The Problem with Traditional Dentistry

By: Dr. Matt Nejad Dec 10, 2021

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In 2005, 166 million dental restorations were placed just in the United States¹. Clinical studies suggest that more than half were replacements for failed restorations.²

Replacement of failed restorations accounts for nearly 70% of all restorative dentistry² and the emphasis on replacement therapy is expected to increase as concern about mercury release from dental amalgam forces dentists to select alternative materials.

Today, more and more patients expect to keep their teeth for life, and that is a reasonable health expectation. There has been considerable progress over the years, with patients retaining teeth for longer throughout life. From the latest figures, 48% of adults aged 20-64 have no loss of permanent teeth³. Unfortunately, the traditional treatment approach has fundamental shortcomings which are in direct conflict with the goal of teeth retention for life. Despite advancements in technology and techniques to restore teeth conservatively, most patients still receive traditional dental procedures which are prone to repeat complications and failures. This traditional treatment cycle, known as the “tooth cycle of death”, ultimately results in loss of teeth. A biomimetic treatment approach overcomes these problems and contributes to the maintenance and retention of teeth for life.

Objectives for Ideal Restorative Dentistry

The first goal of dentistry should be to avoid the need for restorative intervention. However, once restorative treatment is necessary, the ideal treatment approach must:

• preserve maximum tooth structure
• restore the structural integrity of the tooth
• maximize the long-term survival of restored teeth
• minimize the necessity for replacement restorations

These objectives are the key to retaining teeth for life and preventing the tooth cycle of death. Minimally invasive, tooth-preserving restorations are crucial. Many studies have shown that there is a direct correlation between residual coronal structure and tooth survival, therefore, the less coronal dentin and enamel is removed, the higher the survival rate of restored teeth^4,5.

What is the problem with traditional dentistry and the traditional approach?

Traditional dentistry does not adequately meet the objectives for ideal restorative dentistry. In the traditional approach, when a tooth is restored, healthy, intact tooth structure is removed for a variety of reasons including extension for prevention, preparation design, and reduction requirements for adequate material thickness. This approach does not prioritize tooth preservation or the structural integrity of restored teeth. As a result, failures are anticipated to occur periodically, requiring further treatment. Replacement of restorations leads to further removal of tooth structure, compounding the problem and leading to unrestorable teeth and loss of teeth.

Traditional dental procedures and techniques rely on a nonbonded restorative approach, and this is the source of the problem. Today, science supports the many significant advantages of using bonded restorations (direct and indirect) to restore teeth, however, adhesion to tooth structure wasn’t originally possible when traditional dental procedures were introduced.

Traditional dentistry does not preserve tooth structure

When a tooth is restored, healthy, intact tooth structure is removed for a variety of reasons including extension for prevention, preparation design, and reduction requirements for adequate material thickness. Replacement of restorations leads to further removal of tooth structure, compounding the problem and leading to unrestorable conditions and loss of teeth. Traditional dentistry and nonbonded restorations require removal of healthy, intact portions of teeth in order to accommodate the restorative materials and techniques. Nonbonded restorations require more tooth reduction to allow for adequate thickness and strength of the restorative material. As a result, a significant portion of healthy tooth structure must be removed, increasing the chance of complications (sensitivity, pain, cracks, fractures, and root canals). The necessity for mechanical retention and resistance form requires further removal of tooth structure. With a limited amount of total tooth structure available, traditional procedures make it exceedingly difficult to restore teeth throughout life as more tooth structure is lost.

Traditional dentistry requires Mechanical Retention

The natural tooth is an adhesively joined structure. Enamel and Dentin are joined by an extremely strong biological bond via the DEJ. The adhesion of these layers is a critical component of the natural tooth structure and properties. Mechanical retention is not sufficiently compatible with normal tooth function and physiology. Reliance on mechanical retention leads to more invasive treatments (crown preps & ferrule, root canals, posts & cores, pins). Mechanically retained restorations have an increased propensity for cracks and fractures, which frequently lead to root canals. When adequate mechanical retention is not achievable, the tooth is extracted and replaced with a dental implant.

Structural Integrity & Biomechanics are Not Adequately Restored

The structural integrity and biomechanics of intact teeth are not adequately restored with nonbonded traditional restorations. The natural tooth works as a whole system, with the optimal balance of strength, flexibility, and durability arising from its structural components (enamel and dentin) and the strong adhesive interface (DEJ). When tooth structure is removed, the stiffness of teeth is significantly reduced, and the biomechanics of the tooth is significantly compromised. Teeth restored with traditional restorations such as silver fillings do not recover these properties, and so the restored teeth are structurally compromised and will experience higher incidence of cracks, fractures, split teeth, and other complications.

Weak Tooth-Restoration Interface

Nonbonded restorations do not achieve a high-bond strength or seal to tooth structure. During function, stress concentration occurs at the tooth-restoration interface, leading to symptoms and complications including: sensitivity, pain, cracks, recurrent caries, fractures, and ultimately root canal treatment when symptoms can not be effectively managed. Strong adhesion to tooth structure would improve the biomechanics of restored teeth and prevent sensitivity and leakage from a strong adhesive seal.

Traditional dentistry uses invasive treatments that do not maintain the structural integrity of the tooth, kickstarting the “tooth cycle of death”. Biomimetic dentistry focuses on using natural materials that are more closely related to the tooth’s natural composition for long-term.

References:

1. Beazoglou, T., S. Eklund, D. Heffley, J. Meiers, L. J. Brown, and H. Bailit. Economic impact of regulating the use of amalgam restorations. Public Health Rep. 122:657–663, 2007.
2. Spencer P, Ye Q, Park J, et al. Adhesive/Dentin Interface: The Weak Link in the Composite Restoration. Ann Biomed Eng. 2010;38(6):1989-2003.
3. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011–2012. NCHS data brief, no 197.Hyattsville, MD: National Center for Health Statistics. 2015.
4. Carvalho MA de, Lazari PC, Gresnigt M, Del Bel Cury AA, Magne P. Current options concerning the endodontically-treated teeth restoration with the adhesive approach. Braz oral res. 2018;32(suppl 1).
5. Patel DK, Burke FJ. Fractures of posterior teeth: a review and analysis of associated factors. Prim Dent Care. 1995.Mar;2(1):6-10.