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Updates In Direct DentistryPart 2 Montreal Program

Lou Graham DDS University Dental Professionals

Catapult Group Memberlgrahamdds@aol.com

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Age/Health related dentistryConservative/Tooth preserving ideologyA periodontal/restorative approach with state of the art periodontal therapiesHygiene based growthDiagnostic tools that enable my team to follow the philosophyPrevention at every age

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Imagine your hygienist looking at:OcclusionMobilityFremitusUsing articulating paperTooth SleuthsWith Loupes (mandatory)CariVuSpectraDigital x-rays

Either 50 or 60 minutes routinely….building Value

Build Relationship

Establish Credibility

Clinical Screenings

Share Findings

Dr. Exam

Oral Hygiene

Instrumentation

Create Value

Hand-Off

Op Break Down

The key is allowing the hygienist enough time to be a total oral care provider

Build Relationship

Establish Credibility

Clinical Screenings

Share Findings

Dr. Exam

Oral Hygiene

Instrumentation

Create Value

Hand-Off

Op Break Down

30 minutes max

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History of fractured teeth

1 implant as a result of a non restored upper bicuspid

History of Root canals and crowns for fractured teeth

64 years old

Great hygiene

Wears a night guard….or so they say!

She has ready for me….

The history of what’s the patients CC

The necessary x-rays, and associated images

A tooth sleuth with her findings for CrackedToothSyndrome

Articulating paper

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Negative to percussion on 3 and 5 and vaguely positive on 4Tooth sleuth was negative on all (CTS?)Occlusion showed balancing interference on 4 and deep CR contactsNo probings in the area beyond 3’sDecay on distal of 4

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Tell me, and I will forget.

Show me, and I will remember.

Involve me, and I will understand.

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Intra Oral Camera Digital X-ray TransilluminationFluorescence

A study of the United States Department of Labor showed that 83% of all human learning is done

visually whereas only 11% is done through hearing.

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It was found that people retain over 6 times more information when it is presented visually compared

to just verbally

A study conducted by the

Wharton School of Business on the subject of Sales Presentation

revealed that audiences found visual presentations about

70% more persuasive.

It has been suggested that the majority of all plans that go untreated are a direct result of the patient’s lack of

understanding.

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3 Air Techniques Polaris intra oral camera and 3 Spectra Fluorescence

Dexis Digital…replaced my last system that was 6 years old and now 2 Dexis CariVu

Shofu’s new digital camera, Eye Special 2…easiest and best in my hands yet to date, replaced Canon 20D and Canon 11G

Velscope and 1 NOMAD

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Traditional Decay ModelTraditional Decay Model

Caries attack begins in the enamel with demineralization and cavitation. Easily diagnosed

visually, sharp explorer and radiographs.

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New Model for DecayNew Model for Decay

Enamel does not cavitate because of protection from fluoride. Caries begins in dentin through fissures, pits, fractures, and enamel pores. Difficult to diagnose with

traditional methods.

The role of genetics?

30- 35 %

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Multi- factorial disease

Genetics, diet, medication, oral hygiene, stress

Many strains of bacteria (over 40) contribute to the disease.

Bacterial theory is changing!

Trends Micrl. Solving the etiology of dental caries.Simón-Soro A1, Mira A2.Author information

Abstract

For decades, the sugar-fermenting, acidogenic species Streptococcus mutans has been considered the main causative agent of dental caries and most diagnostic and therapeutic strategies have been targeted toward this microorganism. However, recent DNA- and RNA-based studies from carious lesions have uncovered an extraordinarily diverse ecosystem where S. mutans accounts only a tiny fraction of the bacterial community.

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PLoS One. 2012;7(10):e47722. doi: 10.1371/journal.pone.0047722. Epub 2012 Oct 16.

Beyond Streptococcus mutans: dental caries onset linked to multiple species by 16S rRNA community analysis.

Gross EL1, Beall CJ, Kutsch SR, Firestone ND

Streptococcus mutans was the dominant species in many, but not all, subjects with caries. Elevated levels of S. salivarius, S. sobrinus, and S. parasanguinis were also associated with caries, especially in subjects with no or low levels of S. mutans, suggesting these species are alternative pathogens, and that multiple species may need to be

targeted for interventions. Veillonella, which metabolizes lactate, was associated with caries and was highly correlated with total acid producing species.

This study evaluated 1341 lesions that were described as:• Having roughness• Surface opacity

• Not detectable on x-ray

• No cavitation

• Staining

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The study concluded:

For questionable lesions the recommended course of action was simple follow up. This is the same model in Scandinavia where they follow non cavitated lesions with no visible evidence on x-ray

An explorer….a probe….traditional x-rays

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Transference of infective S mutans to other sites?

52% sensitivity / low reliability

False positives & false negatives

Disrupts intact surface layer, eliminating potential for reversal

Loesche et al, J Dent Res 1979Hujoel et al, Caries Res 1995

Lussi, Caries Res 1991

Al-Sehaibany showed tug back by an explorer was only 24% diagnostic, meaning that 76% of the time that tug back was present, there was no caries!

Ekstrand showed that a sharp explorer tip can damage an early de-mineralized white spot lesion of the enamel by cavitating the surface

.

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40-60% demineralization required to produce an image to evaluate

Underestimate size or depth

Insufficient to determine activity level

Low sensitivity39% occlusal50% interproximal

Bader et al 2001

Visual diagnosis can be highly subjective, Kefley and Holt 1993

Treat or NO Treatment

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Francescut and Lussi found that with brown or black stains in fissures were

NOT a good indication to drill because 57% of these lesions

exhibited no caries or caries limited to the outer enamel……..so what about

the other 43%?

Steiner and colleagues (1998)found the dark brown and black stains to have the

highest incidence of caries into dentin and concluded there were no clear

guidelines as to management

Lesions with with light brown or yellow stains had 42% demineralization into the middle 1/3 of dentin

Lesions with an opaquelook had 27% caries into the same 1/3 of dentin

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About 2/3rds advocate surgical treatment once the dentin has reached the outer dentin 1/3rd (D1) and with the aid of an x-ray (yet Low Sensitivity)

The remainder teach treatment when decay is in the inner enamel (E2)

In Florida, doctors who are graduates from all around the US do the following: 60% treat E2 lesions and 40% treat D1

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How many times have you gone into a class 1 and thought it was shallow and “BOOM” your bur just

drops into a large cavity?

Or

Another example, you are removing an alloy or a composite in a class 1 and you see “Brown” as you

are approaching the interproximal?

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120° Tactile Switch Control

SpectraBlue LEDs

PolarisWhite LEDs

Ultrasonically Welded & Sealed Switch Bezels

USB Cable assembly

Centrally Located Controls

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The Spectra fluorescence camera have LEDs that emit high-energy

blue-violet light at 405nm onto the tooth surface.

This wavelength stimulates red porphyrins produced by caries-

related bacteria to emit red light, containing less energy.

Sound enamel, in contrast, sends outa green auto-fluorescence light.

“Doppler Radar” for Caries Detection

Analysis of Spectra images Color Scale and Diagnostic Value

BeginningEnamel Caries

E1

Deep Enamel CariesE2

Dentin CariesD1

Deep Dentin CariesD2-D4

Sound Enamel1.5 2.0 2.51.0 > 3.0

A Picture is Worth a Thousand Words

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Histological Clinical Analysis

Diss. Madani, 2004 Uni Jena

D0 – sound fissuresystem

Nomenclature of Dental Lesions

The vast majority of my initial exams for patients with no occlusal restorations and this will allow me to evaluate both occlusal and smooth surface areas:

For recall exams to follow any changes

For patients with low caries, patients under 30: This has become my adjunct to x-rays and for occlusal caries evaluation, do I really need an explorer for caries detection?

Evaluating caries removal during excavation…When do you stop drilling? And always….prior to any sealant placement!

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Prime and Bond Elect as the Bonding AgentSDR (Universal)

15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

HEMA-free/BPA-free No Phosphoric acid steps

Radiopacity = DentinCariostatic/Bioactivity

Acid NeutralizationFluoride RechargingAnti-Plaque Effect

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BeautiSealant PrimerPhosphonic monomer

Carboxylic monomerWater

Acetone

Catalyst

Others

BeautiSealant PasteMethacrylate monomer (UDMA、3G )

New fluoride charged S-PRG FillerCatalyst

Pigment

Others

Apply Primer and leave 5 sec.

Gentle air for 5 Sec. Apply Paste

Step 1 Step 2 Step 3 Step 4

Cure 10 seconds

Primed Enamel

Healthy Enamel

Etched Enamel

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The ability to monitor potential decay under sealants.

Clear sealant material allowing us to see underneath it

especially with fluorescent caries detection devices that is

highly filled, and transparent

Before sealing

After sealing

Six months after sealing

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Infared light…no radiation

Enamel appears transparent or light

Porous lesions appear darker by trapping and absorbing the light: these include cracks and caries

Video capture….live scans

Stored in Dexis, excellent for communication to patient and yes…to insurance companies

For Identifying decay pre-treatment, early lesions on smooth, occlusal, and proximal surfaces

For Identifying decay during treatment

For Identifying cracks, and to a certain level, the severity of the cracks

For monitoring lesions and saving within the software

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The vast majority of my initial exams for patients who do not have class 2 restorations: Utilized to compliment or substitute for x-rays for evaluation of class 2 lesions, evaluate older restorations for peripheral decay, evaluate for cracks, documentation.

For recall exams same as above

For patients with low caries, patients under 30: This has become my adjunct or replacement of x-rays and for those under 16, do I really need bite wings? In our practice, we use CariVu for these patients and a low dose panorex? Maybe alternate with bite wings?

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D0425If used instead of bite-wings our fee is $61

If used instead of one bite-wing our fee is

$32 which is our fee today for 1 periapicalor bite-wing

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33 year old mom of two

Low caries rate, or so we thought

Uses floss at Christmas for ornaments

Twice a year hygiene visits

Small breaking down class 1 restorations

Asymptomatic

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No question D1 caries

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ICON

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Three Year in vivo results

from the Charite’ Study.58th Congress of the European Organization for Caries Research (ORCA),

Lithuania July 2011

The consensus results revealed progression of 1/24 (5%) and 11/24 (46%) lesions in the test and in the control group, respectively .

Conclusion: For interproximal caries lesions extending radiographically around the enamel-dentin junction (E2, D1) resin infiltration in combination with self-applied non-invasive measures Is more efficacious in reducing lesion progression compared

with self applied non-invasive measures alone.

The study was made up of patients presenting with three proximal lesions.(E2-D1)

They were divided into three Groups; Infiltration, Sealing w bonding agent,

and placebo treatment.

After 2 years the patients were examined radiographically and the lesions were measured by an examiner blind to the treatments.

Results of Progression in %

Infiltration- 16% Sealing 35% Placebo 62%

•Icon provides an innovative, option for treatment of smooth surface and proximal carious lesions.•Instead of taking a “wait and see” approach, Icon can arrest the progress of early enamel lesions up to the first third of dentin – in one simple procedure, without unnecessary loss of healthy tooth structure!

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IS NOT radio-opaque due to the fact that the material would NOT infiltrate. The process takes about 20 minutes per tooth

Billing is 150-200$ and my pitch is…no drilling is best and we follow yearly on x-rays

47 research articles show far less caries after placement than NOT placing

Dam is highly recommended especially in lower posterior

If contacts are tight…orthodontic separator may be required prior to therapy

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Acid Etching for 2 minutesThen rinse and air dry

Rinse and Air dry, then…ICON DRY for 30

seconds, then air dry…keep wedge in throughout treatment

• Infiltration is applied…first for 3 minutes, flossed and light cured and then again

for 1 more minute

Interproximal sealant code is D2990

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