@BrianNovy1. Brian B. Nový, DDS. FACD, FICD, FADI Director of Clinical Innovation, DentaQuest Institute

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1 @BrianNovy1 Brian B. Nový, DDS FACD, FICD, FADI Director of Clinical Innovation, DentaQuest Institute

2 In the interest of transparency This lecture IS NOT sponsored Previous lectures have been sponsored by: GC America, Solution Reach, Xlear CariFree, Air Techniques, Philips, Ivoclar, Triodent, Shofu, SDI, VOCO and GSK Faculty at LLUSD, Western University, HSDM with research funding from Oragenics and others above Director of Clinical Innovation, DentaQuest Institute Photos within this presentation were taken with my iphone, a Canon G6,or Shofu s Eye Special II. Some pictures were obtained from the internet. Images may have been altered for contrast, brightness, and gamma, but no other modifications have been made.

3 We re a think tank in the back and a dental office up front

4 Meet Derek

5 Derek s mouth kept me up at night I searched the literature for answers I expected to find an evidence based treatment for caries I discovered caries brings out the worst in some people

6 Caries Research has been published monthly* for over forty years Dentists have tried to eradicate this disease for more than one hundred years (or maybe they haven t) Caries is the most prevalent disease in the world S. mutans is the second most popular organism in the scientific literature!

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16 Dental Histology Textbook 1927

17 January 2015: In the presence of a biofilm, NaF application resulted in net demineralization In contrast, nhap treatment reduced demineralization... the presence of biofilm enhanced this effect. J Dent Res 2015, pgs. 1-7

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19 dentin remineralization can be achieved and could possibly be used in clinical treatment strategies. coronal lesions extending into dentin can be remineralized.

20 Outer enamel Outer dentin Inner enamel 99% 50% 82% 97% Inner dentin J Dent Res 80(5) 2001

21 Methods of Remineralization Improve the saliva Protect sound surfaces Alter demineralized surfaces Improve the plaque

22 Introducing Eddie:

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24 The technology with the most scientific evidence to support its clinical use is the remineralizing system utilizing casein phosphopeptide

25 Plaque Good plaque contains: ph raising Bacteria Calcium Phosphate Fluoride Protein

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27 8/26/13 5/4/15

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30 Enamel Fluoride: Fluoroapatite, calcium fluoride, and fluoride phosphate complexes. Typically concentrated at the enamel surface Additives Magnesium: Concentrations vary creating isolated pockets of inherent acid solubility Sodium, Chloride, & Lead: Uneven concentrations, little is known about their role in solubility except that high sodium concentrations result in unstable apatite

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33 Atomic enamel Ca P Ca Ca Ca Ca OH F Ca P P Ca Ca Ca Young RA. Biological apatite vs. hyrdoxyapatite at the atomic level. Clin Orthop 113:

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35 An Endemic Developmental Imperfection of the Teeth, Heretofore Unknown in the Literature of Dentistry

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38 Occlusal surfaces rarely show signs of caries from AD The diet of the population living during this period consisted of products containing more strontium than calcium... In the modern diet these proportions have been reversed.

39 There is a clear need for further research, especially on the mineral phases in the dental hard tissues, plaque, and plaque fluid associated with strontium as these may give rise to a better understanding of the subject matter.

40 How well do our therapies work? J Dent Res 88(2) 2009

41 Silver Diamine Fluoride

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43 Silver Diamine Fluoride + Potassium iodide SDF + KI = no black stain.?

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47 Silver Diamine Fluoride

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50 What I m supposed to say

51 What I m supposed to say

52 Only a minute fluoride concentration is needed to initiate and maintain the remineralization process.

53 Revisting Eddie:

54 Is it progressing? Is it arrested? Has it reached the dentin? Should it be restored? How would you chart the distal of #9?

55 Our classification systems are DYNAMIC!

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59 JADA February 2015

60 Sound Initial Moderate Advanced SEAL RESTORE

61 Long before any lesion forms Indigenous microflora protect the host from exogenous pathogens by stimulating a vigorous immune response

62 Saliva (the environment) 99% water 1% other stuff Proteins Histatins, sialin, PRP, Ig s Organic & Inorganic molecules Carbonate, bicarbonate, phosphate Quantity and quality are BOTH important Diluting agent, buffering agent, and antimicrobial agent Saliva provides substrate for bacterial metabolic processes

63 Important Proteins in Saliva Sialin - aka ph rise factor - main buffering protein Statherin - a PRP that stabilizes inorganic ions and allows for supersaturation Mucin - causes bacteria to aggregate Lysozyme antibacterial enzyme used for bacterial warfare (depressed by iron and copper) Lactoferrin - combines with iron and copper to protect lysozyme and deprives bacteria of these metals Salivary peroxidase - reacts with salivary thiocyanate when H 2 O 2 is around and forms hypothiocyanite which inhibits bacterial glucose metabolism Lactoperoxidase - adsorbs to hydroxyapatite altering primary bacterial attachment

64 Sialin aka ph Rise Factor gly-gly-lys-arg

65 Sialin urea CO 2 and ammonia

66 [There exists] a strong correlation between elevated levels of free arginine in saliva and caries resistance

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68 My hero Israel Izzy Kleinberg

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73 Izzy wanted me to understand antibiotics kill more than we realize

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75 The Risky Risk Assessment Everyone is enamored by risk assessments Dental schools WCMID ADA State dental associations Hygienists

76 You are about to hear controversial material Remember what Steven Covey says, Be Responsible!

77 The best predictor of future lesions is the presence of lesions or restorations

78 How were these RISK ASSESSMENTS created? Caries Risk Assessments are based on end stage disease manifestations Isn t this a problem? What causes this disease?

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80 Caries Risk Assessment works because of the identification of risk factors, patient behavior change, & Risk-appropriate recare

81 Transition to Caries Risk Assessment Caries Risk works because of the Conversations! identification of risk factors, patient behavior change, & Risk-appropriate recare

82 Begin by asking yourself Is caries active Is there one lesion? An initial lesion A moderate lesion An advanced lesion Are there more than six filled surfaces?

83 You may need to look in the mouth Is caries active Is there one lesion? An early lesion A moderate lesion An advanced lesion Are there more than six filled surfaces?

84 Then it s time for motivational interviewing Where do you live? What s your favorite candy? What s next to your bed?

85 What s on your nightstand?

86 What s your favorite beverage?

87 The inherent issue with CRA How many times a day do you eat or consume: hard candies, sticky candies, cough drops, throat lozenges, cookies, cakes, pastries, doughnuts, fig newtons, tortilla chips, potato chips, Cheetos, crackers, bread, jams, jellies, marmalades, preserves, fruit juice, soda, pop, sweet tea, diet soda, or any other food that causes cavities?

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89 = CARIES

90 @briannovy1 Peace be with you It is a privilege to treat another human If you don t enjoy it, you re not doing it correctly.