Dear Niek ,

after discussion with my colleagues prosthesis (dental hospital), it appears that no special recommendation is followed in the situation you propose . For all patients , the elementary principles of hygiene and disposal of dental plaque and some tips on diet are given. Nothing more.

That's an interesting question, Niek.

Are you refering  to pre-fabricated crowns for children or crown/inlay restoration for adults?

Either way, as Gillet stated, it's essential that oral health is controled, for further teeth rehabilittion.

Best regards!

I am not referring to children, The Hall technique of course is especially for caries active kids.

Question is: would you make a crown in a high risk patient with a good oral health (some patients still have caries). Or the other way around: would you make a crown in a low risk patient with a moderate oral health.

Ok.

I think both - always controling oral health.

It's a very good question, but what choice do we have? 

There are many patients where we fail to control the cariogenic risk, I imagine that in Holland public health programs work very well, it seems that is not the reality of the rest of the world Prof. Opdam.

Also in the Netherlands we still have the high risk patients. And a new group is the elderly that become high risk due to medication, dry mouth and reduced selfcare.

In those patients we always tend to restore with direct restorations (composite in most cases, sometimes amalgam, sometimes GIC). 

Dear Niek,

In my experience in a university setting,  it is advocated that the patient has a good oral hygiene and that all caries is controlled in the mouth prior to commencing with 'advanced restorative dentistry'.

However, having said that it is a reality that in most dental practices, no  formal caries risk assessment is completed .A number of factors would play a role in the final decision-making and it would be interesting to have a global comparison .

I would avoid to insert indirectly restoration in case of low oral hygiene

Dear Niek,

Yes, I would  - as you know - recommend crowns/indirect restoration to caries active patients also. The quality of a restoration from start will influence longevity and if sufficient quality of a direct restoration is not possible, I would recommend an indirect. Of course all restoratinons will last shorter in caries risk patients and the patient has to accept the higher cost of the indirect but longer lasting restoration. 

Best greetings, Ulla   

The question almost answers itself. A patient presents with a high caries rate and a rather broken down dentitiion. The answer surely is to control the disease first by restoring all the lesions in a normal manner and controlling the disease. Once the disease is under control decisions can be made on which teeth should be crowned or inlayed and which spaces need to be restored with fixed C & B work. The patient is included in this discussion and decision making and is therefore encouraged to be part of the thinking on the decision. If they are not prepared to modify their dietary intake and hygiene routines  then the final decision on C&B can be delayed until such time as they become sufficiently knowledgeable and responsible to care for the relatively expensive rehabilitation. The final decision is always the patient's to make. 

I could not agree more with Dr. Mount. Besides, who can guarantee that, even after the patient reach what is considered a controlled disease status, for how long they are to remain like that...It is the dentist's responsibility to keep checking on the patient's oral health status. Unfortunately, good oral health is priority only for us dentists and professors.

I also like to supplement with another question.

Can you make a repair of a direct restoration amalgam or resin in a patient at high risk of caries?

I recently read an article that stated as a contraindication(,http://www.dovepress.com/getfile.php?fileID=22062) I'm really not sure

I think that is possible to place indirect restorations in patients with high risk of dental caries, but the control during time is very important in order to have success of therapy. 

I like the vision of Dr. Mount, which we also educate in the Netherlands. 

Regarding the repair in high risk patients: I think this is a very good indication. As your restoration turnover rate will be higher, repair will reduce the amount of tooth substance loss and higher risk for complications that is inevitably related to replacement. When you read the results of my clinical repair cases (JDent,2012) you will see that the prognosis of a repair in case of secondary caries has a higher survival then repairs due to fracture.

Dear Niek, In my opinion,

We tend to keep teeth with indirect restorations, even when the first appointment suggest a high carie risk ....but we have several steps before deciding. Especially, we spend time to explain hygiene (as you probably do also) and we often use a temporary crown to be able to follow hygiene improvements. We still fight ! I assume that your decision is also a public health decision no ?

In my opinion, I agree with Oliver. It is the most important to follow the patients in order to improve your hygiene improvements. 

In Children dentistry, we routinely practice Preformed Stainless Steel Crowns in high risk patients. Infact high risk is one of the indications for it.

My issue with placing a crown on a caries risk patient is we are not treating the disease but more the end point of the disease. As dental physicians we need to engage in patient centred care. There are may aids we can offer patients to motivate them to stop one of the most preventable diseases-dental caries. I concur with Oliver  temporary coronal full coverage is an option as the patient has ajourney to gain optimal oral health.

I agree wth Dr. Handbury. By placing crowns based only on high caries risk, we are overtreating. Caries risk changes with improved oral habits.Hhowever, in cases where multiple repairs would be indicated and still have a fair to not-so-good prognosis, I would prefer full coverage restorations. However, I speak only for pediatric patients. I routinely place sealants on the deciduous molars in high risk cases and move on to preformed crowns only if repeated visits do not show improved oral hygiene behaviour.

Diagnosis as to the etiology of the caries, and then oral disease control is the first step. If possible, the patient must be educated, brought to a level of understanding about the disease, and motivated to be engaged and take part in the treatment - "there's nothing a dentist can do that will overcome what the patient will not do." Included in this oral disease control phase may be interim restorations as a trial to see if the patient complies and can care for their dentition. Following this disease control phase the decision to place a crown vs a large restoration should be much clearer. My guide is if I cannot adequately isolate the tooth and place a matrix that will yield a well contoured and fitted direct restoration, then an indirect restoration (crown or inlay or onlay) is a better choice, because its contours can be controlled in the lab; and its fit in only dependent on me being able to isolate and make an impression of a well prepared margin on tooth structure. I have always believed that one of the indications for an indirect restoration is the inability to place a properly contoured matrix. Please feel free to contact me if this explanation is unclear.

My practice is in geriatric dentistry so lot of my patients are high caries risk patients. I definitely prefer a full crown better than a big indirect restoration, porcelain retain less biofilm than composites or even the enamel do. 25% of posterior class I and II indirect composite restorations fail during the first five years after placement, and failures increase in high caries risk patients. 

In my practice and in my university, we believe in full coverage porcelain crowns for patients with high caries risk for the simple reason, plaque formation is more on resins, then on enamel and pretty less on Porcelain.

We practice ceramic crowns for patients with high caries risk once the caries is stabilized till then glass ionomer restorations are better choice

In my privet practice in Damascus, tooth vitality determines the type of restoration:

vital tooth= no full crowns(either Amalgam or Composite).

non vital tooth with one or both marginal ridges lost: Full crown.

In my opinion every restoration has a service time, so why starting with the most destructive of tooth structure(full crown) whatever the patient's oral hygiene is.

Oral Hygiene commitment is a behavioral act by the patient which can be encouraged ,but not controlled, by the Dentist .  

I agree with Prof.Niek J M Opdam, and would complement if it would be necessary made a full crown, for esthetic reasons it would be necessary to certifie yourself that  the person is not at risk classification any more or at least in risk factors for caries were controled

High caries risk patient:

1) Stabilize disease.

2) GI restorations leach F+ hence preference

3) If e/c restoration warranted : Zirconium/metal are most plaque resistant followed by porcelain.

4) crown margins need to be equgingival or supragingival for maintenance 

5) crown lengthen to keep margins supragingival or remove the tooth

6) prescribe an F+ tpaste/rinse

Hope this helps. If you would like me to elaborate on any of the above points feel free to let me know

I agree with Prof.Niek J M Opdam, It is mainly based on primary teeth or permanent teeth and also maintains of oral hygiene.

In my practice I generally prefer direct restorations with composite in a very extensive range and I made very good experience with this. I do this, of course adhesive, but strictly under rubber dam technique. But I see also limits of this technique by the dimension of the defect, I think mostly limited by mechanical liability.

I make no difference in treatment by the caries frequency, but I make a difference in pre-treatment. A crown is of course no causal treatment of caries. Also the caries incidence is not stable at all, the dentist has the possibility to change it in more cases that most of us think.

On the other hand, if you say, you only place indirect restorations in patients with a stable mouth condition: nothing is stable! If the patient will have a stroke on the next day, what about his caries frequency?

A filling has in most cases a shorter lifetime than a crown, but I can also refill a tooth. A crown can get caries at the neck of the tooth, and I think, the risk of tooth loss is higher in this case.

It would be an interesting research, not to compare lifetime of fillings vs. crowns but lifetime of teeth treated with fillings vs. treated with crowns. I believe, the lifetime of teeth teated with fillings will be longer ( depending on the performance of the filling and also the performance of the crown).

Another approach of research could be: can the often cited "antibacterial" surface of ceramic really bring progress for the lifetime of a tooth or is it more a fig leaf for fail of prevention efforts? (Are there studies available?)

According to the question: My way to handle this is not the common way in Germany. It has changed, but still Germany makes a lot of - and I think too much - crowns. One reason may be, that fillings are still too less payed in our insurance systems, so there is an inducement for making crowns.

Best regards

Rudolf Ritt

Rudolf, I cannot more agree with you! you're hitting the nail in many ways:

- there is no such thing as a stable mouth, probably a more and less stable mouth, but looking into the future is difficult. What about: predicatble dentistry, often adressed by prosthodontists, is there any???

- It's all about the longevity of the denititon and no of the restoration. however, a good study design is difficult for this. Certainly it is impossible to do this with an RCT

- crowns and fillings, what makes the difference: the money and the skills, nobody vcan tell what restoration is better for the oral health of the patient.....

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