V. CONCLUSIONS AND RECOMMENDATIONS

The changing environment in which dentistry is being practiced will continue to have a dramatic impact on how dental amalgam is used and how its benefits are assessed. Declining dental caries rates in children and young adults indicate a need to reassess assumptions about the optimal approach to managing dental caries in the population. Historically, high rates of dental caries have led to a common view that caries attack was unavoidable and that, once a lesion was initiated, it would continue to increase in size if left untreated. The best long-term treatment was believed to be complete excision of carious tooth structure and adjacent sound tooth structure that might become carious in the future. The perception that there are "self-cleansing" areas of the teeth that do not predispose to carious attack was the rationale for extending cavity preparations beyond the extent of the carious lesion. This rationale was intuitive, however, and has proven to not be justified scientifically.

Effective preventive methods and the emergence of improved restorative materials permit a more conservative restorative approach and, generally, a wider spectrum of appropriate clinical choices than in the past. Although there is no single, ideal dental restorative material, certain materials offer advantages when used in specific clinical situations. For example, when minimal carious lesions occur in nonstress-bearing areas of posterior teeth, composite resins may be used as an alternative to dental amalgam, and they provide the advantage of preserving the maximum amount of sound tooth structure.

It is apparent that dentists will be treating patients with markedly varying oral health needs in the coming years. Some patients will present with rather low levels of dental caries that are not extensive in size. These patients will benefit from concerted prevention efforts and the use of smaller, nontraditional cavity preparations in posterior teeth, quite often employing newer dental restorative materials such as composite and glass ionomer cements.

Other patients will demonstrate higher levels and more extensive types of dental caries and/or many dental restorations that require replacement. Patients with extensive caries or in need of replacement restorations still will require aggressive preventive interventions but, generally, they will not be able to be managed as conservatively as patients with few, nonextensive caries. Restorations requiring replacement largely reflect the more destructive era of dental caries and the more extensive restorative approaches of the past. Once a large restoration has been placed, it cannot be replaced with a smaller one.

The qualitative value of a sound tooth versus a minimally restored tooth, a minimally restored tooth versus a moderately restored tooth, or a moderately restored tooth versus a totally rehabilitated tooth should not be overlooked. When dental caries are found in early stages or simply suspected, "wait and watch" is a rational alternative to definitive restoration, especially if patients can adopt more healthful practices and dentists can offer preventive interventions that may arrest early lesions.

The shift away from amalgam as the material of choice in many clinical situations has begun already and can be justified scientifically based on declining caries rates and the emergence of new and improved materials and methods. There continue to be, however, substantial oral health benefits that accrue to individuals and the population from the use of dental amalgam.

Based on a review of scientific evidence presented in this report, several broad recommendations can be made about the prevention and management of dental caries in the contemporary environment.

Recommendations for Research

The U.S. Public Health Service, as well as other Federal departments (the Department of Defense, the Department of Veteran Affairs), continues to sponsor and conduct research on dental amalgam and other restorative materials, and the National Institute of Dental Research Long-Range Research Plan for the Nineties points to areas of additional research interest in restorative materials. The following broad array of research recommendations was identified by the Ad Hoc Subcommittee on the Benefits of Dental Amalgam as important areas to pursue, based on a review of the relevant scientific literature conducted during development of this report.

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