Aspects of Treatment of Cavities and of Caries Disease
One has to differentiate between treatment of cavities and treatment of the disease process resulting in cavities. The normal treatment of a tooth with a cavity is a filling or, if the cavity is large, a crown. Large cavities may involve "root-fillings" or even extraction of the tooth. A variety of materials are used globally: composites, amalgam, gold, porcelain, and others. Options for replacing extracted teeth include removable prostheses, fixed bridges, or implants. The more complex treatments are costly, and no country has been able to afford to introduce systems in which all dental costs are covered by public funds. Moreover, a filling does not affect the disease process causing the cavities. Treatment must be directed against the causative factors (described earlier). For the individual case, several options are available in addition to the various fluoride programs mentioned: dietary counseling, sugar substitutes, antimicrobial agents to reduce plaque and specific bacteria, and the use of saliva-stimulating products.
In many developing countries, the lack of dental manpower means that carious teeth remain untreated. The ratio of dentists to population is particularly unfavorable in the African region compared with Western European countries. For instance, according to CAPP, the ratio is 1 to 1.2 million in Ethiopia, 1 to 225,000 in Mali, and 1 to 166,000 in Zambia, against about 1 to 1,000 in Scandinavian countries and 1 to 2,100 in the United Kingdom (see http://www.whocollab.od.mah.se/index.html). In India, the ratio is 1 to 27,000 in the urban areas but 1 to 300,000 in the rural areas (Shah 2001). Such ratios mean that neither dental caries disease nor the cavities will receive proper attention.
After taking into consideration the high costs for dental treatment and the lack of dentists, atraumatic restorative treatment (ART) was introduced. This approach requires only hand instruments rather than sophisticated electric dental drills, and trained dental auxiliaries can deliver ART. The public dental health services in South Africa adopted the approach as an appropriate and economic means of providing basic restorative care in certain communities. A randomized clinical trial conducted in Tanzania showed no statistically significant differences between the retention of occlusal amalgam (74 percent) and ART occlusal restorations (67 percent) after a six-year follow-up (1992-98) (Mandari, Frencken, and Van't Hof 2003). A potentially affordable treatment procedure that could prevent untreated carious teeth from being extracted, ART may have relevance to some middle-income countries, although the method is not realistic for most low-income countries, where sustainability of such programs would be low.
