Sir, with all this information on longevity and further interventions1, what should we answer when a patient asks 'how long will this last?

We can, of course, quote the published papers but shouldn't the real answer be 'I don't know how long my restorations last' unless the practitioner has undertaken a proper audit of this type of treatment. I also wonder how reliable and useful is the information given over in the above1 and preceding articles.

While recognising that the figures are drawn from actual treatments carried out – ie what practitioners did – we do not know why they did what they did and what their decision making process was. Secondly, how is this information to be used when there is a patient in the dental chair?

A look at Cochrane reviews will reveal that most relevant papers published in relation to the above or related topics are excluded because of bias or inadequate protocols.

With restoration failure, there is no universally applied standard. There are, then, two possibilities; if the restoration is replaced, it is considered to have failed or the restoration has failed when the decision to replace it was based on clearly defined guidelines.

The lack of controlled clinical trials shows the difficulties of carrying out these trials in practice and therefore, throws into question the motivation in the decisions made by the practitioners who carried out the treatments reported on in this paper.

There are several factors that contribute to prescribing patterns:

  • Undergraduate or postgraduate training

  • Time available for treatments

  • Financial pressures

  • Gender

  • Age

  • The environment the practitioner is working in be it general practice, hospital or academic.

All of these will influence, more or less, the choice or preference for treatment.

Daniel Kahneman, in his book Thinking, fast and slow2 writes: 'The extent of consistency is often a matter of concern' and mentions how experienced radiologists who evaluate chest x-rays as 'normal' or 'abnormal' contradict themselves some of the time when they see the picture on different occasions.

As human beings we are not as consistent or reliable as we would like to think. And how useful is this information?

With the patient sitting in the dental chair, the question that confronts the dentist is 'what do I do here?' The practitioner has to make a decision within the context of the patient. If the tooth were out of the mouth and held in the hand the 'best' way to bring it to form and function may be one type of treatment.

But, in the context of the mouth, modifying factors have to be taken into account and the option for 'best' treatment may be quite different.

The real challenge is for practitioners to be aware of all the treatment options and how and why they arrive at the option of choice and to be conscious of the question as to whose interests are being served in the provision of treatment. Is it the patient's or the dentist's? Hopefully, both!