS in a community or to prevent their occurrence.
The answer does not need stating, so why do large seg-
ments of the dental profession appear to ‘accept’, as if it
were inevitable, the occurrence of avoidable dental dis-
eases such as dental caries and periodontal diseases?
What has contributed enormously to the present pro-
file of traditional dentistry, including the teaching in den-
tal schools, has been the widespread dissemination of

the amount of operative treatment the patients received
over a 5-year period related very much to their dental
office attendance patterns and to the number of teeth
which already contained restorations [20]. Indeed, it was
found that the average number of tooth surfaces restored
during any one course of treatment was approximately the
same on average, regardless of the frequency of the
courses. Thus the patients who went to the dentist more
frequently received more restorations per unit of time (al-
most in direct proportion to the number of courses of
treatment received). Further, the proportion of restora-
tions that were replacements increased markedly as the
total number of restorations present increased.
Somewhat inevitably, therefore, it was found that the
more restorations a patient had, the more the patient was
likely to receive. And the people who received the most
restorations tended to be relatively well educated and con-
ditioned to visiting their dentists regularly. Overall, it was
found that 50% of restorations were placed in the teeth of
just 12% of the population. This 12% therefore represents
a group at high risk of receiving yet more restorations;
after all, they had their restorations examined more fre-
quently than those who attended more rarely, so the
chances of a morphologically defective restoration being
targeted for replacement were greater in these individuals.
Certainly it cannot be assumed that dentistry, as widely
practised, is necessarily good for the teeth. The corre-
sponding figures for other countries may differ somewhat
from those given above, but it is likely that equivalent
scenarios are found elsewhere.

The use of outdated concepts of cavity design (perpetuating Black-type cavities involving excessive cutting of sound tooth substance)
is commonplace [30, 31]
and
Dentists fail to appreciate the exacting nature of restorative procedures.
y
16
Med Princ Pract 2003;12(suppl 1):12–21
Elderton
Table 1
(continued)
It is no surprise therefore that
Restorations of mediocre quality are readily placed [30, 31].
Sadly
These restorations often contain characteristics consistent with inbuilt obsolescence.
In addition
Bur damage, for example, is imparted commonly to the adjacent tooth [32]
and
Non-physiological approximal contours frequently lead to plaque accumulation and periodontal disease.
y
In due course the patient is recalled but
Recall assessments of restorations tend to be idiosyncratic [33].
Thus, for example,
Ditched margins are commonly assumed to signal failure of the restoration [5, 30]
and
Existing restorations are readily deemed to have failed [20, 34], particularly if the patient has just changed from a previous dentist [35].
However
The matter of why restorations have failed is not questioned by the dentist or patient.
y
Nevertheless
Restorations are readily cut out and replaced

Crowning may be effected as a ‘cure-all’ procedure.
However
The crown fails to properly fit the margins of the prepared tooth
and, if visible,
The crown looks artificial.
y
Quality General Dental Care
Med Princ Pract 2003;12(suppl 1):12–21
17
Table 1
(continued)
Inevitably
Plaque stagnation, halitosis and periodontal disease (and perhaps caries also) increase.
y
In due course
The need or perceived need for endodontic treatment arises.
y
However
Root canal preparation is often inadequate
and
Root canal obturation is often incomplete, leaving a nidus for continuing bacterial proliferation.
y
Not surprisingly
Periapical seepage of bacterial toxins occurs
so
The periapical lesion persists.
y
This may lead to
Apicectomy and retrograde root filling taking place, though without first making the root canal filling adequate.
y

y
Next
An abutment tooth fails and is extracted
so
A larger bridge is made involving more teeth.
y
18
Med Princ Pract 2003;12(suppl 1):12–21
Elderton
Table 1
(continued)
Because the bridge morphology is compromised
Plaque accumulates and periodontal disease increases.
y
Indeed, from the very beginning, the following almost ubiquitous and vain scaling scenario is likely:
Each scaling results in clean teeth for a day
but
Bacterial plaque then returns, engendering further periodontal disease.
However
The periodontal disease is not properly evaluated or documented.
Indeed
The periodontal disease is not prevented or treated.
Instead
Further scaling takes place, leading to clean teeth for another day.
But inevitably
Bacterial plaque returns to continue the disease process
and
Irreversible alveolar bone loss is liable to take place as periodontitis takes a hold.
At the same time
Halitosis becomes a real issue for the patient

and
He/she loses any zest for quality care.
Sadly
Burn-out rather readily sets in and the dentist spirals downwards [43].
y
This inevitably means that
Any hope of quality dental care is gone forever.
Quality General Dental Care
Med Princ Pract 2003;12(suppl 1):12–21
19
The Repeat Restoration Cycle
Research over the last 20 years or so has made it possi-
ble to assemble a model of the potential chain of events
that embraces many shortcomings of traditional restora-
tive treatment, namely the repeat restoration cycle. This
potential chain of events is given in table 1. The contents
of this table form an integral part of the text of this paper
and should be read at this stage.
The repeat restoration cycle is driven by a culture of
drill-related dentistry. Thus, many dentists have an urge
to place and replace restorations, apparently feeling ‘com-
fortable’ when they intervene invasively [8, 20, 42]. Fur-
ther, there is an apparent disregard for the inevitable
weakening of the teeth in the process, especially as the res-
torations are placed and replaced over the years. After all,
by virtue of the repeat restoration cycle, it is inescapable
that restorations are often not very durable (many surviv-
ing only for a few years) [44–49]. And, of course, restora-
tions do not cure caries anyway.
The characteristics of the repeat restoration cycle are

required in dental education [50].
By referring to restorations as ‘treatment’, the profes-
sion has drifted hopelessly away from evidence-based
dentistry [6]. Yet the profession is steeped in the use of the
term when often no treatment is in fact provided, just res-
torations that readily lock the patient into the repeat res-
toration cycle, each restoration being less prophylactic
and more iatrogenic than the one before. Thus, to the
patient who asks ‘Do I need any treatment?’ it is a very
naive dentist who replies, ‘Yes, two fillings.’ A more
appropriate reply might begin along the lines of, ‘Yes, you
have two carious lesions, so we need to set about altering
the nature of the chemical processes going on in your
mouth in order to cause the lesions to arrest ’
With the public’s increasing awareness of the short-
comings of traditional restorative dentistry and, at the
same time, a heightened understanding of the possibilities
for prevention, patients can be expected more and more
to demand preventive ‘quality’ dental care. Indeed, it
seems that the supply-and-demand forces of the market-
place will reinforce the scientific argument and put in-
creasing pressure upon dentists to adopt a more pre-
ventive approach to the management of caries, defective
restorations and periodontal diseases. Then the patient
who attends regularly will become less ready to accept an
apparently unending commitment to restorations and
re-restorations, with scales and polishes thrown in from
time to time.
As caring professionals, dentists should stop pretend-
ing that operative treatment is necessarily rational. Pre-

Standard, invasive dental treatments such as restora-
tions and scaling are in general not an effective way to
manage dental caries and periodontal diseases. Much
more emphasis should be placed upon the assessment of
each and every carious and periodontal lesion with a view
to allowing a possible natural arrest of the processes to
occur, aided by specific preventive measures as appro-
priate. Existing restorations should not necessarily be
replaced just because there is a moderate degree of mar-
ginal breakdown. In view of the adverse potential of the
repeat restoration cycle, the withholding of restorative
treatment when appropriate may itself be considered a
prime preventive measure. Indeed, the universal adop-
tion of a preventive, evidence-based approach to treat-
ment decisions could be by far the most powerful factor in
reducing the restorative burden of dental practice.
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