Oral health is an integral part of the overall health of children.
Dental caries is a common disease in children, which can have significant
consequences (1). The concept of minimally invasive dentistry,
increasingly applied to the caries treatment, includes a modified surgical
approach and smaller tooth preparations based, as far as possible, on
individual caries risk assessment (2). This concept has been
insufficiently known in Russia. During Soviet time, necessity and
possibility to spare dental tissue were undervalued. The motto of Soviet
health care was priority of prophylaxis, realized in children by medical
checkups in kindergartens and schools (so-called dispensarization) (3). As
for dental care, initial and sometimes questionable caries lesions were
treated by dry cutting, often with dull rotary instruments, which led to
excessive removal of dental tissues. Explorer fixation in a pit or fissure
(‘stickiness’), enamel surface roughening and discoloration were used as
diagnostic criteria for caries. Today, probing of suspected lesions with
checking the stickiness is regarded obsolete, since it achieves no gain of
sensitivity and might cause damage (4-6). Discolouration (black or brown)
has not been shown to improve diagnostic accuracy for caries (5).
Dentistry in the former Soviet Union has been united with oral
medicine under the designation “stomatology”. Some broadly used textbooks
of stomatology (7,8) were written by maxillofacial surgeons, while caries
and other purely dental topics were presented without discussion of modern
knowledge. Superficial caries was defined as a lesion limited to the
enamel without involvement of enamel-dentin junction (7,9,10). Mechanical
preparation and restoration were recommended as treatment for superficial
occlusal caries (9,11) or for superficial caries in general (7,10,12,13),
while this recommendation was sometimes stressed as “obligatory” (9).
Individual anatomic features of pits and fissures as a possible cause of
explorer stickiness (5) were not discussed in the handbooks and
monographs. Erosion as an entity to be distinguished from caries was
either not discussed at all or mentioned fluently without specifying
therapeutic consequences of such distinction. In some handbooks cutting-
and-filling was recommended as a treatment of choice also for large areas
of enamel pigmentation with an intact surface: “mechanical preparation of
hard dental tissues and filling can be performed without waiting for
cavity formation” (9). Accordingly, many “lesions”, treated by mechanical
preparation, were in fact anatomic variants of grooving, fissures and
pits, pigmented fissures, erosions etc. First restorations were placed on
average relatively early in childhood. Exploration with a probe was
habitually performed with application of excessive force, which could be
partly explained by the fact that “enamel softening” was presented in
handbooks as a diagnostic criterion of early caries (13). It is common
knowledge today that enamel demineralization and softening can be
reversible especially in children. Consent for the treatment during
dispensarizations was often not asked from children and adolescents (or
their parents). Understandably, the checkups and treatments were performed
under time pressure. All the above, together with poor quality of filling
materials, caused an early start and acceleration of the restoration/re-
restoration cycle (14) with rapid enlargement of the cavities: the
restorations failed, the cavities were further enlarged, which eventually
led to fractures and extractions. Indications for extensive prosthetics at
an age of 30 years or earlier have been not infrequent.
As for endodontic therapy, it can be seen on radiograms that quality
of root canal treatment was often inadequate, and sometimes only traces of
filling material are visible in the roots. Quality of treatment was
additionally impaired, especially in children, by limited availability of
effective anesthesia. Pulpitis treatment and endodontic manipulations were
usually performed without local anesthesia, after arsenic trioxide
devitalization of the pulp. Fear of the dentist, a real phobia in some
cases, prevented not only children but also adults from asking
professional help after failure of restorations or tooth fractures, when
restoration is indicated indeed; and the patients waited for their
pulpitis or periodontitis, which often ended up with an extraction.
Besides, one of the problems of Russian dentistry and medicine in general
has always been limited access to foreign literature, leading to partial
isolation from the state-of-the-art level (15). Review of Russian-language
dental journals from the last two decades showed that traditional approach
to the caries treatment (“extension for prevention”) has never been
seriously questioned. Caries overtreatment was not commented even in
articles dedicated to ethics in dentistry (16). Caries activity and risk
assessment for the purpose of treatment individualization has been rarely
discussed, and proposed criteria of caries activity - number of cavities
and devitalized teeth (17), are doubtful because participation of the
iatrogenic factor is difficult to evaluate retrospectively. It is known
from practice that accelerated restoration cycle can cause more rapid
tooth destruction than caries. The term ‘minimally-invasive dentistry’
appears only in singular Russian-language publications from the recent
years. Such articles are devoid of literature overview and are in fact
aimed at promotion of certain products (18).
Free medical insurance in Russia covers dental treatment (excerpt
prosthetics). However, some dentists at the state policlinics receive also
private patients, the border between a state policlinic and a private
praxis being thus effaced. The best way to improvement of dental care
should be propagation in dentistry of the same ethical principles as in
medicine in general: “dentistry for the patient” instead of the “dentistry
for the dentist” (19). Besides, economical re-routing of dental practices
is needed, so that they could survive using preventive and minimally-
invasive methods more extensively (20). It should be noted in conclusion
that controversies of caries treatment in Russia give rise to questions
that should be answered on the basis of scientific evidence: which dental
lesions, in children or in adults, must be treated by cutting and which
ones can be left for observation or non-invasive treatment? For this
purpose, comparative studies of patients treated by conventional and
minimally-invasive (or non-invasive) methods should be performed, with
maximally long follow-up time (optimally lifelong), to include into
statistics and evaluation all late failures of restorations. Evidence-
based research must be nonbiased and non-financially oriented (19).
Average deceleration of tooth decay (21) because of fluorides, better oral
hygiene and, probably, more conscious diets, is also an argument in favor
of lesser invasiveness of caries treatment. Besides, assessment of caries
activity for the purpose of treatment individualization remains an
important topic for research and practice. Apart from objective criteria
of caries activity (6), case history should also be taken into account
(5): if a patient does not notice over years any spontaneous tooth decay,
it can be considered as an argument in favor of lesser mechanical
preparation of his cavities after failed previous restorations. In other
words, patients (and children’s parents) should be involved in treatment
decisions in a meaningful way, with due consideration being given to their
needs, desires and abilities (22).
REFERENCES
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Preventive oral health intervention for pediatricians. Pediatrics
2008;122(6):1387-1394
2. Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. J Am
Dent Assoc 2003;134(1):87-95
3. Avraamova OG, Leont'ev VK. The prospects for the development of
prophylactic dental programs in Russia (a historical and situational
analysis) (in Russian) Stomatologiia (Mosk) 1998;77(2):11-18
4. Neuhaus KW, Ellwood R, Lussi A, Pitts NB. Traditional lesion
detection aids. Monogr Oral Sci. 2009;21:42-51
5. McComb D, Tam LE. Diagnosis of occlusal caries: Part I. Conventional
methods. J Can Dent Assoc. 2001 Sep;67(8):454-457
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detection. J Am Dent Assoc. 2006;137(12):1675-1684
7. Bazhanov NN. Stomatology (in Russian). Moscow: Meditsina; 1997
8. Bazhanov NN. Stomatology (in Russian). Moscow: Geotar-med; 2001
9. Lukinykh LM. Treatment and prevention of dental caries (in
Russian). Nizhny Novgorod: NGMA; 1998
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Moscow: Meditsina; 1991
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Stomatology. Handbook for practical training (in Russian). Moscow:
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approach to the treatment of dental caries. Klinicheskaya stomatologiia
2004;(1):10-13
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Russian). Klinicheskaya stomatologiia 2005;(1):24-27
19. Hochman RM. Minimally invasive dentistry. JADA 2006;137(3):296
20. Ericson D. The concept of minimally invasive dentistry. Dent
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health personnel: change or decay. Report of the WHO Expert Committee.
WHO, technical report series 794, Geneva, 1990
22. Krebs K.A. Response from the AAP. J Am Dent Assoc. 2005;
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Conflict of Interest:
None declared
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